B is the correct answer. Answer C - The scenario identifies the sepsis was not present on admission therefore it is not assigned as primary diagnosis Answer D - R65.21 is for septic shock and this is not documented Answer A - sepsis due to unspecified staphlococcus is not identified as the systemic infection. View ICD-10-CM guidelines for instructions
B is the correct answer. When a patient has bilateral glaucoma and each eye is documented as having a different type of stage, assign the appropriate code for each eye rather than the code for bilateral glaucoma. Tabular index indicates to "code alo underlying condition" or the recurrent actue iridocyclitis.
A is the correct answer. Per guidelines if the patient is asymptomatic and has not been treated for any HIV illness, the correct code is Z21. The depression is the primary reason for the visit and would be the first listed diagnosis of F32.1.
A is the correct answer. When a definitive diagnosis is made by the provider the signs and symptoms are not reported. See ICD-10-CM guidelines
Per ICD-10CM guidelines do not code signs and symptoms. Edema is a symptom of both hypertension and CKD. ICD-10CM guidelines state there is a casual relationship assumed between CKD and hypertension unless the provider specifically states that the hypertension is not related to the CKD, giving this patient hypertensive chronic kidney disease instead of regular hypertension.
The provider performs an excision, not an incision, completely removing the cyst. The excision is intermediate because it involves subcutaneous extensions and the repair is included with the procedure.
ICD-10 PCS are used as procedure codes for inpatient visits. DRGs use similar ICD-10CM weights for facility reimbursement and ICD-10CM are used as diagnosis codes for all healthcare settings.
Pediatric vaccines with counseling are coded per component. Each first component of a vaccine (Measles and Diphtheria in this case) are coded as one unit of 90460. Each additional component to the vaccine (mumps, rubella, tetanus and acellular pertussis) receive another 90461 for an additional component code.
16025 covers whole face burns and includes debridement
Cystitis is an infection of the bladder. The provider must specifically state that the infection or condition is not affecting the pregnancy for an incidental code. The patient is experiencing blood in her urine, which gives us the hematuria portion of the diagnosis.
HIPAA Privacy Rule Section 164.510(b)(3) allows providers to discuss PHI with family members if they determine it is in the patient's best interest for coordination of treatment or payment, unless the patient has expressed wishes that their information is not shared with family.
The Inpatient Prospective Payment System drives value-based care by paying inpatient stays based on DRGs (Diagnosis-Related Group(s)) which are groups of diagnoses with similar weights in order to determine "how much" a patient's stay ought to cost. These drivers force hospitals to work to be most efficient in their use of resources to come in under what they will be paid in order to avoid losing money.
RVUs multiplied by conversion factor gives you the amount payable for a provider's fee schedule.
The HAC-POA (Hospital acquired condition, present on admission) program was created by the Deficit Reduction Act of 2005--any of these conditions which are not present on admission and could have reasonably been prevented by following accepted standards of care will not be reimbursed. Usually, adding the DRG weight would have increased the facility's reimbursement, but this forces hospitals to avoid hospital acquired conditions, rather than profit from them.
The Balanced Budget Act mandated that SNF-PPS be paid per diem for all costs, which is based on a case-mix of diagnoses.
Payment status indicator C indicates that the HCPCS is only performed in an in-patient setting.
Rubber stamps were prohibited by CMS in 2015 for provider authentication
There are 18 unique identifiers protected by HIPAA. Only the first 3 digits of a patient's zip code is not PHI, as long as there are more than 20,000 people in the group that forms all zip codes. E.g. 123XX+123XY+123XZ have more than 20,000 people. Otherwise the zip code must be changed to 00000.
EHRs are defined by NAHIT as being able to communicate and exchange data with multiple systems. EMRs do not have this capacity.
Systemized Nomenclature of Medicine--Clinical Terminology (SNOMED CT) is the global standard for clinicians and is used to define terms in EHRs around the world.
CC, HPI, ROS, and PFSH are the components of patient history. ROS is performed to make sure the provider did not miss any relevant complaints and can be pulled from the HPI if needed.
CMS conditions of participation require that the patient's history and physical be completed and documented within the patient's record within 24 hours of admission, but not greater than 30 days prior to admission.
Physician queries must be non-leading, not based on reimbursement, for the purpose of improving patient care and open-ended, or Yes/No questions. Providers must not add documentation solely for the purpose of being reimbursed and it must be within a reasonable time frame
Procedures include a minor evaluation and management service. If the patient complains of an abscess and a I&D is performed, only the procedure should be reported. If the patient comes in complaining of hypertension and an abscess is discovered, then it would be acceptable to report an evaluation and management service.
According to ICD-10CM guidelines, urosepsis is a nonspecific term and has no tabular position. The provider must be queried for clarification.
