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Changes take effect January 1, 2018. CPT codes are maintained by the American Medical Association and are updated quarterly. The main update is done January 1. 312 Total Code Changes: 170 new codes, 82 Deleted Codes & 60 Revised Codes.
Radiology, Laboratory, and Pathology are not addressed in this tutorial.
Patients admitted to a free-standing psychiatric facility or to a designated/licensed psychiatric unit of an acute care or critical access hospital are subject to the coding guidelines for long term care facilities and the UHDDS definition of principal diagnosis (that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care) applies.
ICD-10-CM and ICD-10-PCS Code Sets were updated on October 1, 2017. For the ICD-10-CM code set there are: 360 new codes, 227 revised diagnosis code titles and 142 “invalid" codes. The objective of this tutorial is to Identify the new ICD-10-CM and ICD-10-PCS codes for FY 2018, identify CC’s and MCC’s in the 2018 ICD-10-CM Classification and become familiar with updated coding guidelines and conventions.
tutorial will discuss the following ICD-10-CM topics: Overview of Chapter 1, HIV/AIDS, Sepsis,
and MRSA. It includes diseases generally recognized as
communicable or transmissible. Chapter 1 has an instruction
to use an additional code to identify resistance to
antimicrobial drugs (Z16). This guideline should be
followed when assigning any code from this chapter.
Correct reporting of injection/infusion/hydration services relies on the ability to count and record total infusion or hydration hours. Correct drug administration reporting is
based on complete and specific nursing documentation of the
service. This would include the name of the medication,
specific route of administration, start time and stop time for
infusions, and whether or not the medications mixed in one
syringe or bag.
The respiratory system, also sometimes called the pulmonary system, is the body system responsible for supplying the blood with oxygen, which is then transported throughout the body. While this is the most important function of the respiratory system, there are many other important functions.
There are distinct differences in the terms
sepsis, septicemia, and systemic inflammatory
response syndrome, (SIRS). This educational
tutorial will discuss their differences, and how
they are interrelated, along with their common
The coding of respiratory failure when it is present with other conditions has long caused confusion for coders. Recent changes in the coding guidelines for respiratory failure have sought to improve code use understanding. This tutorial will help the coder to recognize the indicators of respiratory failure and to become familiar with the coding guidelines in the coding of respiratory failure.
Modifier 73 and 74 were established to assist hospital outpatient reporting associated with the use of resources in the event a surgical or diagnostic procedure is cancelled due to extenuating circumstances or those that threaten the well-being of the patient. This tutorial will instruct the coder in the correct use of these two modifiers.
This tutorial will discuss the following ICD-10-CM topics: 1) Conventions, 2) Neoplasms, 3) Infectious & Parasitic Conditions, and 4) Blood & Blood Forming Organs.
This tutorial will discuss the following ICD-10-CM topics: 1) The Endocrine System, 2) Mental & Behavioral Disorders, 3) Diseases of the Nervous System, 4) Diseases of the Eye & Ear, 5) Diseases of the Circulatory System, and 6) Diseases of the Respiratory System.
This tutorial will discuss the following ICD-10-CM topics: 1) Diseases of the Digestive System, 2) Diseases of the Skin & Subcutaneous Tissue, 3) Musculosketal & Connective Tissue, 4) Genitourinary, 5) Pregnancy, Childbirth & the Puerperium, 6) Prenatal, 7) Congenital Malfunctions, Deformation & Chromosomal Abnormalities, 8) Symptoms, Signs & Abnormal Clinical & Lab Findings.
This tutorial will discuss the following ICD-10-CM topics: 1) Injury, Poisoning, and Certain Other Consequences of External Causes, 2) External Causes of Morbidity, 3) Factors Influencing Health Status and contact with health services, 4) Factors Influencing Health Status and contact with health services.
The digestive system includes all of the organs and structures that aid in the digestion and elimination of food. It includes the gastrointestinal tract, also known as the alimentary canal, as well as other accessory organs. The gastrointestinal tract includes all of the structures and organs extending from the mouth to the anus. The accessory organs are all of the organs that aid in digestion, such as the liver, gallbladder, and pancreas.
The genitourinary system includes organs of the reproductive and urinary systems. They are included together due to their proximity and because they share common pathways. One important distinction between coding in the ICD-10-CM and ICD-9-CM is that the ICD-10-CM requires more specificity in terms of the site of injury/diagnosis.
The circulatory system is made up of the heart and the blood vessels that carry the blood throughout our bodies. The heart is the hard-working muscle whose function is to pump the blood through the vessels. There are three basic types of blood vessels: arteries, veins, and capillaries. You will learn more about each of these later in the lesson.
The skeletal system has many important functions. Our bones are strong enough to bear weight, yet light enough to allow for flexible movement. In addition, many of our bones provide protection for our internal organs. For example, our skull protects our brain, and our rib cage protects our heart, kidneys, and other organs. Our bones also store materials our body needs, such as calcium, magnesium, phosphorus, and bone marrow.
The nervous system consists of the brain, spinal cord, and all of the nerves inside and outside those structures. It receives sensory information from all the parts of your body, processes that information, and stimulates muscles and glands to move or secrete hormones. In addition, it allows people to engage in cognitive tasks, such as retrieving memories, learning new information, and communicating with other people.
Coding emergency room visits is not as difficult as the coding of inpatients, but it does require the application of the outpatient coding guidelines. A standard set of procedures typically relates to this patient type, and varies slightly by facility. This tutorial will discuss the coding guidelines for both ICD-9-CM diagnosis and CPT-4 procedure coding. Typical procedures to look for in the ED setting will be discussed as well.
These patients present for outpatient testing or therapy per a physician's order. The order must give a reason, (diagnosis), for the test. A diagnosis of "rule out" is not acceptable and the physician should be queried for a more definitive diagnosis.
This tutorial will describe the debridement process for skin, soft tissue and bone, providing definitions and examples. Active wound care and fracture care related to debridements will be delineated. The differences between ICD-10 and CPT debridement coding guidelines will be discussed.
Coding cardiology diagnosis and procedures can be a challenge to even a seasoned coder. In this tutorial you will learn some of the most current cardiology procedures, terminology and coding applications, including electrophysiolgic studies and automatic defibrillator insertions, and replacements.
What is documentation and why is it important? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care.
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This presentation gives information regarding the diagnostic and procedural coding guidelines for the accurate reporting of endoscopic examinations of the intestines which are classified to these four groups: proctosigmoidoscopy, sigmoidoscopy, colonoscopy, and colonoscopy through stoma.
Congestive Heart Failure, (CHF), is the condition in which heart disease, causes breathlessness and abnormal sodium and water retention, often resulting in edema. The congestion occurs either in the lungs or peripheral circulation or both, depending on whether the heart failure is right sided or general. Congestive heart failure (CHF) is the most frequent cause of hospitalizations in the United States. Approximately 4.7 million people in the U.S. suffer from congestive heart failure.
Coding obstetrics and delivery follow their own separate guidelines and rules. This tutorial provides coders guidance and coding applications that will give clarity to coding obstetric and delivery cases.
As many as 40 million people suffer from some form of pain. Since the new codes for pain were introduced in 2006, coders have been challenged in their use. This tutorial will help the coder understand the pain condition and how to apply the diagnostic codes according to official coding guidelines.
The reporting of whether a device is used, its type, function and whether it should be reported can be a challenge in PCS coding. The device used in a procedure if appropriate is designated by the sixth character of the code. There are certain root operations that always use a device designation; those are: Insertion, Replacement, Supplement, Change, Removal, and Revision.
On June 25, 2010, President Obama signed into law the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010,” Pub. L. 111-192. Section 102 of the law pertains to Medicare’s policy for payment of outpatient services provided on either the date of a beneficiary’s inpatient admission or during the three calendar days immediately preceding the date of a beneficiary’s inpatient admission to a “subsection (d) hospital” subject to the inpatient prospective payment system (or during the one calendar day preceding the date of a beneficiary’s inpatient admission to a non-subsection (d) hospital).
Coding of the Human Immunodeficiency Virus, (HIV), and associated conditions can be a challenge to coders. California law poses even further cause for concern, as certain HIV related codes cannot be reported for patients seen in the California health care system. This tutorial will help coders understand the disease, conditions and symptomatology involved and how they are translated into diagnostic coding. In addition, California HIV reporting requirements will also be addressed.
The Office of Statewide Health Planning & Development (OSHPD) is a California state agency that is tasked with promoting healthcare accessibility through facilitating analysis of California’s healthcare infrastructure, providing information about healthcare outcomes, and promoting a diverse and competent healthcare workforce, in addition to other roles. As part of this mission, OSHPD requires that hospitals submit particular data on a regular basis. This tutorial will provide descriptions of some of the data elements required in these reports.
This tutorial will cover the following PCS topics:
1) General overview of PCS
2) Root Operations
3) Conventions and Guidelines
4) Coding Cases
This tutorial will cover the following PCS topics:
1) General overview of PCS
2) Root Operations
3) Conventions and Guidelines
4) Coding Cases
This tutorial will discuss the following ICD-10-CM topics: Overview of Chapter 19, Poisoning, Adverse Effects, Underdosing, and Toxic Effects.
Chapter 16: Certain conditions originating in the perinatal period: P00-P96. For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth.
This tutorial will discuss the following ICD-10-CM topics: Fractures, External Causes of Morbidity, and Transport Accidents.
This tutorial will discuss the following ICD-10-PCS topics: 1) Conventions and Guidelines, 2) Medical and Surgical Section; Definitions and Guidelines, 3) Approaches, Devices and Qualifiers, and 4) Root Operations Review for Medical and Surgical Section.
On October 1, 2015, the United States health care system transitioned from the current International Classification of Diseases, ICD-9-CM, diagnosis and inpatient procedure codes to a more detailed Tenth Edition-ICD-10-CM. ICD-10-PCS (Procedure Coding System) is an alphanumeric procedure classification system that will be implemented for inpatient hospital settings only and will replace Volume 3 of ICD-9-CM.
The human body has three types of joints: fibrous, cartilaginous, and synovial. Fibrous joints are sometimes called fixed joints. The joints connecting the bones that make up the skull are examples of fibrous joints. Cartilaginous joints are only slightly moveable. The synovial joints of our body allow for the largest range of motion. There are 6 types of synovial joints.
Our body has over 640 skeletal muscles that make up the bulk of our body and more than half of its weight. There are three types of muscles in our bodies: involuntary (smooth), cardiac, and skeletal (striated). While there are distinctions among the different types of muscles, they all have the ability to contract, relax, be excited by a stimulus, and return to their original size and shape.
Laceration repairs take into consideration many coding guidelines which can cause confusion for coders. Physician documentation is paramount in reporting the correct type, site and size of the repair. This tutorial will educate the coder on the various wound closures with respect to CPT coding rules and guidelines.
New and changed CPT4 codes are introduced for 2009. These changes are effective January 1, 2009. This tutorial will list the new codes and changes. New technology codes must be used if they exist in place of the CPT code. The new technology codes are not discussed in this tutorial.
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