AMA Bookstore News, July 12, 2012
Best Practices for ICD-10-CM Documentation and Compliance, 2012
Preparing for implementation of the new ICD-10-CM code set requires more detailed documentation. Understanding these requirements is vital to a successful transition. The AMA makes it easier with this new, helpful resource that identifies the necessary requirements and provides the tools for an effective documentation analysis and corrective action plan.
- Identification of diagnoses/conditions requiring additional documentation—a comprehensive review of the ICD-9-CM chapters with the corresponding ICD-10-CM chapters requiring additional documentation, along with a discussion of the relevant coding guidelines and coding notes
- ICD-9-CM to ICD-10-CM comparison of code categories and Subcategories—identify specific documentation elements such as the more specific site or body part descriptions 2012
- Comparison table—shows the ICD-9-CM codes and the applicable ICD-10-CM codes for the same condition
- General and specialty-specific checklists—help identify documentation deficiencies and the documentation elements for categories, subcategories and/or codes needed for the ICD-10-CM code set
- End of chapter quizzes—tests your knowledge of the information contained in each chapter
Advanced Anatomy and Physiology for ICD-10-CM/PCS: An essential resource for diagnostic and procedural coding
Developed with the medical coder in mind, this new title introduces the ICD-10-CM and PCS systems, identifies their differences and provides an advanced understanding of anatomy, body systems and disease processes. The ICD-10 code set will require more accuracy and understanding of human anatomy and physiology to code appropriately, Advanced Anatomy helps you prepare.
- Detailed, full-page anatomy illustrations—help better interpret clinical notes allowing you to code with more specificity
- Chapter quizzes—test your knowledge and understanding of the content of each chapter
- Extensive Table of Contents—detailed listing of every chapter, section, table and illustration allows you to locate important information quickly
- Earn up to 10 CEUs—earn 6 CEUs from AHIMA and 4 CEUs from AAPC
ICD-10-CM 2013: The Complete Official Draft Code Set
Prepare for the future of diagnostic coding with the latest and most comprehensive version of the official government draft of the ICD-10-CM code set. This codebook presents the complete code set—a total of 21 chapters—within a tabular list of diseases and injuries.
- ICD-10-CM conventions and official guidelines—educate you on appropriate and consistent coding
- Color coding—alerts you to fourth, fifth, sixth, and seventh character requirements as well as to instructional notes and deactivated codes
- Indexes to diseases and injuries and to external causes—make navigation of the code set quicker
- Table of drugs and chemicals—provides an easy-to-read list of substances and the codes they relate to when it comes to poisoning, adverse effects, and underdosing
- Neoplasm table—aids in the accurate coding of neoplasms by anatomical site and nature or the neoplasm
The product showcase featured in AMA Bookstore News changes with each edition. This offer is only valid until August 6, 2012.
Proper assignment of a diagnosis code from the highly specific ICD-10-CM code set requires a more detailed approach to documentation. Best Practices for ICD-10-CM Documentation and Compliance helps coders, physicians and other health care providers develop the ability to document a patient's case with precision and accuracy.
Transitioning to ICD-10-CM requires not only a strong grasp of diagnosis coding, but also strong documentation skills. Best Practices follows the ICD-9-CM codebook, with chapters that correspond to those of the ICD-9-CM codebook. All chapters begin with a basic comparison of the two code sets and the organization of each as well as discussion of includes and excludes notes. A general overview of documentation requirements and official ICD-10-CM guidelines follows. Then the chapter delves in to the requirements for specific conditions, diseases, and disorders providing the following:
• A list of documentation and coding elements
• A mapping of ICD-9-CM codes to relevant ICD-10-CM codes
• A documentation and coding example coded for both ICD-9-CM and ICD-10-CM to help illustrate differences and similarities
Each chapter ends with a quiz allowing the reader to test retention and understanding of the guidelines, documentation requirements and code assignment. Answers to the quizzes include rationales to improve comprehension.
Order today and save 30%. Hurry! This offer expires August 6.
Purchasers of the CPT® 2013 Data File will now have access to two new sets of code descriptors: CPT® Consumer Descriptors and CPT® Clinician Descriptors. This is the first time that the AMA has made these descriptors available with the CPT Data File.
The consumer descriptors will translate each code descriptor from the official CPT code set into language that is easily understood by the average patient and/or his or her caregiver. The objective is to simplify the highly technical CPT code descriptors into something more patient focused and patient friendly. CPT Consumer Descriptors may prove useful in any situation where clear communication in nontechnical language is important.
Consumer descriptors also support the following two key objectives of the Meaningful Use Stage 2 proposed rule:
- To provide patients clinical summaries for each office visit
- To provide patients the ability to view, download, and transmit their health information to a third party, such as eligible professionals, eligible hospitals, or critical access hospitals.
Consumer descriptors have the potential to be used within electronic health record patient portals, discharge summaries, and explanation of benefits forms.
A sample of a translation of an official CPT code descriptor to a consumer descriptor follows:
Official CPT code descriptor
30130, Excision inferior turbinate, partial or complete, any method
CPT® Consumer Descriptor
30130, Removal of nasal air passage
The clinician descriptors will describe clearly and specifically the procedure or service performed by a physician or qualified health care provider at the point of care. The purpose of the clinician descriptors is to describe accurately clinical events rather than billable events. The clinician descriptors will also benefit those health care providers and workers who have little or no knowledge of coding by providing a better, more clinical understanding of the CPT code set.
Development of CPT® Clinician Descriptors often generates more than one clinician descriptor for each official CPT code descriptor.
A sample of a translation of an official CPT code descriptor to its clinician descriptors follows:
Official CPT code descriptor
30130, Excision inferior turbinate, partial or complete, any method
CPT® Clinician Descriptors
30130, Partial Excision of Inferior Turbinate
30130, Complete Excision of Inferior Turbinate
And like the consumer descriptors, clinician descriptors support the Meaningful Use Stage 2 proposed rule. In this instance that objective is to allow eligible professionals, eligible hospitals, or critical access hospitals who transition or refer a patient to another care setting or provider to create and transmit a summary care record.
Clinician descriptors have the potential to be used for defining a subset of medical procedures and services within an electronic health record, documenting medical procedures and services, conducting research, and reporting clinical and statistical data.
Pre-order your copy of the CPT® 2013 Data File and its new consumer and clinician code descriptors today. For pricing and to license this content for more than 25 users, send an email to Intellectual.Property.Services@ama-assn.org or call (312) 464-5022.
The final omnibus rule for HIPAA is anticipated to publish in late summer or early autumn 2012.
National coordinator for health information technology Farzad Mostashari made the announcement at last month’s Health Privacy Summit in Washington, D.C.
The final rule will extend liability under HIPAA to business associates and subscontractors.
Work on HIPAA Plain and Simple: Beyond the Final Rule third edition will begin upon publication of the final rule. The new edition will expand upon the topics of enforcement, the accounting of disclosures, and contracts with and disclosures to business associates while providing new content on migrating to operating rules and meaningful use. Pre-order now for delivery by July 2013.
Satisfy HIPAA workforce training requirements now with AMA HIPAA School. This online, three-course program covers patient health information security, HIPAA privacy compliance and HIPAA security compliance. Each course takes approximately two hours to complete. Test results are archived and CEUs can be earned.
Registration for CPT® Changes 2013 Workshops has been open since May! Seats are filling for this annual December event hosted in venues throughout the country.
Sign up today and save with early-bird pricing.
Question: What is the appropriate CPT code to report when a physician removes a bead (that he was able to visualize with his nasal speculum) from a child’s nose using forceps (without local or general anesthesia)?
Answer: Report code 30300, Removal foreign body, intranasal; office type procedure, for physician removal of a foreign body from the inside the nasal cavity in the office.
Want more coding Q&A? Subscribe to CPT® Assistant Newsletter today!
CodeManager® Online can instantly improve the accuracy of your coding process. Dan Reyes, the AMA’s Director of Online Business Development, is conducting a complimentary webinar on August 14th to demonstrate how the intuitive capabilities and wealth of coding data found in the Elite level can ensure you receive less claim denials and get paid faster. Register today.
Reyes has worked for the AMA for 20 years, is the former managing editor of CPT® Assistant and most recently played an integral role in the development of AMA Coding Online.
Follow along and learn as he walks you through the features of the Elite level, including date-of-service searching, LCDs, more than 20 years of historical data, direct links to other AMA Coding Online products and so much more! Attendees also have the opportunity to submit questions during a Q&A session at the end of the webinar.
Our recently released white paper covers understanding and readiness as they apply to ICD-10. Free to all and written by the Clinical Informatics Department of the AMA, this white paper can be downloaded now.
The paper—titled "What You Need to Know for the Upcoming Transition to ICD-10"—discusses the significant improvement of ICD-10 over ICD-9 as well as the structural differences between the two code sets that make implementation complex. Additional points of discussion include:
- Historical information
- Code set differences
- Helpful comparisons
- Reasons for the conversion
- Compliance date information
- Transition preparation steps
- Crosswalking concerns
Already have your copy? Share the knowledge! Forward your copy of AMA Bookstore News to a colleague who you think would also benefit from the information. Then turn your attention toward a host of other ICD-10-themed products from AMA including books and workshops.
On August 23, the AMA presents a one-day workshop in Denver on ICD-10-CM coding. Interact with health care professionals, earn CEUs and receive a free copy of the best-selling Principles of ICD-10-CM Coding as coding expert Robin Linker walks you through the intricacies of ICD-10 implementation and coding.
The venue for this date is the Westin Denver Downtown Hotel, a four-diamond hotel located in the Tabor Center near the famous 16th Street Mall, Colorado's leading tourist destination. A limited number of seats are available so don't delay. Register today!
The workshop will also be held in Chicago on July 18 and September 19.
Attendees of ICD-10 workshops lead by Linker have said the following:
- “Robin provided helpful tips to help prepare while implementation is delayed.”
- “Ms. Linker was very knowledgeable, detailed and experienced.”
- “Robin is very informative. She teaches the material in a very easy way to understand.”
- “Robin was a very eloquent speaker! She was very helpful in the details of the upcoming changes and made it much less scary.”
Prepare now and learn how with the help of the AMA.
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