Publications & Blog

Find the latest news from the Haugen Consulting Group. Check back frequently for updates.

CPT Coding: Saline Infusions For Diagnosis and Therapy

Blog Post: Digging into HIM & Coding

Pay close attention to the descriptor for 96365: “Intravenous infusion, for therapy, prophylaxis, or diagnosis.” A provocative test is one in which the patient is subjected to a substance, stimulus, or maneuver which then elicits a measurable response, which can take the form of a positive lab test, a positive physiological measurement, or occurrence of a symptom. Let’s look at some examples we might encounter while coding where a diagnostic or therapeutic saline infusion would be correctly assigned 96365 instead of the hydration code 96360. | Read More.

Take the Pain Out of Your Release of Information Process

Blog Post: Digging into HIM & Coding

What seems to be a straightforward process for HIM professionals may often cause headaches. For example, the release of information (ROI) process seems straightforward; a request for information arrives in the office and we fulfill the request. But perhaps a variety of information requests are accepted by the organization, the requests do not ask for specific documents, or conversely, requests may ask for the entire medical record. Two key release of information policy items will strengthen your ROI processes: a description of what constitutes a valid authorization to release information and a listing of hospital documents that are never released as part of a request. | Read More.

Total Shoulder Arthroplasty Coding Riddle:  Lesser Tuberosity Osteotomy

Blog Post: Digging into HIM & Coding

“Osteotomy”…sounds fancy!  Most of the time we code an osteotomy there is a distinct clinical indication and a deliberate surgical technique to fix it.  Examples include acetabular osteotomy for hip realignment, vertebral osteotomy for decompression and realignment, and mandibular osteotomy for bite correction.  These are big surgeries and often the main procedure being coded. But what about the “lesser tuberosity osteotomy” done in concert with a total shoulder arthroplasty (replacement).  What is it and how do we code it? | Read More.

Hydration Infusion Coding at Midnight – The “Orphaned” Service Interval

Blog Post: Digging into HIM & Coding

Let’s suppose IV hydration is initiated on a patient, running consecutively and started at 11:45pm on day 1 until 1:20 am on day 2.  That’s one hour and 35 minutes of total running time by the clock, so it’s worth one initial and one additional CPT hour.  | Read More.

Healthcare Data – Hold on to Your Assets!

Blog Post: Digging into HIM & Coding

Understanding the complexity of healthcare data is more important than ever due to the evolution of electronic health information and preparation for future evolution involving new technologies such as artificial intelligence. | Read More.

Song of a Story-Teller: Patient-Focused Coding

Publication: ICD10 Monitor

Coming off of two weeks of health information management (HIM) conferences and listening to presentations on incorrectly reporting combination codes and the importance of coded data for quality and data analytics, in addition to speaking on the topic of ICD-10-CM diagnosis coding in the outpatient setting, it appears to me that we’ve lost the art of telling the patient’s story. | Read More.

Strategies for implementing a CDI program

Publication: MGMA Connection

Clinical documentation is at the heart of every patient encounter, whether the encounter is inpatient or outpatient. Since their inception, clinical documentation improvement (CDI) programs have focused on inpatient encounters and hospital stays. Before implementing a CDI program, it is important for practices to understand the benefits, goals and guidelines set forth by the industry.| Read More.

Who Can Document What for E/M?

Publication: MGMA Connection

Documentation requirements for an evaluation and management (E/M) service are clearly outlined in the 19951 and 19972 Documentation Guidelines for Evaluation and Management, published by the Centers for Medicare & Medicaid Services (CMS). However, in many situations, E/M services are provided under the direction of a physician with ancillary staff, residents and students involved in the visit. This may lead to misunderstanding of who can document certain parts of the E/M service, including the three key components of history, exam and medical decision-making.| Read More.

Solving the Inpatient Conundrum of Coding for Acute Kidney Diseases

Publication: HCPro

As with many diagnoses in the inpatient setting, acute kidney disorders can be confusing for coders to report due to multiple abbreviations and varying clinical criteria. Although the ICD-10-CM codes for the genitourinary system may seem straightforward, they don’t always line up precisely with the provider’s documentation in the medical record. | Read More.

Navigating Telehealth Billing Requirements

Publication: MGMA Connection

Medicare Part B covers a limited range of tele-health services, and the Centers for Medicare & Medicaid Services (CMS) provides guidelines for reporting these services using specific terminology. Understanding these terms is critical for both providers and originating sites to ensure eligibility, service delivery and proper reimbursement. | Read More.

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