Blog & Publications

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Your Ultimate Guide for CPT Coding Resources

Blog Post: Digging into HIM & Coding

When coding CPT, have you ever wondered where to look for official coding guidance, or whose rules you should be following? Back in 1992, when I first started coding, the 1995 and 1997 guidelines didn’t even exist! We didn’t have any rules back then, or at least none that I can remember.
Today, lots of entities have their own sets of rules, and each set is different. Then, to add another layer, different payers have their own opinions and rules which adds stickiness to the situation. Boy have times changed! | Read More.

Coding Adventures in Bleeding Disorders and Conditions

Blog Post: Digging into HIM & Coding

If you look in the index you will find that under “hemorrhage” there are entries for at least 16 of the 19 chapters in ICD-10-CM! It is a miracle of anatomy that we have this complex, personal ocean of cells, nutrients, and substances coursing through our bodies keeping us alive minute by minute but there are many causes for hemorrhage and many problems that occur when our blood ends up in places where it doesn’t belong! | Read More.

Can Midline Catheters Placed by Vascular Nurses Be Reported?

Blog Post: Digging into HIM & Coding

Midline catheters (MLCs) are similar to peripherally inserted central catheters (PICC lines) but they are shorter and the tip doesn’t reach the central venous system. Previous CPT coding advice was to code MLCs as PICC lines with a modifier for reduced services, but as of 2019, new instructional notes direct that MLCs are reported with the following CPT codes | Read More.

The 10-Year Coder Challenge: Growing Your Skills Beyond CCs and MCCs

Publication: ICD10 Monitor

At the beginning of the year, Facebook’s 10-year challenge hit the web with users posting comparison profile pictures from 2009 alongside their 2019 selfies. I’ve seen a recent resurgence of the 10-year challenge over the last week and will admit that even I took part by posting a drawn image of a 2009 stick figure alongside a plumper 2019 version holding tacos. That got me thinking about the coding industry, what’s happened in the last 10 years, and where we’re headed in the next decade. | Read More.

Regenerative Peripheral Nerve Interface (RPNI)

Blog Post: Digging into HIM & Coding

What is this new procedure, where a free muscle graft is wrapped around a cut nerve ending, like a piece of sashimi around the end of a piece of spaghetti? The muscle graft doesn’t “do” anything active to the nerve, it just acts as a target for reinnervation by the nerve, so things stay organized and neuroma is less likely to form. This creates a challenge in choosing a PCS root operation. So if you’re hungry for the PCS coding implications, read on! | Read More.

Unique HIM Solutions at Wray Community District Hospital

Blog Post: Digging into HIM & Coding

Wray Community District Hospital recently engaged Haugen Consulting Group (HCG) to conduct an assessment of the Health Information Management (HIM) department. The assessment identified several opportunities within the department. The bigger challenge was implementing changes without leadership in the department. | Read More.

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.

Stepping Back to Lead

Blog Post: Digging into HIM & Coding

Colleen Houck is a New York Time’s bestselling author of the Tiger’s Curse series and her words of wisdom are: “You must learn to take a step back and visualize the whole piece. If you focus only on the thread given you, you lose sight of what it can become.” While young adult literature might be an odd place to look for HIM leadership, envisioning, and innovation, her message is clear – take a step back and visualize. | 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.

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