Home Town Health – April 2017 Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding Healthcare Coding and Consulting Services (HCCS)

Agenda AHA Coding Clinic Spotlight CPT Assistant Updates Hot Topics

Home Town Health - April AHA Coding Clinic and CPT Assistant Spotlight

Home Town Health - April Question: IP ONLY …Is "concern for" a term of uncertainty that allows the "subdural empyema" to be coded, since it was documented at the time of discharge?......  

Home Town Health - April Answer: "Concern for" is and uncertain diagnosis It is coded following the guideline for "uncertain diagnosis" in the inpatient setting   Source:  ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Pages: 18-19 Effective with discharges: February 18, 2018

Home Town Health - April ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 H. Uncertain Diagnosis If the diagnosis documented at the time of discharge is qualified as “probable”,“suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or othersimilar terms indicating uncertainty, code the condition as if it existed or wasestablished. The bases for these guidelines are the diagnostic workup, arrangementsfor further workup or observation, and initial therapeutic approach that correspondmost closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short- term, acute,long-term care and psychiatric hospitals. Source: ICD-10-CM Coding Guidelines

Home Town Health - April Question …What is reported when the procedure is performed solely for lysis of intestinal adhesions?....  

Home Town Health - April Answer Code 44005, Enterolysis - or code 44180, Laparoscopy, surgical, enterolysis may be reported, as appropriate Source:       CPT Assistant, February 2018 Page: 11 Category: Frequently Asked Questions

Home Town Health - April Question   …..What do you report when this laparoscopic hysterectomy scenario is performed?.....

Home Town Health - April Answer Report code 58571 or 58573 Vaginal cuff closure is part of the hysterectomy, regardless of the approach Source:  CPT Assistant, February 2018 Page: 11 Category: Frequently Asked Questions

Home Town Health - April Items of Interest…. CMS Paid $367 Million in Non-Compliant OP Physical Therapy click here https://oig.hhs.gov/oas/reports/region5/51400041.pdf

Home Town Health - April Items of Interest…. Quarterly HCPCS Code Updates here - Effective Date 4/1; 3 New Codes:

Home Town Health - April Learning Outcomes AHA Coding Clinic Spotlight CPT Assistant Updates Hot Topics

Home Town Health - April References ICD-10-CM/PCS AHA Coding Clinics CPT Assistant

Thank You For Your Time Value Quality We welcome all questions! jcuster@hccscoding.com Thank You For Your Time