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  • Coding Careers: Learning to Embrace the Detours

    by Rebecca Harmon, MPM, RHIA, CCA

    Like many people, I’ve experienced a number of career “detours”. Some of these detours were intentional while others were self-inflicted, and a few were just the luck of the draw. We start our careers and have a general idea of where we want them to go and how quickly we should get there – and when we run into a detour, it can present a real challenge for us. Continue reading

  • Physician Query Process: Part 10: Timing of a Physician Query

    by Christopher G. Richards, RHIA, CCS

    A concurrent query is initiated while the patient is still in house; it occurs in real time and both encourages and enables more timely, accurate, and reliable responses. Continue reading

  • Laparoscopic Converted to Open – Code Both, But How?

    by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA

    Guideline B3.2d says to code both the laparoscopic inspection and the open procedure. Coding the open procedure is just assigning a regular code for what was performed, but what are they inspecting? That’s the tough question. Is it the body part they intended to perform the procedure on or the cavity in which it’s found? Both seem logical but both can’t be correct. Continue reading

  • Significant Change to ICD-10-PCS Body Part Key: Cranial vs. Spinal Structures

    by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA

    A significant change in ICD-10-PCS for FY2016 didn’t take place in the tables; it took place in the Body Part Key. In FY2016, the body part value for Dura Mater covering the spinal cord is classified as Spinal Meninges rather than Dura Mater. This change also affects Arachnoid Mater and Pia Mater of the spinal cord. Continue reading

  • Breathe Easy: Coding Respiratory Failure in the Inpatient Setting

    by Pamela J. Haney, MS, RHIA, CCS, CIC, COC

    Respiratory failure is a condition in which not enough oxygen passes from the lungs into the blood. The body’s organs, such as heart and brain, need oxygen-rich blood to work well. It can also occur if the lungs cannot properly remove carbon dioxide (a waste gas) from the blood. Too much carbon dioxide in the blood can harm the body’s organs.
    Continue reading

  • Coding of Fish-mouth Incisions and Flaps

    by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA

    The patient had a below-the-elbow amputation of the right forearm. The surgeon described using a fish-mouth type of flap closure. My students in class recently questioned whether this flap closure should be coded separately.
    Continue reading

  • How I Overcame Uncertainty When Applying ICD-10-PCS Codes

    by Angela Lehoux, CCS

    Before I attended the Advanced Training ICD-10-PCS Workshop with Lynn Kuehn and Gail Smith, I doubted every PCS code I put on a chart. I just didn’t feel confident in what I was doing. I didn’t understand the PCS system and I felt like I was never going to “get it.” When was I going to have time to memorize 31 root operations? How do I know what the qualifier is for? Is there no one who can explain this to me in laymen terms and help it make sense? Continue reading

  • Medical Coders: Giving Back and Paying it Forward

    by Rebecca Harmon, MPM, RHIA, CCA

    In my last blog I used the example of rush hour traffic to illustrate how the act of giving can seed a more positive and fruitful experience in job seeking. As luck would have it, I experienced another traffic incident this week that again inspired me to think about how we navigate our jobs and careers. Continue reading

  • Emergency Department Coders: Get the E/M Level Your ED Providers Deserve!

    by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA

    I’ll bet you know that Emergency Department encounters require three out of three key components to be met or exceeded before the E/M code of that level can be assigned. But, did you know that Emergency Department encounters get a “break” on calculating the History key component? Continue reading

  • Physician Query Process: Part 9: Documentation Precision and an Example of How a Good Physician Query is Developed

    by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

    We talk about precision in the context of documentation of an unspecified diagnosis when clinical reports and clinical documentation is noted to suggest a more specific diagnosis. For coding purposes, there exists a need to request further specificity or the degree of severity of a documented condition. Continue reading

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