Medical Auditing & Coding Blog


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Respiratory Coding in FY2020

Often in emergency and acute care healthcare settings, we find patients with a diagnosis of “Respiratory Failure.” Clinical coding and clinical documentation improvement (CDI) professionals need to have a strong knowledge and understanding of both medical/clinical aspects of diseases as well as the coding guidelines and rules. This blog includes a brief discussion of the clinical aspects and ICD-10-CM coding of Respiratory Failure.

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Sepsis Documentation and Coding Guidelines (2020 Update)

We know that SEPSIS is a life-threatening condition and there has been much discussed about this subject in many clinical circles as well as in clinical coding and clinical documentation improvement (CDI). The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) and follow Official Guidelines.

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Don’t forget the 7th character when assigning Chapter 19 ICD-10-CM diagnosis codes!

The 7th character represents the type of encounter, or phase of treatment; this could be an initial encounter, a subsequent encounter, or a sequela (previously known as a late effect).  The conditions found in Chapter 19 of the codebook are Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) and most of these require the 7th character to identify the type of encounter. 

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Robyn Petersen
Are your SNF Coders Ready for PDPM?

I am sure you were all relieved when CMS granted a 30-day grace period before commencing with the new Patient Driven Payment Model (PDPM) in the SNF and Long Term Care settings. But that grace period is coming to an end in 3 weeks, after which time some 34,877 codes will be on the Return to Provider (RTP) list which was generated by CMS. This means that claims with these RTP codes assigned as the first listed code on the MDS Assessment, Section 10020B, are identified as “unable to process” and the claim is returned to the provider for correction and resubmission. This delays payment considerably, which has long range ramifications on your cash flow.

Ensure your SNF coders are ready for the significant coding changes that will be enforced beginning 11/1/2019!

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Robyn Petersen
RAPs, Enhanced Oversight, What does it mean for new HHAs?

Newly-enrolled Home Health agencies are now required to undergo an enhanced oversight provisional period wherein the Request for Anticipated Payments (RAPs) are suppressed, effective now (March 2019). According to CMS, this provisional period will last at least 30 days, but don’t forget to submit a RAP at the beginning of each 60-day Home Health episode or you will not be paid when the final claim is submitted! 

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Robyn Petersen