In Coding
Jul 18th, 2014
Question: When does a “history of cancer” diagnosis begin? For example, if a patient has been diagnosed with cancer, does a “history of” diagnosis start immediately, or after a predetermined time? Answer: According to ICD-9-CM guidelines, “history of” means the condition no longer exists and no active treatment is being received (although the condition can ...
Jul 15th, 2014
Highlights from Rhonda Buckholtz’ testimony, CMS announcements, an open letter from AAPC to Secretary Burwell, and an invitation for an AAPC-CMS joint webinar. On June 10, 2014, representatives across multiple industries participated in a National Committee on Vital and Health Statistics (NCVHS) hearing. Spokespeople from AAPC and the Centers for Medicare & Medicaid Services (CMS) offered ...
In Audit
Jul 1st, 2014
Question: If the provider documentation states that a patient is taking a certain medication, may we report the diagnosis that the medication is meant to treat? Answer: Never infer a diagnosis from medications prescribed, test results, or any other data, no matter how informed or educated your opinion. If the provider doesn’t explicitly document the ...
In Audit
Jul 1st, 2014
Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI) program. A query is a communication and education tool that prompts physicians to provide detail about under-reported conditions found in the medical record. Queries may address several documentation areas...
Jun 19th, 2014
Measles is making a comeback. The Centers for Disease Control and Prevention (CDC) recently reported 477 confirmed cases of the measles (rubeola) in the first six months of 2014. A graph created by the CDC shows the rapid increase in cases and outbreaks this year compared to past years. Measles was deemed “eliminated” in the ...