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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.
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.
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
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.
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
will discuss the following ICD-10-CM topics: Overview of
Chapter 1, HIV/AIDS, Sepsis, and MRSA
tutorial will discuss the following ICD-10-CM topics: Overview
of Chapter 19, Poisoning, Adverse Effects, Underdosing, and Toxic
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
This tutorial will
discuss the following ICD-10-CM topics: Fractures,
External Causes of Morbidity, and Transport Accidents.
tutorial will discuss the following ICD-10-PCS
Conventions and Guidelines,
2) Medical and Surgical Section; Definitions and
Devices and Qualifiers,
Root Operations Review for Medical and Surgical
tutorial will discuss the following ICD-10-CM
& Parasitic Conditions,
Blood & Blood Forming Organs.
tutorial will discuss the following ICD-10-CM
The Endocrine System,
Diseases of the Eye & Ear, 5) Diseases of the
Circulatory System, and 6) Diseases of the Respiratory System.
tutorial will discuss the following ICD-10-CM
Diseases of the Digestive System, 2) Diseases of the Skin &
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.
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 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.
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
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
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
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.
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.
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
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
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.
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.
With the inception of the MS-DRG,
(Medicare Severity-Diagnostic Related Group), system, October 1, 2007,
the addition of an MCC, (Major Co-morbid condition), or CC, (co-morbid
condition), could mean the difference of several thousand dollars per
DRG case. This tutorial will discuss those MCCs or CCS which are
commonly missed and what documentation to look for.
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.
The Office of
Inspector General, (OIG), is targeting wound debridement and
wound care for medical necessity and correctness of coding.
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 ICD9 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.
& Endoscopic Exams
CPT and ICD-10-PCS
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.
As of January 1, 2005, a new form of
reimbursement was established by CMS for Psychiatric facilities,
to report Medicare patients. This tutorial presents the DRG
methodology based reimbursement system, termed Inpatient
Psychiatric Facility Prospective Payment System.
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.
Sepsis and septicemia have
previously been considered synonymous terms used heavily in the
medical field. Despite this, coding guidelines now place these
terms into two separately identifiable disease states. This
educational tutorial will discuss this difference between the two as
well as their related conditions.
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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