HIM Factoids

HIM facts, tips, and tidbits from our team of experts to yours. 



HRG's Top 3 Reasons For Improper Payment:

  1. payment is made for services that are incorrectly coded
  2. do not meet Medicare's coverage and medical necessity criteria
  3. the documentation submitted does not support the ordered service


There are so many reasons that you should be auditing this year but we have our Top 6 that we believe are most important. 

  • New and revised codes in both coding systems effective Oct 1st, 2016 and Jan 1st, 2017.
  • Return of the RACS (Recovery Audit Contractors)
  • 2016 CMI (Case Mix Index)
  • New official guidelines for coding and reporting for 2017
  • Patient status audits


CMS releases 2018 ICD-10-CM codes for October 1 implementation. Starting October 1, you’ll be able to select a specific ICD-10-CM code when a patient is in remission from abuse of each of a variety of substances, including alcohol, opioids, cannabis and nicotine.

Those nine new codes are among 360 new, 142 deleted and 226 revised diagnosis codes in the final 2018 update posted to CMS’ website June 13. The final 2018 ICD-10-CM codes include 322 more changes than what was released in the 2018 IPPS proposed rule in April. Explanatory information included with the substance abuse remission codes will classify the severity of the use as mild, moderate, or severe to better coordinate ICD-10-CM coding with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Take note of more changes in the final code set:

  • Myocardial infarction (MI) codes added. New codes for myocardial infarction type 2 (I21.A1) and other myocardial infarction type (I21.A9) mean you will need to take into consideration the type of MI the patient is having. A type 2 MI describes a myocardial infarction due to demand ischemia. In addition, notes added under ST-elevation MI codes (I21.0-I21.4) clarify that the condition is a type 1 MI.
  • Heart failure gets new codes. The code set has new codes for various types of right heart failure, including acute (I50.811), chronic (I50.812), acute on chronic (I50.813), and unspecified (I50.810). You’ll also have new codes to report for right heart failure due to left heart failure (I50.814), biventricular heart failure (I50.82), high-output heart failure (I50.83) and end-stage heart failure (I50.84) for patients with an advanced form of the disease who no longer respond to medication.
  • Antenatal screening codes expand reporting options. Practices will be able to report specific screening tests administered to pregnant patients, such as fetal growth retardation and chromosomal abnormalities with 17 new Z-series codes.
  • Non-procreative genetic counseling visits will be coded with Z71.83.

The final code set includes more than 100 deletions that were not in the proposed code set, including a reversal on new codes.

Here are the highlights of those changes:

  • Three anorectal abscess codes for horseshoe, ischiorectal, and supralevator abscesses were issued in the proposed code set but were not included with the final codes.
  • The head injury section of Chapter 19 will lose 68 subsequent encounter and sequela codes. One example is S06.2X7D (diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter). Because the code indicates the patient died, the concept of follow-up care did not make sense for the codes.
  • Deletion of 36 thumb subluxation and dislocation codes. The codes represent initial and subsequent encounters, as well as sequela.


HCC (hierarchical condition category) coding is hot right now in this new world of value-based and risk adjustment payment models. HRG coders are skilled HCC coders and are familiar with the challenges to accurate HCC reporting.

Here are some common HCC coding errors:

  • An HCC diagnosis that is billed but not noted in the physician’s chart documentation
  • Chronic conditions and status codes i.e. BKA (below knee amputation) that are not documented on an annual basis
  • The electronic health record was unauthenticated (not electronically signed)
  • A cancer diagnosis that is unclear if it is active or should be reported as a history code
  • Chronic conditions such as hepatitis that are not documented as chronic
  • The record does not contain a legible signature with credentials
  • Documentation that does not say the HCC condition was monitored, evaluated, assessed or treated (MEAT)
  • Highest degree of specificity was not assigned to the diagnosis
  • A causal relationship or manifestation code is missing, most common with diabetic complications

Him fact

Preventive services include their initial Welcome to Medicare, Initial and Subsequent Annual Wellness Exams (the name is a bit misleading, as this is mostly paperwork and planning), as well as many screening tests and counseling options. 

**Quick note: “Screening” implies that the patient has not already been diagnosed with this condition.



As of January, 2017, reimbursement for Moderate Sedation (aka Conscious Sedation) has been unbundled. There are new codes with new descriptions and guidelines. The requirements for this sedation billing includes the pre-service, intra-service and post-service work. However, it is the intra-service work that drives the time-based code selection.
Look for the following:

  • Start time of administration of the sedating agent(s)
  • End time when the procedure is completed, the patient is stable for recovery and the physician (or other qualified health professional) ends the ad-ministration of the sedation agent(s)
  • Only intra-service time can be counted 


Comments were due April 7, 2017 for the proposed new ICD-10 CM (diagnosis) and ICD-10-PCD (procedures) codes for the 2018 and 2019 fiscal years.  Types of myocardial infarctions (MI) and heart failure classifications where two subjects with new proposed codes including “a new subcategory is proposed for right heart failure (I50.84). New codes have been proposed for biventricular failure (I50.82), high-output heart failure (I50.83), end-stage heart failure (I50.84), and other heart failure (I50.89). These new codes will provide more information regarding the patient’s severity of illness,” Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer.
Read full article here: https://www.icd10monitor.com/comments-due-friday-on-proposed-new-icd-10-codes



Top 6 Challenging DX To Code

  • pneumonia
  • renal failure
  • respiratory failure
  • congestive heart failure
  • sepsis
  • malnutrition


100% of our coding and HIM leadership team are ICD-10 profecient and ready to help! 



Industry standard for medical coding accuracy is 95% or higher. 


Internal goal is routinely 98% or higher!