** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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.

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.

Feeling the Burn: Confessions of a Formerly Burned Out Coder

Publication: ICD10 Monitor

On any given day, if you walked into my home office, you might think you were in a spa. The walls are painted a soothing aqua color (at least, I think it’s soothing), a scent diffuser releases a pleasant tea tree oil scent (good for the voice on those days when I present webinars), and Asian meditation music plays softly on an endless loop. At second glance, you would see an enormous desk cluttered with two large computer monitors, code books, copies of articles I’ve printed with the intent to read, and a planner opened to the current week with color-coded notes regarding weekly
meetings, to-do lists, and deadlines. It might seem like a stark paradox, but I like to call it balance. And it’s taken years to achieve. | Read More.

Talking with Your Younger Self with Kristi Pollard

Publication: NEC Podcast

Kristi is a senior consultant for Haugen Consulting Group where she is responsible for the development of live and web-based coding training materials, presentation of live trainings and webinars, and conducting coding audits. Kristi has an extensive background in coding education and consulting and is a national speaker on topics related to medical coding and code-based reimbursement. | Read More.

Advice for Coding Medical Necessity on Outpatient Claims

Publication: RAC Monitor

There’s the textbook answer on how we should be coding, and then there’s the reality that not all payers adhere to the coding guidelines, and they don’t all use the fields available on the UB-04. So when the textbook answer doesn’t pay claims, what’s the proper course of action? | Read More.

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