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Past Articles Listed By Subject
Coding/documentation

 

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Getting ready for ICD-10 changes

Oct. 1, 2013, is the current deadline for switching from ICD-9. More

Evaluating and managing hospital E/M services

Key components of E/M must be documented for every encounter More

Whose documentation counts?

More

Prolonged service proficiency

The coding and billing of prolonged services depend on the face-to-face time spent with the patient over and above the average. More

Correct classification of chronic kidney disease

As the U.S. population ages, chronic kidney disease is becoming more and more prevalent. More

Placing priority on pressure ulcers

Current emphasis on public reporting of quality scores has helped make accurate documentation and effective management of pressure ulcers crucial health care considerations. More

Recognizing acute respiratory failure

Acute respiratory failure is a common diagnosis, especially among patients admitted with heart failure, pneumonia or chronic obstructive pulmonary disease. More

New subsequent observation codes

Three new CPT codes have been developed to address longer-stay observation care. More

Pneumonia

The clinical distinction between community-acquired pneumonia and health care-associated pneumonia is crucial for correct management and antibiotic selection. More

Weighing in on BMI

A patient's body mass index can have a profound effect on the complexity of care and the risks of complications, morbidity and mortality. More

Chronic respiratory failure

Chronic respiratory failure is usually recognized by a combination of chronic hypoxemia, hypercapnia and compensatory metabolic alkalosis. More

Urinary catheter-associated infections: Before or after admission?

Any infection related to a device or catheter of any type is classified for coding purposes as a complication of care. More

Sepsis: SIRS due to an infection

The current definition of sepsis is not well known by most physicians. Many think a diagnosis requires positive blood cultures and is associated with an extremely grim prognosis, but this is no longer so. More

Drug dependence and abuse

For coding purposes, the term “addiction” is not used, but is treated as synonymous with “dependence.” More

Acute renal failure

Documentation and coding of acute renal failure can be problematic, as many different criteria may be used to define the condition. More

Accelerated hypertension

Coding terminology hasn't caught up with the currently accepted clinical diagnostic terms for severe, uncontrolled hypertension. More

Encephalopathy

Most patients who are admitted to the hospital with the symptom of mental status alteration actually have encephalopathy as the cause. More

Heart failure: The importance of precision

For coding purposes, it is no longer enough to say that patients have “CHF” or “congestive heart failure.” More

Documenting altered mental status

When a patient is admitted with an acute change in mental status, the physician should drill down to determine the known or suspected causes of the change. More

Respiratory failure in COPD patients

In some cases of chronic obstructive pulmonary disease, it may be appropriate to assign a principal or secondary diagnosis of acute respiratory failure. More

Documenting and billing for critical care services

To avoid rejection of critical care codes, physicians must be familiar with coding definitions, and documentation must reflect the professional services that support the codes. More

Consultation confusion

CMS stopped paying for services billed as consultations as of Jan. 1, 2010. What does this mean for hospitalists? More

Documenting adverse drug reactions and poisonings

Adverse effects of a correctly administered drug or drugs must be coded and reported differently than the misuse of a drug, which is classified as “poisoning” in ICD-9-CM coding. More

Walking the tightrope of medical necessity

Our columnist discusses key elements of deciding the appropriate level of care for a given patient (inpatient versus outpatient or outpatient with observation). More

Using observation services

Hospitals often struggle to achieve compliance with CMS’ regulations for determining whether a patient should be classified as an inpatient or an outpatient with observation services. More

CMS updates payments, quality measures for 2010

October 1 is an important time to evaluate coding changes because it’s when CMS’ annual update to the inpatient prospective payment system (MS-DRGs) takes effect. More

Accurate coding for transfer to post-discharge facilities

Accurate ICD-9-CM codes for diagnoses and procedures performed during a hospital stay will only partially determine payment. Discharge status codes must be given equal attention. More

Reporting malnutrition

Documenting malnutrition as a secondary diagnosis helps establish the severity of an underlying illness, improves publicly reported data, and can increase reimbursement to the hospital. More

Accurate coding improves payments, quality ratings

Accurate coding has a significant impact not only on a hospital or practice’s finances but also on quality ratings, as Medicare’s new coding system increasingly is being used to profile hospitals and physicians. More

Coding cardiac conditions

Acute coronary syndrome is a very popular diagnosis frequently documented when a patient presents to the hospital with chest pain thought to be cardiac in origin. For accurate coding, physicians should document unstable angina or acute myocardial infarction. More

Coding Corner

Reporting diabetic manifestations

More

Capturing charges on the go

Billing software saves money when it complements hospitalists' workflow

Using a handheld electronic device to capture procedure codes isn't new, but as the technology improves, the approach is becoming particularly appealing to hospitalists. More

Documenting skin ulcers: The pressure is on

Physicians must carefully identify patients at high risk of developing pressure ulcers and then initiate and document prevention strategies. More

Stroke versus transient ischemic attack

Distinguishing between stroke and TIA requires taking into consideration various definitions, including cerebral infarction, cerebral hemorrhage, aborted stroke, impending stroke and TIA.
More

Insufficient insufficiency

Physicians often use the term renal insufficiency to communicate the status of a patient’s renal function, but this isn't enough when the medical record supports a more specific condition.
More

Is it sepsis?
February '09

Billing and coding
Specific documentation helps optimize payments for heart failure
January '09

Billing for interactions with a patient’s family or other caregiver

More than 44 million Americans care for an adult family member or friend. Physicians often will discuss the care of a patient with the patient’s caregivers, and may be able to bill for these interactions.
December '08

Coding corner: ICD-9 changes take effect
October '08

Billing in the ED and transitional care units
August '08

Coding corner
Billing for routine perioperative care by hospitalists may require modifiers
June '08

Coding corner
Advice on discharge billing, and whether critical care codes depend on location
April '08

Paying by numbers
CMS’s new MS-DRG codes require more precise diagnostic reporting
March '08

Coding corner

Billing Medicare based on time and revised rules on verbal orders
February '08

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