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Coding Sample Policies and Forms
ICD-10 Tip Sheets
Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director HIM, NCAL revenue cycle at Kaiser Foundation Health Plan Inc & Hospitals, in Oakland, CA, shares three ICD-10-CM/PCS coding tip sheets:
Infusion documentation examples
Paula Lewis-Patterson, BSN, MSN, NEA-BC, the clinical administrative director of the ambulatory treatment center at The University of Texas MD Anderson Cancer Center in Houston, provided these and other examples of good and poor documentation for infusions as part of HCPro's audio conference, 2012 Injections and Infusions: CPT Changes, Nursing Documentation Requirements, and Billing Process Review.
ICD-10 Competency Assessment for Coders: Anatomy and Physiology--Integumentary System
This sample of ICD-10 questions about the integumentary system is an excerpt from HCPro’s ICD-10 Competency Assessment for Coders, which is a resource included in the ICD-10 Training Toolkit, a comprehensive tool that provides the building blocks for your training programs for physicians as well as coding, HIM, documentation, and billing professionals in both inpatient and outpatient settings.
Click here for the answer key.
2012 CDI Pocket Guide
Authors Dr. Richard Pinson and Cynthia Tang provide detailed clinical and coding information regarding heart failure in this excerpt from the Association of Clinical Documentation Improvement Specialists’ 2012 CDI Pocket Guide, a 200+ page pocket manual to help CDI and coding professionals focus on the most common high-volume, high-yield opportunities to improve clinical documentation, coding, and DRG assignment.
ICD-10 Flashcards
This is a sample of flashcards (part of HCPro’s comprehensive ICD-10 Training Toolkit) related to ICD-10-PCS and obstetrics. The complete set of 124 ICD-10 flashcards can help strengthen your staff members' grasp of ICD-10-PCS as well as root operations.
Charging for Supplies
Many facilities struggle to determine which ancillary services they can appropriately bill separately for inpatients. Denise Williams, RN, CPC-H, Director of Revenue Integrity Services for Health Revenue Assurance Associates, Inc, in Plantation, FL, provided this sample policy that facilities can use to decide what services to separately bill for inpatients.
ICD-9-CM Updates: Readiness Assessment
In order to correctly assign the new ICD-9-CM codes that took effect October 1, it is important for coders to understand both the clinical background and coding guidelines associated with these annual changes. In this assessment, Lolita M. Jones, RHIA, CCS, references a compilation of key clinical and coding guidelines about the revisions, deletions, and additions to ICD-9-CM. The coding guidelines addressed in this assessment are based on the official changes to the tabular list of the ICD-9-CM diagnosis and procedure codes. The clinical guidelines addressed in this assessment are based on the September 2010 and March 2011 minutes of the ICD-9-CM Coordination and Maintenance Committee.
Device quick reference list
Special billing rules apply when a facility receives a device at no cost, a credit for the full cost of a device being replaced, or a credit equal to at least 50% of the cost of the replacement device. Christi Sarasin, CCS, CCDS, CPC-H, FCS, principal of Sarasin Consulting Group in Friendship, MD, created these lists of codes to flag for special review to determine whether a facility received a device at a reduced cost.
Outpatient rehabilitation checklists
Physician practices, therapy providers, and facilities are all seeing more outpatient therapy denials. Sharon Bolarakis, CPC, CPC-I, CPMA, provided these three checklists to help you determine if all of the documentation needed for coding and billing is present.
Audit Checklist: Observation Decision
Elin Baklid-Kunz, MBA, CPC, CCS, director of physician services for Halifax Health in Daytona Beach, FL, provided this checklist to help when auditing for the decision to place a patient in observation.
Query Process Flow Chart
This sample flow chart illustrates the physician query process from initial query submission through to resolution. Lynne Spryszak, RN, CCDS, CPC-A, CDI education director at HCPro, Inc., in Danvers, MA, included this chart in her 2010 audio conference presentation "Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification."
ICD-10 fracture extension codes
Lolita M. Jones, RHIA, CCS, principal of Lolita M. Jones Consulting Services in Fort Washington, MD, provided this handy reference to help coders select the appropriate seventh character for ICD-10 fracture codes.
Injections and infusions coding examples
These injections and infusions coding examples were created by Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C. for HCPro’s January 19, 2011 audio conference, “Injections and Infusions: Solutions for Common Coding and Billing Questions.”
ICD-10-PCS flashcards
ICD-10 implementation will be costly for hospitals. But teaching coders the root operations for ICD-10-PCS coding doesn’t have to be. Simply cut on the dotted lines of this handy set of flashcards, which were featured in a recent issue of Medical Records Briefing. On one side, you’ll see the various root operations; the other side lists their corresponding definitions and provides examples and other relevant information coders should know about the terms.
Sample query for unspecified chest pain
Susan A. Klein, BSN, RN, C-CDI, director of clinical documentation management at Saint Peter's University Hospital in Monroe Township, NJ, provided this sample query to HCPro’s Association of Clinical Documentation Improvement Specialists (ACDIS). Note that best practice regarding query templates is to include your own facility medical staff in their creation and to vet them with your facility coding, compliance, and legal team. In general, it is best practice to have the CDI task force work across various departments to develop queries. The ones provided on the ACDIS website are donated by members to serve as templates.
Endovascular revascularization coding tool
CPT® codes 37220–37235 are to be used to describe endovascular procedures performed percutaneously and/or through open surgery exposure for occlusive disease. Lolita M. Jones, RHIA, CCS, principal of Lolita M. Jones Consulting Services in Fort Washington, MD, and an AHIMA-Approved ICD-10-CM/PCS Trainer, created this tool to help coders determine the correct code forendovascular revascularization.
Severity of illness for various conditions: Clinical definitions
This tool from the Physician Documentation Improvement Pocket Guide, which you can share with your physicians, contains clinical definitions for the severity of illness of multiple commonly missed documentation improvement opportunities.
Error point system for auditing evaluation and management codes
When performing chart audits, especially those involving CPT® and evaluation and management codes, there are a number of ways in which you can determine error rates. One method is using a point system, which places a weighted point for each type of finding. Joe L. Rivet, coding compliance specialist at Hall, Render, Killian, Heath & Lyman in Troy, MI, shares this sample error point system for determining coding error rates. Typically the higher the weight, the more significant the error. The facility would need to determine what is an acceptable point level for passing and audit.
Sample physician query tracking spreadsheet
Rose T. Dunn, MBA, RHIA, CPA, FACHE, shares a physician query tracking spreadsheet in The Coding Manager’s Handbook to help you track the query process by having users capture important data, including the reason for the query, the physician queried, the coder or clinical documentation specialist who initiated the query, as well as the DRG or APC before and after clarification from the physician.
Tip sheet for pediatrician documentation
Pamela P. Bensen, MD, MS, FACEP, shares this checklist that you can use to communicate documentation requirements to pediatricians.
Appeal letter for denials due to unbundling
Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, an independent coding consultant in Melba, ID, shares this sample appeal letter for denials due to charges the payer states should have been bundled instead of charged separately.
CPT Coding resource: Lesion Excision
Lolita M. Jones, RHIA, CCS, owner of Lolita M. Jones Consulting Services in Fort Washington, MD, developed this chart to assist coders in choosing the correct excision code.
Inpatient Physician Query Process
This Inpatient Physician Query Process form outlines a sample policy for querying physicians to clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure. Learn more about HCPro’s Physician Queries Handbook by Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, James S. Kennedy, MD, CCS, Marion Kruse, MBA, RN, and Lynne Spryszak, RN, CPC-A, CCDS, at the Healthcare Marketplace.
Evaluation and Management Audit Tool
Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, an independent coding consultant in Melba, ID, shares this tool for auditing E/M codes and assigning the appropriate level code.
History of Present Illness Reference Tool
Use this sample reference tool to determine the chronological development of a patient's current illness from the beginning or from the previous encounter to the present. Michelle Solomon, BA, LPN, CPC, revenue team manager of primary care at Henry Ford Health System in Detroit provided this sample tool.
Injections and infusions handout
Ensuring accurate capture of injection and infusion administration and drug codes is an important part of ensuring your facility receives the reimbursement it deserves. Sharon Clayton, RN, MS, MBA, CPC, president of Key Healthcare Consulting, LLC, provided this sample injection and infusion handout to help with coding accuracy.
Sample query form for chest pain
Use this sample query form for chest pain when you need more specific documentation from physicians. James S. Kennedy, MD, CCS, director at FTI Healthcare in Atlanta provided this sample form.
Sample query form for heart failure
Use this sample query form for heart failure when you need more specific documentation from physicians. James S. Kennedy, MD, CCS, director at FTI Healthcare in Atlanta provided this sample form.
Sample query form for malnutrition
Use this sample query form for malnutrition when you need more specific documentation from physicians. Faye Anderson, RHIA, division director for HIM at Southeast Alabama Medical Center in Dothan, AL, provided this sample form.
Sample Template for Initial Preventive Physical Examination
Lori-Lynne Webb, CPC, CCS-P, CCP, an independent coding consultant in Melba, ID, shares this sample template for an initial preventive physical examination (IPPE). This can be a handy tool to ensure that physicians don’t overlook IPPE requirements.
Sample postoperative pain injection form
This form, which is an excerpt from HCPro’s book, Orthopedic Coding Guide for Ambulatory Surgery Centers, Second Edition by Lolita M. Jones, RHIA, CCS, is a sample postoperative pain injection form that one surgery center developed to ensure comprehensive postoperative pain control documentation. For more information, please visit HCMarketplace.com
Care Plan at risk for Pressure Ulcers
Care Plan at risk for Pressure Ulcers
Medicare Part B 2008 HCPCS and modifier annual update chart
Medicare Part B 2008 HCPCS and modifier annual update chart by
Lori-Lynne Webb, CPC, CCS-P, CCP, independent coding consultant located in Melba, ID.
Sample policy on standardizing E/M audits
Sample policy on standardizing E/M audits
Audit results
Audit results
Clinical Documentation Request
The form is used to measure a patient's degree of malnutrition.
Blue card: Bacteremia sepsis
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Blue chart designed to help clinical documentation of Bacteremia sepsis. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/
POA query form
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Present on Admission (POA) query form designed to help clinical documentation improvement specialists identify whether an associated condition was present at the time of the order for an inpatient admission. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/
Heart failure chart
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a heart failure chart designed to help clinical documentation improvement specialists identify signs and symptoms of heart failure in the medical record. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at www.cdiassociation.com
Fifth digit classification table
A fifth lymphatic and hematopoietic tissue category code digit denotes a specific location where the lymphoma occurs. For example, lymphoma can occur in any one of the following locations on the body:
Sample coding career ladder
When managers propose coder compensation levels to an organization's human resource department, they typically take into account both credentials and experience. For this reason, most HIM departments implement a coding career ladder that outlines objective and measurable criteria for advancement. The criteria must also define proficiency and can be tied to production expectations developed for the department. The following is one example of a coding career ladder. Consider implementing a similar system in your hospital if you don't already have one in place.
Acute respiratory failure documentation prompter
Use this acute respiratory failure documentation prompter to help prompt physicians to document language that will affect severity-adjusted DRGs.
Cardiovascular prompt card
Use this card to help prompt physician documentation for various cardiovascular conditions.
Cardiac CCs
Use this prompter to help capture cardiac CCs.
Discharge summary/discharge order form
Use this nifty form to track discharges, final diagnoses, and more.
Source: North Kansas City (MO) Hospital. Reprinted with permission.
Record review for H&Ps
Use this chart to ensure that critical elements appear on your history and physical forms.
Source: Adapted from: Ongoing Records Review, Third Edition: A Guide to JCAHO Compliance and Best Practices, Coyright 2003, HCPro, Inc.
Nephrology Attending Evaluation
Use this nephrology attending evaluation to track patients' condition.
Source: Oregon Health & Science University, Portland. Reprinted with permission.
Signature identification form
Use this form to help clarify physician signatures in the medical record.
Source: Medical College of Ohio Hospitals. Reprinted with permission.
Query tracking sheet
Use this form to track queries as well as post-query payments.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html
Respiratory failure clarification tool
Use this tool to clarify respiratory failure and query physicians for documentation improvement.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-1047.html
Unapproved abbreviations review tool
Disseminate this list to your coding staff so that they may track physician usage of unapproved abbreviations.
Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Cardiology doc pocket tool
This pocket guide for cardiology physicians includes common cardiology DRGs, common cormorbidities, and common conditions of catheterization patients.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html
Denial appeal letter
Use this sample letter when appealing denials at your facility.
Source: Denial Management: Key Tools and Strategies for Prevention and Improvement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-3659.html
Documentation content/quality deficiency form
Use this form to track documentation and quality deficiencies.
Source: Adapted from: Seven Steps to HIM Compliance, copyright 1998 HCPro, Inc.
Facility E/M guidelines based on a point system
These facility E/M guidelines use a point system to determine each level of care.
Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission.
For More information visit: http://www.hcmarketplace.com/prod-1740.html
Facility E/M guidelines based on staff interventions
These facility E/M guidelines use staff intervention to determine each level of care.
Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission.
For More information visit: http://www.hcmarketplace.com/prod-1740.html
Facility E/M guidelines based on staff time
This set of facility E/M guidelines uses time as a determining factor for each level of care.
Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission.
For More information visit: http://www.hcmarketplace.com/prod-1740.html
General Progress Note Template
Use this template for a general progress note.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html
Observation services guidelines
These observation services guidelines define observation, explain average lengths of stay, outline what observation excludes, explain necessary documentation, and discuss medical neccesity.
Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission.
For More information visit: http://www.hcmarketplace.com/prod-1740.html
Metric template
Use this sample metric template for RVUs, uncollectable AVRs, and registration processes.
Source: Revenue Cycle Management: A Best Practices Toolkit, reprinted with permission
For more information visit: http://www.hcmarketplace.com/prod-4003.html
Pneumonia query form
Use this sample pneumonia query form to ensure accurate data reporting for your facility or practice.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html