Newsletter

PROGRESS NOTES: Copy and Paste with Caution

By Richard Schamp, MD
Chief Executive Officer

Our service to clients involves reading encounter notes for coding, auditing and training purposes. We read A LOT of notes. Sometimes we see portions of notes that are strikingly similar to previous documentation. Copy/pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy/paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s…

14 Dec

Documentation Dispatch: Coding Lymphoma

in Articles Knowledge Center Newsletter | tagged: coding lymphoma coding

By Susan Trapuzzano, RN, CPC, CRC

Lymphoma is a type of blood cancer originating from the lymphatic system. Lymphomas are classified into two main categories, Hodgkin’s and non-Hodgkin’s lymphoma.

Hodgkin’s lymphoma affects the lymph nodes or extranodal lymphoid tissues, such as stomach, spleen, lung, bone and skin. Most often, this disease originates in a lymph node and spreads to adjacent nodes or to extranodal tissue via the lymphatic system. The most common symptoms are often painless, enlarged lymph nodes (neck, armpits…

10 Oct

Documentation Dispatch: The World of ICD-10 Coding for Asthma

in Articles Newsletter | tagged: coding asthma ICD-10 ICD-10 Asthma

By Debra L. Byble, CPC, CRC

When ICD-10-CM was implemented, it was no longer necessary to code for the difference between extrinsic or intrinsic asthma. Found in section J45 of ICD-10-CM, asthma now requires documentation of mild, medium, and severe asthma. Further documentation is needed to assign the correct code between the differences of intermittent, and persistent. The greater specificity of ICD-10-CM requires another level of detail: uncomplicated, (acute) exacerbation, and status asthmaticus.

Below are some samples of how the codes…

10 Oct

Progress Notes

in Articles Newsletter | tagged: 1/3 audit data integrity

By Richard Schamp, MD
CEO, Capstone Performance Systems

Capstone is pleased to continue its growth and to support to PACE and other organizations providing care to vulnerable citizens. To better serve our clients, we have recently welcomed several new staff members to the Capstone team with a wealth of experience directly relevant to the needs of our clients. See the article below for more details about our new colleagues. Additionally, be on the lookout for announcements in the coming months as…

13 Jul

CODING NOTES: Tips for coding Degenerative Disc Disease (DDD) in ICD-10

in Articles Newsletter | tagged: coding Degenerative Disc Disease

By Debbie Ploschnitznig, CRN-C

Degenerative disc disease (DDD) describes the symptoms of pain and possibly radiating weakness or numbness stemming from a degenerated disc in the spine. Simply put, degenerative disc disease occurs when an intervertebral disc loses its integrity, eventually causing pain. The condition is most often caused by age-related deterioration of the spine. (more…)

13 Jul

PROGRESS NOTES: CMS Final Reconciliation Delayed

in Articles Newsletter Uncategorized | tagged: CMS reconciliation delay value-based payment

By Richard Schamp, MD, CEO

PACE organizations are accustomed to receiving final reconciliation of the prior year’s Part C and Part D payments in July. This reconciliation is reflected in the Monthly Membership Report (MMR) and typically includes a positive true-up payment, especially if retrospective reviews were done in timely fashion. However, this year the PY2016 reconciliation is delayed until October, as CMS communicated during their April CMS Risk Adjustment EDS & RAPS User Group presentation. The delay is due to…

11 May

RAPS Data Integrity Audit

in Articles Newsletter | tagged: Capstone RAPS audit RAPS audit RAPS data integrity

By Richard Schamp, MD

Chief Executive Officer, Capstone Performance Systems

We have been describing multiple aspects of risk adjustment compliance in our newsletters, along with helpful tips on documentation and coding. CMS requires PACE, Medicare Advantage and similar organizations to submit all relevant diagnosis codes at least once yearly. A “relevant” code is one that impacts Part C or Part D payment. Failure to submit all relevant codes is an important compliance issue. To help our clients with the dual challenges…

10 May

Documenting and Coding Nephropathy and Chronic Kidney Disease

in Articles Clinical Documentation Excellence Newsletter Uncategorized | tagged: coding chronic kidney disease coding CKD coding nephropathy documenting CKD

By Richard Schamp, MD
CEO, Capstone Performance Systems

Definitions
Nephropathy refers to any disease of the kidney. In common clinical parlance, the term is modified by an etiology referring to one of over a dozen types, such as analgesic nephropathy, gouty nephropathy or most commonly, diabetic nephropathy. Chronic Kidney Disease (CKD) is defined by GFR (Glomerular Filtration Rate) less than 60 ml/min per 1.73 m2 and/or kidney damage for three or more months. The presence of albuminuria is most commonly used to…

10 May

Documenting Functional Quadriplegia

in Articles Newsletter Uncategorized | tagged: coding functional quadriplegia documenting functional quadriplegia functional quadriplegia HCC

By George W. Brett, MD

Chief Medical Officer, Capstone Performance Systems

It is unlikely that a clinician would overlook properly documenting a patient with neurologic quadriplegia resulting from a cervical spine injury. However, somewhat less obvious might be functional quadriplegia that results from a patient’s severe weakness. This condition is the inability to move due to disability or frailty caused by another medical condition but not from direct physical injury or damage to the brain or spinal cord (ACP Hospitalist Coding…

10 May

How Past Conditions Affect Current Documentation and Coding

in Articles Clinical Documentation Excellence Newsletter | tagged: Capstone Performance Systems coding history of documenting history of documenting past conditions

By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C

We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice. Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present. However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer…

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