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Look for them at a hospital near you. The ICD-10-PCS update for fiscal year 2023 is now available. To prevent coding errors that result in claim denials, inpatient coders should download the code files and familiarize themselves with the changes to inpatient coding that go into effect Oct. 1. The fiscal year (FY) 2023 ICD-10-PCS […]
The post New Procedure Codes Coming This Fall appeared first on AAPC Knowledge Center.
AAPC’s coding expert, Raemarie Jimenez, gives you the scoop on next year’s updates. Code update season is always an exciting time of year. With it brings new, revised, and deleted CPT® codes and coding guidelines that become effective Jan. 1. There are always a lot of changes to learn about: CPT® 2022 includes 249 new […]
The post Master 2022 CPT® Changes With This Expert Overview appeared first on AAPC Knowledge Center.
AAPC’s coding expert Raemarie Jimenez gives you the scoop on next year’s updates. Code update season is always an exciting time of year. With it brings new, revised, and deleted CPT® codes and coding guidelines that are effective Jan. 1, 2020. There are a lot of CPT changes to learn about: The CPT® 2020 code book […]
The post Master 2020 CPT Changes With This Expert Overview appeared first on AAPC Knowledge Center.
Tips from this month’s issue
Small breaches could become a big problem (p. 1)
1.Regional offices were advised to increase investigations of breaches affecting fewer than 500 individuals. Investigators will look for evidence of systemic noncompliance, such as multiple small breaches and common root causes.
2.Implementing OCR’s directive may be a tall order for resource-strapped regional offices, and it’s difficult to predict what the outcome will be.
3.Because small breaches weren’t investigated on the same scale as large breaches, OCR has much less data on them. Stepping up small breach investigations will mitigate that and may lead to improved guidance on key HIPAA pain points.
4.Although large breaches grab attention, they’re statistically less likely than small breaches.
5.But even a breach involving a single patient’s records can have serious consequences for the individual and even impact his or her safety if the medical record becomes compromised as a result.
6.Large health systems may lose sight of the details and brush off small breaches, but it’s the duty of privacy and security officers to take every breach, no matter how large or small, seriously and ensure the organization does so as well.
The cost of a data breach (p. 4)
7.Data breach costs vary between industries but healthcare, a highly regulated industry, sees especially high data breach costs.
8.Direct costs include remediation efforts and possible fines, but indirect costs are sometimes more difficult to identify and quantify.
9.Breach notification costs are the highest in the U.S.?first class postage adds up fast.
10.The more quickly a breach is identified and contained, the lower the cost. A well-prepared security incident response team is a smart investment that will pay off.
11.Participating in threat sharing may also be linked to lower data breach costs, but executive leaders may be concerned that sharing information on cybersecurity threats will put confidential information at risk. But no sensitive business information needs to be disclosed to participate.
12.Direct breach costs may be significant on their own but may not stack up against other risks an organization faces. Remember that one of the indirect costs of a data breach can be bad debt via medical identity theft. Bad debt is a top financial risk, and any measures that can bring that risk down are worth investing in.
Is HIPAA enough? (p. 8)
13.The rise of ransomware and other threats has led some stakeholders and lawmakers to question whether HIPAA is robust enough to provide even a reasonable bare minimum of security.
14.OCR has pointed fingers at executives for failing to support strong security programs, but the agency has no power to hold those executives accountable.
15.OCR recommends that CEs and BAs follow NIST’s cybersecurity framework, but that standard is only optional?not required?and many organizations may choose to not spend more resources on security than required.
16.Failure to complete an organizationwide risk analysis will land a CE or BA in hot water if a breach happens, but other federal agencies are critical of OCR’s risk analysis guidance, calling it inadequate.
17.HIPAA is designed to work with state laws. CEs and BAs must follow all applicable state privacy and security laws. In some cases, state laws may be stricter than HIPAA and provide stronger security requirements or clearer guidance.
Never miss another education opportunity that offers AAPC-approved continuing education units (CEUs)! Look in the Knowledge Center for weekly announcements of upcoming events. Here’s what is available this week: Setting Your Business Up for MIPS Success in 2019 DATE: Tuesday, June 18 – 10 AM PT | 1 PM ET CUE Credit: 1.0 Cost: FREE In […]
The post CEU Opportunities this Week appeared first on AAPC Knowledge Center.
Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube (BDET), published by the American Academy of Otolaryngology ̶ Head and Neck Surgery, June 4, is important because BDET is newer technology and may be rejected for payment by third-party payers as “experimental” or “investigational.” The American Academy of Otolaryngology’s (AAO) statement will be integral to […]
The post You’ll Need This to Get Balloon Dilation of the Eustachian Tube Paid appeared first on AAPC Knowledge Center.
Please let me know what you think. Thanks!
———————-
OBJECTIVE
BP (!) 172/90 | Pulse 68 | Temp 98.6 °F (37 °C) (Oral) | Resp 16 | Ht 5′ 9" (1.753 m) | Wt (!) 152 kg (335 lb) | SpO2 94% | BMI 49.47 kg/m²
Physical Exam
Physical Exam
Constitutional: She is oriented to person, place, and time. Non-toxic appearance. She does not have a sickly appearance. No distress.
In wheelchair
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
Pulmonary/Chest: Effort normal and breath sounds normal.
Musculoskeletal: She exhibits edema. She exhibits no tenderness.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Lesion noted. She is not diaphoretic.
Is this exam Detailed if following 1995 guidelines? I think it qualifies for a EPF on both the 1995 and 1997 guidelines.
Please let me know what you think. Thanks!
———————-
OBJECTIVE
BP (!) 172/90 | Pulse 68 | Temp 98.6 °F (37 °C) (Oral) | Resp 16 | Ht 5′ 9" (1.753 m) | Wt (!) 152 kg (335 lb) | SpO2 94% | BMI 49.47 kg/m²
Physical Exam
Physical Exam
Constitutional: She is oriented to person, place, and time. Non-toxic appearance. She does not have a sickly appearance. No distress.
In wheelchair
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
Pulmonary/Chest: Effort normal and breath sounds normal.
Musculoskeletal: She exhibits edema. She exhibits no tenderness.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Lesion noted. She is not diaphoretic.
Can anyone take a stab at this and let me know what you think?
Thanks,
Jo
——————————————————————————————-
Chief Complaint: new patient
HPI: 77 y.o. female who is here to estab care w/ new pcp
Health Maintenance:
AAA screen: NEVER
DEXA: NEVER
Mammogram: > 10 YRS
Colorectal ca screen: NEVER
FOBT: DOES EVERY YEAR- NEGATIVE
Depression screen: TODAY
Optho exam: A LITTLE OVER 1 YR
Hep B screen: UNK
Hep C screen: UNK
Flu vaccine: 10/18
Pneumococcal vaccine: NEVER
Zoster vaccine: NEVER
TDap: 2014
Review of Systems:
Constitutional: Negative for weight loss and fever/chills.
Eyes: Negative for visual blurring, double vision, eye pain, scotomata/blind spot, visual loss, red eye and itchy eye.
Ears/Nose/Mouth/Throat: Negative for hearing loss, tinnitus, dizziness, epistaxis, frequent upper respiratory tract infections, sinus trouble, sore throat, runny nose, bleeding gums, dental problem, sinus pain and hoarseness.
Respiratory: Negative for cough, productive sputum, hemoptysis, shortness of breath, wheezing and dyspnea on exertion.
Cardiovascular: Negative for palpitations, irregular heart beat, chest pain, nocturnal dyspnea, trouble lying flat, lower extremity edema and claudication.
Gastrointestinal: Negative for dysphagia, dyspepsia, odynophagia, hematemesis, abdominal pain, exccessive gas or bloating, bright red blood per rectum, constipation, diarrhea, jaundice, nausea, vomiting, abdominal cramps and loose or frequent bowel movements.
Musculoskeletal: Negative for painful gait, back pain, bone pain, muscle pain , muscular weakness, fatigue, nocturnal cramping, joint pain, joint swelling and varicose veins.
Skin: Negative for rash, pruritis, pain, abscess and mass.
Neurologic: Negative for headaches, syncope, paralysis, numbness or tingling of hands, numbness or tingling of feet, involuntary movements, tremor, muscular weakness and vertigo.
Psychiatric: Negative for depression, anxiety, sleep disturbance, difficulty with memory, nervousness, marital problems, abusive relationship, excessive alcohol consumption and illegal drug usage.
Endocrine: Negative for hot flashes, heat/cold tolerance , polyuria and polydipsia.
Hematologic/Lymphatic: Negative for anemia, bleeding problems, easy bruising, fever, night sweats, chills and swollen nodes.
Immunologic/Allergies: Negative for itching, hives and allergies.
History:
Past Medical/Surgical:
Past medical history: Patient has a past medical history of Hyperlipidemia and Hypertension.
Past surgical history: Patient has a past surgical history that includes Cholecystotomy.
Family:
Family history: Patient family history includes Breast Cancer in her daughter; Hypertension in her mother; Ovarian Cancer in her sister.
Social:
Social history: reports that she has never smoked. She has never used smokeless tobacco. She reports that she does not drink alcohol or use drugs. Her sexual activity history is not on file.
History
Drug Use No
History
Sexual Activity
Sexual activity: Not on file
Social History
Occupational History
Not on file.
Fish Oil-Omega-3 Fatty Acids 300-1,000 mg capsule
hydroCHLOROthiazide (HYDRODIURIL) 25 mg tablet
lovastatin (MEVACOR) 20 mg tablet
No current facility-administered medications for this visit.
Allergies:
Allergies: She has No Known Allergies.
Physical Exam:
BP 134/73 | Pulse 97 | Temp 97 °F (36.1 °C) (Tympanic) | Resp 14 | Ht 5′ 5" (1.651 m) | Wt 66.2 kg (146 lb) | SpO2 97% | BMI 24.30 kg/m²
Body mass index is 24.30 kg/(m^2).
Constitutional: no acute distress and well developed/well nourished
Eyes: extra-ocular muscle intact (EOMI) bilaterally, lids/conjunctiva normal bilaterally and anicteric bilaterally
Ears/Nose/Mouth/Throat: oropharynx pink and moist, tympanic membranes intact bilaterally and sinuses nontender
Cardiovascular: nondisplaced place of maximal impulse (PMI), normal s1, s2 , regular rhythm, no murmurs, no rubs and no gallops
Respiratory: clear to auscultation bilaterally, normal chest expansion & respiratory effort, no rales, no wheezing and no accessory muscle use
Back: no deformity and no costo-vertebral tenderness (CVAT)
Gastrointestinal: normal bowel sounds, no hepatosplenomegaly, non-tender and no masses
Musculoskeletal: normal gait, no clubbing, cyanosis and full range of motion of joints: all 4 extremities.
Extremity: no peripheral edema and no swelling/erythema/tenderness
Neuro: alert, awake & oriented times three (AA&O x 3), normal light touch sensation and normal strength
Vascular: No venous stasis changes or ulcers
Lymphatic: no cervical nodes, no axillary nodes , no inguinal nodes, no auricular nodes and no epitrochlear nodes
Psych: normal judgment and insight, normal mood/affect and non-anxious
Skin: no rash, warm and dry
Labs/Imaging:
Assessment/plan:
77 y.o. female here for check up and f/u on HTN and HLD
1. HTN-
– ct pres meds
– BP controlled
2. HLD-
– ct pres meds
– obtain recent blood work results
3. Health Care Maintenance
– check routine labs
– Age appropriate cancer screening: refer for mammo and colonoscopy, rec complete skin exam,
– Bone density screening- recommend Vitamin D 1000 units per day, refer for DEXA
– Optho- recommend annual optho exam
– Podiatry- recommend annual pod exam
– Diet- choose foods low in saturated fats and high in fiber. Fresh food is nutritionally better than most prepared foods. Consume multiple servings of fruits and vegetables every day.
– Exercise- walk briskly (powerwalk) 150 minutes per week (30 minutes a day, 5 days a week)
– Wear seatbelts- anytime you are in a moving vehicle, including the backseat.
– Use helmets- for skiing, snowboarding, in-line skating and biking.
– Safe sex- use condoms to reduce your risk of HIV and STIs, screening for STD’s
– Skin- ABCD’s of skin changes, SPF 15 or greater, avoid prolonged exposure to direct sunlight.
– Oral care: Brush and floss your teeth twice a day.
– Vaccines- Flu- UTD, Tdap- UTD
– PNA vax given, tolerated well, no side effects
Visit Diagnoses and Associated Orders
Hypertension, unspecified type – Primary
ICD-10-CM: I10
ICD-9-CM: 401.9
Postmenopausal
ICD-10-CM: Z78.0
ICD-9-CM: V49.81
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]
Visit for screening mammogram
ICD-10-CM: Z12.31
ICD-9-CM: V76.12
Screening for osteoporosis
ICD-10-CM: Z13.820
ICD-9-CM: V82.81
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]
Senile osteoporosis
ICD-10-CM: M81.0
ICD-9-CM: 733.01
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]
Need for prophylactic vaccination against Streptococcus pneumoniae (pneumococcus)
ICD-10-CM: Z23
ICD-9-CM: V03.82
PR PNEUMOCOCCAL VACCINE, 23 VALENT, ADULT [90732 CPT(R)]
pneumococcal 23-val vaccine (PNEUMOVAX) 25 mcg/0.5 mL solution [19753]
Hyperlipidemia, unspecified hyperlipidemia type
ICD-10-CM: E78.5
ICD-9-CM: 272.4
I have a really basic question.
Does this code: https://coder.aapc.com/cpt-codes/77262 require documentation to be submitted alongside the claim?
Same for this code: https://coder.aapc.com/cpt-codes/77299 (unlisted code) require documentation?
Thank you very much,
Best regards,
Ricky