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Charts
ICD-9
ICD-10
Abstracting
Abbreviations
100
AER/AOS/AOM/ACC/ACC
What are the outpatient STAR patient types (charts) that we code?
100
14,000
What is the number of diagnoses codes in ICD-9? ICD-10 has 71,000 Dx codes.. much greater specificity!
100
72,000
What is the number of procedure codes in ICD-10? ICD-9 has 4,000 procedure codes....... To succeed in ICD-10 coders really need to know ANATOMY! There is tremendous specificity in I-10 coding.
100
Abstract GUI
What is Star function the coders utilize to enter in all their codes? This is how we get the data to PFS and what helps to "get the bills out the door." All coders abstract not only the diagnoses and procedure codes, but also verify many critical fields like attending, admit/discharge dates, d/c disposition, transfer facilities, surgeons and dates of px.
100
CHF
What is Congestive Heart Failure? The CDS and Coding Teams work diligently to get answers from physician (queries) regarding the type of CHF the patient has: systolic? diastolic? acute? chronic? acute on chronic? There are different codes for each one and the greater the specificity we acquire, the better the code, the severity score, and the reimbursement
200
The chartmaxx field would state "Emergency"
What is the Visit Type in chartmaxx for AER and AOS
200
ICD-9 Procedure codes and CPT-4 procedure codes
What are the types of procedure codes that outpatient coders must put on all of their cases? All outpatient coders, with the help of the 3M encoder, must submit not only ICD-9 codes but also CPT-4 codes on all outpatient cases. CPT is also for physicians's offices and NEVER for inpatient coding.
200
This event is one we all thought we would have been retired for, before it was mandated in the United States.
What is to go live date of ICD-10 coding?
200
Home, Home with Hospice, Transfer to psych, Expired, Expired with autopsy, Jail
What are some discharge dispositions?
200
COPD
What is Chronic Obstructive Pulmonary Disease? COPD = chronic bronchitis and asthma
300
AAM/AAB/AAP/AAR/AAS
What are the inpatient STAR patient types (charts) that we code?
300
577.0
What is the code for acute pancreatitis?
300
K859
What is the ICD-10 code for acute pancreatitis. There are 7 translation options from the one ICD 9 code of 577.0 to the ICD-10 codes.....that is how detail specific ICD-10 will be.
300
MIDS
What is the state required data reporting tool? Medical Incident Data Set. All acute care inpatient and emergency visits must be reported through the MIDS system. Cat Falcao in PFS is responsible for transmitting the data which comes from everyting the coders abstract in Star. When errors are detected in the software, the coders get cases back to correct.
300
POA and HAC
What is Present on Admission and Hospital Acquired Conditions? Inpatient Coders must report the POA status for every diagnosis. Was the condition present at the time of the admit order or not? HACs represent a list of Dx the Feds have created reimbursement penalties IF they were NOT present on admission.. (they won't count as CCs/MCC's) implying the hospital gave the pt the condition... e.g. Stage 3, 4 Pressure Ulcers, catheter associated UTIs, objects left in during surgery, etc.
400
Alphabetical by date
What is the filing rule for inpatient charts on the uncoded or the coded shelves? While we are very much chartmaxx oriented, the ROI team may still need to pull paper charts so it is important we keep the files neat and alpha by date for easy retrieval; and leave outguides when we take something.
400
99.04
What is the ICD-9 procedure code for blood transfusion?
400
30243N1
What is ICD-10 procedure code for blood transfusion? There are 8 translation options for px code 99.04 when converting it to ICD-10
400
Abstractor Results Patient Information
What is the interface document from Star to CMaxx called?
400
SOI and ROM
What is Severity of Illness and Risk of Mortality? Each inpatient case is ranked (via UHC) with a SOI score- the goal is that through excellent documentation and proper and thorough coding we capture the truest reflection of how sick the pt was.... ROM involves the expected vs actual deaths that occur... when we show the highest severity of the patient's condition, the expectation of death is more justified. If we don't code thoroughly and the pt dies, that will look bad in our ROM score. Expected deaths vs actual deaths. Codes like V66.7 encounter for palliative care (end of life) help justify the expected outcome in some expirations.
500
These charts are not "coded" by Medical Records
What are ASE-series cases, AOP- outpatient referred, AOB- LEV labor evals or other o/p in a bed, ARH- rehab series. There are many registrations that get their "codes" from the admitting dx upon registration and do not require us to do any coding. ROI Teams still work with these charts, but coders do not.
500
00.66
What is the ICD-9 procedure code for PTCA? (percutaneous transluminal coronary angioplasty) For ICD-10 there are 8 tanslation options that include 4 body parts and 2 approaches... 02714ZZ = dilation of coronary artery, 2 sites, percutanous endoscopic approach
500
10/1/13
What is the Federally mandated, HIPAA required, go live date for ICD-10 in the USA? We are the last developed country to go on this.... ICD-9 is 30 years old..... UK 1995, France 1997, Australia 1998, Canada 2001 Those countries are preparing for ICD-11
500
3M Encoder
What is the grouper program that calculates the DRG?
500
CMI
What is Case Mix Index? The CMI represents the overall SOI of the entire inpatient population. This index is used to calculate reimbursement so the higher it is helps us capture more revenue.