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Adrienne Commeree , CPC, CPMA, CCS, CEMC, CPIP , breaks down spinal anatomy and ICD-10-PCS coding for spinal fusions and laminectomy procedures. Paul Evans, RHIA, CCS, CCS-P, CCDS, give coders ICD-10-PCS documentation and coding tips for three of the most common, and commonly misunderstood, procedures performed via bronchoscopy. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about the section added to ICD-10-PCS for 2016 for reporting new technology procedures. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, writes about key details in documentation that coders will need to look for in order to report procedures using the root operation Dilation. Shelley C. Safian, PhD, RHIA, CCS-P, writes that inpatient Removals of a device from a lower bone may be performed less frequently than other procedures, which creates a need for more education on reporting ICD-10-PCS codes from table 0QP. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , and AHIMA-approved ICD-10-CM/PCS trainer, writes that reporting imaging, nuclear medicine, and radiation therapy procedures will dramatically change depending upon whether the patient has been admitted into a hospital or is being cared for as an outpatient. Sarah Nehring, RHIT, CCS, CCDS , breaks down ICD-10-PCS coding for spinal fusions based on details in the operative note. Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, especially Control and Repair. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews scenarios for initial, subsequent, and sequela encounters, and helps coders better understand how to assign seventh characters for each type of encounter. Gretchen Young-Charles, RHIA, and Anita Rapier, RHIT, CCS, review how to differentiate these root operations and report associated devices. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Adriane Martin, DO, FACOS, CCDS , reviews some of the ICD-10-CM/PCS code and CC/MCC updates that made the final cut in the fiscal year 2019 IPPS final rule. Kennedy gives solutions for coding compliance for conditions such as sepsis, coma, and encephalopathy. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , provides background on vaccinations and writes that coding for vaccine administration isnt relegated to the outpatient coder; inpatient coders also have codes to report for vaccine administration. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , breaks down documentation and ICD-10-PCS coding for amputations of the upper and lower extremities. Adriane Martin, DO, FACOS, CCDS, says that knowledge of coding guidelines and Coding Clinic advice, as well as an understanding of the spine anatomy and the spinal fusion procedure itself, can go a long way toward helping put together the pieces of the fusion puzzle. When deciding to learn about ICD-10-PCS, its important to first understand the basics and compare and contrast ICD-10-PCS and CPT. Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO, reviews the basics of reporting with ICD-10-PCS including how to use the ICD-10-PCS manual, decipher root operation guidelines, and identify the principal procedure in physician documentation. Joel Moorhead, MD, PhD, CPC, writes about details for spinal conditions for coders to consider when choosing the most accurate ICD-10 codes for diagnoses and procedures. 
Read up on the updates and CMS process for implementing code changes biannually. Spinal fusion procedures are reported using two different ICD-10-PCS tables, depending on the location of the vertebrae fused. Adriane Martin, DO, FACOS, CCDS, reviews recent Coding Clinic, First Quarter 2019, advice, which includes guidance on reporting abdominal aortic aneurysm (AAA) repairs, spinal fusions, Whipple procedures, midline and central venous catheters, and more. Jennifer Avery, CCS, COC, CPC, CPC-I, Anita Rapier, RHIT, CCS, and Cheree Lueck, BSN, RN, provide tips for determining the correct root operation. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Six ICD-10-PCS root operations require a device, including Revision, Replacement, and Removal. Kimberly Cunningham, CPC, CIC, CCS , and other professionals comment on commonly seen MS-DRGs and inpatient conditions, including which terms coders need to look for in documentation to arrive at the most accurate MS-DRG and codes. This article reviews HCPros 2018 coding productivity survey and reviews data on factors that have affected coder productivity, remote coders, and collaboration between coders and CDI specialists, including charts coded per hour and coding accuracy standards. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes about these changes and helps to decipher the new guideline changes. 
Read up on reporting requirements and ICD-10-CM/PCS coding for craniotomies and deep brain stimulation (DBS). Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, reviews updates in Coding Clinic about coding orthopedic procedures in ICD-10-PCS, coma data in ICD-10-CM, and both cardiovascular procedures and diagnoses. Note : To access this free article, make sure you first register here if you do not have a paid subscription. 
Learn more about root operations that involve the physician looking at a patient, Inspection and Map. Sarah Nehring, CCS, CCDS , says to ensure ICD-10-PCS coding accuracy and appropriate MS-DRG assignment, inpatient coders must understand the device being inserted and how to apply the coding conventions and guidelines for pacemaker-related procedure coding. In this article, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O , reviews ICD-10-CM and ICD-10-PCS coding for common types of cancer. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM coding for common labor and delivery complications, and ICD-10-PCS coding for cesarean deliveries. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Sarah Nehring, CCS, CCDS, reviews ICD-10-CM reporting for the novel coronavirus (COVID-19) as well as ICD-10-PCS reporting for procedures such as mechanical ventilations, tracheostomies, and extracorporeal membrane oxygenations. ICD-10-PCS will completely change the way coders report inpatient procedures. Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , reviews Coding Clinic , First Quarter 2020, guidance, which includes topics such as reporting vaping-related disorders, malnutrition, and bariatric procedures. Sarah Nehring, CCS, CCDS, RHIT , writes that the increased complexity and cost of implantable cardiac defibrillator devices is reflected in the higher relative weight and longer length of stay for these MS-DRGs compared to pacemaker MS-DRGs. Sharme Brodie, RN, CCDS, CCDS-O , writes that the cost of new technologies can lead to an overwhelming financial burden to hospitals and patients, which is why accurate reporting of ICD-10-PCS codes in the new technology section of the ICD-10-PCS manual is more important than ever. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, tackles the fiscal year (FY) 2020 IPPS final rule to highlight 2020 code set and guideline changes. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, reveal potential trouble spots for the new coding system. Its that time of year when coders eagerly await the release of the new ICD-10-CM/PCS codes and guideline updates for the upcoming year. CMS recently released the 2018 IPPS final rule, which featured 2,916 of its now-annual ICD-10-PCS code additions, deletions, and revisions. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews changes that were made in the 2017 ICD-10-PCS Official Guidelines for Coding and Reporting to arteries and stents. John C. Alexander Jr., MD, MBA, James Fee, MD, CCS, CCDS, and George W. Wood II, MD, offer insight into which specialties will be most impacted and how coders can talk to surgeons about the query process. Adriane Martin, DO, FACOS, CCDS, writes that treatment of peripheral arterial disease (PAD) is variable and includes both medical and surgical therapy. In this article, Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS , offers coding tips for reporting spinal surgery cases in ICD-10-PCS and examines the correct use of each character. Approximately 185,000 amputations occur in the U.S. each year, according to the Amputee Coalition. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , reviews inpatient reporting and guideline updates for fiscal year 2020. With all the hoopla over sepsis, pressure ulcers, and diabetes coding, theres a little gem of coding advice that has been overlooked since ICD-10 was released: pneumonia and chronic obstructive pulmonary disease. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes that its not unusual for an outpatient coder to advance their career by diving into inpatient coding. Jillian Harrington, MHA, CCS, CCS-P, CPC, CPC-P, CPC-I, MHP, reviews the components in operative reports coders will need to find in order to report ICD-10-PCS codes for spinal fusions. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, discusses strategies for reporting, and better understanding, pyeloplasty in ICD-10-PCS. Judith L. Kares, JD, discusses the FY 2021 IPPS payment factors, such as MS-DRG relative weights, that currently determine hospital reimbursement. In part two of this two-part series, Sharme Brodie, RN, CCDS , reviews the recent guidance from Coding Clinic , Second Quarter 2019, including systemic inflammatory response syndrome, partial hip replacements, and more. Surprisingly, thyroid disease is more common than diabetes or heart disease, with an estimated 20 million Americans having some form of the disease. Determining the most specific ICD-10-PCS code for a procedural service can be tricky given that there are 34 character values and over 78,000 ICD-10-PCS codes for 2022. Note: To access this free article, make sure you first register if you do not have a paid subscription. Adriane Martin, DO, FACOS, CCDS , describes key takeaways from Coding Clinic , Second Quarter 2019, including helpful advice on well-known coding challenges and their impact on severity and DRG assignment. Sarah Nehring, RHIT, CCS, CCDS, reviews several new COVID-19-related ICD-10-CM and ICD-10-PCS codes recently released by CMS that will become effective January 1. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , breaks down ICD-10-CM and ICD-10-PCS coding for fusion procedures. Laurie L. Prescott, MSN, RN, CCDS, CDIP, provides coders with tips on coding heart failure, obstetrics, and linking language, and also offers the latest guidance given by AHA Coding Clinic for ICD-10-CM/PCS on these topics. Its important for inpatient coders to frequently review hospital-acquired conditions (HAC) and the rules governing their assignment in order to ensure proper reimbursement. Adriane Martin, DO, FACOS, CCDS, reviews Coding Clinics Third and Fourth Quarter 2018 advice including reporting for coronary artery bypass grafting, drainage of an abscess in the submandibular space, and diabetes. 
Adriane Martin, DO, FACOS, CCDS, reviews Coding Clinic guidance published in the first and second quarters of this year as it pertains to coding guidelines, severity of illness, and MS-DRG assignment for the inpatient setting. Sharme Brodie, RN, CCDS, reviews 2017 First and Second Quarter Coding Clinic advice, which includes sequencing chronic obstructive pulmonary disease with other respiratory diagnoses and body mass index reporting instructions. A handful of new ICD-10-CM/PCS codes took effect April 1. Note : To access this free article, make sure you first register here if you do not have a paid subscription. The fiscal year 2020 IPPS proposed rule includes nearly 1,500 CC/MCC designation changes, which impact MS-DRG groupings used to calculate pricing for inpatient hospital claims. Given the frequency of this condition, it is imperative that inpatient coding professionals have a clear understanding of the surgical treatment of PAD to avoid costly ICD-10-PCS errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Coders will need to master root operations in order to be successful in ICD-10-PCS. Note: To access this free article, make sure you first register if you do not have a paid subscription. Dawn Valdez RN, LNC, CCDS, reviews MS-DRG and code assignment for COVID-19-related pediatric multi-system inflammatory syndrome (PIMS), as well as common findings and treatments for the condition. Assigning the appropriate ICD-10-PCS code for spinal procedures can be a challenge for inpatient coders as they need to correctly identify each character of the seven-character code. For patients who suffer from frequent symptoms of gastroesophageal reflux disease (GERD), the provider may have to increase to prescription strength medications and possibly consider surgical intervention for severe cases. Note: To access this free article, make sure you first register if you do not have a paid subscription. In part two of this two-part series, Audrey Howard, RHIA, covers fiscal year (FY) 2022 updates to ICD-10-PCS reporting for spinal procedures, specificity updates to the ICD-10-CM official coding guidelines, and modified MS-DRG logic for type 2 myocardial infarctions. This article breaks down potentially confusing ICD-10-PCS guidelines for obstetric and cardiovascular procedures. With March declared National Endometriosis Awareness Month, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, details endometriosis-related procedure reporting for inpatient coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I , reviews the anatomy of the brain and details treatments and surgeries associated with the brain and how to report them in ICD-10-CM/PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription. 
The FY 2017 IPPS proposed rule addresses MS-DRG classifications and relative weights pertaining to the categories of other cardiothoracic procedures without MCC, and injuries, poisonings and toxic effects of drugs. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O, HCS-D, reviews the 2020 ICD-10-CM code changes for atrial fibrillation, as well as the clinical background and ICD-10-PCS reporting for related procedures. Queries will no doubt increase due to the increased specificity in ICD-10-PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Note : To access this free article, make sure you first register here if you do not have a paid subscription. While it is essential to receive continuing education on ICD-10-CM/PCS code selection, it is also important to stay current with industry news. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , details important ICD-10-PCS code updates and MS-DRG designation changes found in the fiscal year (FY) 2021 IPPS final rule. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , evaluates medical terminology used to describe mechanical ventilation and breaks down ICD-10-PCS coding for this procedure. 
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Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, discuss how the clinical documentation improvement department at their facility operates and their process for conducting a baseline audit and determining query rates across specialties. Sarah A. Nehring, CCS, CCDS, details ICD-10-PCS reporting for extracorporeal membranous oxygenation (ECMO) procedures and says basic knowledge of what an ECMO procedure is, how it is established in a patient, and why it is used can have a large impact on proper reporting and hospital reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Since the physician doesn't need to use a specific root operation term in documentation, coders should not rely solely on the term the physician uses. A transcatheter aortic valve replacement (TAVR) is an interventional cardiology procedure that has proven to be an important life-saving cardiac intervention frequently seen by inpatient coders. Root operations are the fundamental building block of ICD-10-PCS codes, but providers may not use the same terminology coders are familiar with. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes that understanding spinal anatomy, the reporting of detailed spinal diagnoses, and the selection of applicable procedure codes can ensure that these complicated claims are reimbursed correctly and in compliance with coding guidelines. Assigning time-based ICD-10-PCS codes for mechanical ventilation management can be challenging. In this article, Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews ICD-10-PCS reporting for common digestive procedures including the Whipple procedure and lysis of adhesions. Richard D. Pinson, MD, FACP, CCS , discusses the new Sepsis-3 definition and how the classification has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association. As far as I can tell, a blood transfusion is usually administered to whatever peripheral IV line/site is available, unless otherwise contraindicated or instructed differently by a specific physician order. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about how to report biopsies in ICD-10-PCS since the code set does not include the term among available root operations. A spinal fusion, or surgery to permanently connect two or more vertebrae in the spine, is sometimes necessary to correct spinal deformities and instability. Treatment options for spinal conditions are varied and may include pain management with medications, injections, or surgical interventions. Part two of this two-part series will review HACs in particular as part one focused on present on admission indicators. Keeping up with changing coding guidance adds to the complexity of reporting digestive procedures. In Major Diagnostic Category 1, Diseases and Disorders of the Nervous System, which covers MS-DRGs 020-103, CMS made changes to the classification of the diagnoses of functional quadriplegia and precerebral occlusion or transient ischemic attack with the use of a thrombolytic, as well as for the insertion of a responsive neurostimulator system. Laura Legg RHIT, CCS, CDIP, looks at the results of Central Learnings second annual ICD-10 Coding Contest and highlights ways facilities can use the data to improve coding performance and accuracy. Mechanical ventilation is a life-saving intervention used for acutely ill patients who cannot breathe on their own. Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used have to come from the physician in the progress note or can this particular information be extrapolated from nursing notes, orders, etc.? Brush up on documentation and ICD-10-CM/PCS coding for neuroendoscopy, posterior fossa decompression, and embolectomy/thrombectomy procedures. This article reviews changes to ICD-10-PCS codes including the addition of short-term device characters and various table updates. Note: To access this free article, make sure you first register if you do not have a paid subscription. James S. Kennedy, MD, CCS, CDIP , writes that if a payer has criteria that differs from that of the provider or the facility, Recovery Auditors can deny ICD-10-CM/PCS codes they deem not to fit these criteria. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Lung cancer is the leading cause of cancer death, making up almost 25% of all cancer deaths in the U.S., according to the American Cancer Society. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Laurie L. Prescott, MSN, RN, CCDS, CDIP , details the basics of ICD-10-CM/PCS for newer inpatient coders including a review of the ICD-10-CM seventh-character extension, placeholder use, and ICD-10-PCS root operations. ICD-10-PCS defines the root operations in very specific ways and coders need to know the definitions and the nuances of the root operations. Note : To access this free article, make sure you first register here if you do not have a paid subscription. The only difference between ICD-10-PCS root operations Excision and Resection is the amount of the body part removed. Adriane Martin, DO, FACOS, CCDS , highlights important changes in the 2020 IPPS proposed rule affecting MS-DRG and ICD-10-CM/PCS code assignment. Cranial diagnoses present with varied symptoms and require an individualized approach to treatment. Note: To access this free article, make sure you first register if you do not have a paid subscription. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, address the inpatient side of bariatric surgery, and how obesity and body mass index play a role in coding. In this article, Nehring covers ICD-10-CM/PCS coding and clinical indicators for cardiogenic shock, intra-aortic balloon pumps, and more. William E. Haik, MD, FCCP, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Jonathan Besler, CPA, MA , and Mary Devine, RN , write that while it is well-known that ICD-10-CM/PCS code assignment impacts hospital reimbursement and compliance, there is an additional code that often flies under the radar for inpatient coders and has a huge impact on reimbursement: the discharge status code. Review these root operations that involve taking out all or some of a body part. CMS released the fiscal year (FY) 2022 IPPS proposed rule on April 27, with proposals for the annual ICD-10-CM/PCS code update, the creation of new MS-DRGs, and increases to hospital payment rates. A cesarean section is typically performed when complications from pregnancy make a traditional vaginal birth difficult. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews ICD-10-PCS documentation and coding for mechanical ventilation. Inpatient coding for brain surgery can be challenging as many approaches, techniques, and devices may be used to treat cranial abnormalities. Note : To access this free article, make sure you first register here if you do not have a paid subscription. Coders need to know the definitions and the nuances of the root operations, especially those involving a device. In this article, Stephen Houlahan, RN, MSN, MBA, CCDS, reviews TAVR history, clinical background, and documentation and reimbursement methodologies to ensure proper education and compliance for facilities. James S. Kennedy, MD, CCS, CDIP, CCDS , reviews readmission rates and writes that if physicians learn the foundations of readmission measurement and implement some basic principles and workflows for reporting clinically accurate ICD-10-CM/PCS coding, hospitals can succeed with readmission measures. The ICD-10-PCS Official Guidelines for Coding and Reporting were updated for 2020 to include guidelines for coding brachytherapy performed in the inpatient setting.
