Inpatient Facility Coding & Compliance Alert

Heads up: Coders will need to know even if the physician doesn’t use a device. If your coders tackle a case today with documentation of "right carotid endarterectomy," the ICD-9 diagnosis choices are simple. All that will change, however, under ICD-10-PCS. Best bet: Don’t scramble to educate physicians in 2014. Educate coders and start training providers to improve their documentation now.  Say Good-Bye to the Simplicity of ICD-9   Coders currently assign diagnosis 38.12 (Endarterectomy of other vessels of head and neck) for cases with notes such as "right carotid endarterectomy for a critical right internal carotid artery stenosis." When you map 38.12 to its ICD-10-PCS equivalents, however, you see that providers must give more specific documentation before the case can be coded. The necessary details fall into four areas: Type of procedure: You need to know whether the right carotid endarterectomy was a "dilation" or "extirpation." A "dilation" means [...]