More than ever before, HIM is being recognized as an enterprise profession important to ambulatory, acute, and postacute settings. A good example of the transformation is HIM's involvement in CMS' risk adjustment and Hierarchical Condition Category coding system.
Coding and documentation should tell a patient's complete story. With the greater specificity in ICD-10, organizations should be better able to capture these stories, and the respiratory codes, listed in Chapter 10: Diseases of the Respiratory System (J00?J99), are no exception.
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-10-CM diagnosis codes. While changes in documentation requirements for pregnancy, coma, diabetes, fractures, and pressure ulcers are frequently cited, less information is available regarding the documentation requirements for procedures.
A team of researchers may have uncovered what many involved in the transition to ICD-10 have feared all along: Disruption of data and financials is on the horizon.
The April 1 confirmation of the delay in implementing the ICD-10 code set certainly took the wind out of many healthcare organizations' sails. Those organizations spent countless hours and dollars preparing for the go-live date that was six months away.
The Protecting Access to Medicare Act of 2014 was recently signed into law, and what might seem on the surface like a straightforward attempt to prevent cuts to Medicare physician rates is actually more than meets the eye.
With the biggest change to the coding world just around the corner, dual coding in ICD-9 and ICD-10 is one task that should be at the top of everyone’s list of implementation priorities.
Communication is a major portion of the documentation and coding conundrum. Creating avenues for information exchange with the physician community is essential to the success of clinical documentation improvement (CDI) and the capture of coded data. Physicians take a variety of courses (e.g., pathology, physiology, disease manifestations, etiology, and process) throughout their academic medical education. However, their education does not address the importance or the details of documenting medical terminology with specific information that corresponds to ICD-9 and ICD-10 codes. Physician profiles and scorecards have been linked to ICD-9-CM codes; physician awareness of this and future linkage to ICD-10 is necessary.
CMS has finalized changes to packaged services and E/M CPT® codes for clinic visits with the much-anticipated November 27, 2013 release of the 2014 outpatient prospective payment system (OPPS) final rule.
