AHIMA 2018 Roundup

“Inspiring Leadership, Influencing Change” rang out at every General Session and throughout all the Educational Tracks at the 90th Annual AHIMA Convention and Exhibit held September 22 – 26 in Miami, Florida.  Transforming HIM, revisiting processes and evaluating technological solutions were hot topics welcomed by convention participants.  Politics was also among the engaging sessions as Donna Brazile and Karl Rove entertained with Point/Counterpoint, highlighting Democratic and Republican views.  The drive toward optimization through best practices of CDI and Coding while encouraging physician inclusion in, “a day in the life of a coder” received a standing ovation.  Clinical validity with clinical insights from chart reviews, Risk Adjustment while improving quality measure through data abstraction proved to be of interest, leaving the participants wanting more.  Gaining efficiencies through the engagement of technology, with the consolidation of technical and professional coding practices shed light on the possibilities when thinking outside the box.  Exhibitors were better than ever, bringing their best ideas with shared steps toward implementation sure to inspire and influence positive change.  The giveaways were second to none; convention goers leaving the exhibit hall with bags loaded.  Accolades for all who presented, exhibited, planned and participated; can’t wait for Chicago 2019!!

global medical coding company

What Does ICD-11 Mean for Global Medical Coding Companies?

Global medical coding companies must keep up with industry technological and regulatory changes, and the recent announcement of ICD-11 is another change that we must adapt our processes to meet. But before we get into what the ICD-11 changes mean for medical coding companies, let’s remind ourselves of the purpose of ICD, and how essential it is to global medical coding. ICD, or the International Classification of Diseases, is a tool for reporting and grouping conditions and factors that influence health. The purpose of ICD is to allow for a standardized and systematic recording, analysis, interpretation, and comparison of medical data collected. Most useful to medical coders, ICD is used to translate diagnoses into alphanumeric codes which permit storage, retrieval, and analysis. Whenever the ICD is revised and updated, it means that global medical coding companies like ECLAT Health Solutions must take necessary measures to comply with its new structural changes.


According to World Health Organization’s (WHO) recent release, some major structural changes are set to be implemented under ICD-11. One of the key revisions is meant to simplify coding structure and electronic tooling, which is meant to allow health care professionals to more accurately record conditions. This means that for global medical coding companies, this new and simplified coding structure must be comprehensively understood by its professionals. Extensive training, research, and practice are all required for medical coding companies to ensure that coding quality and accuracy will not be lost amidst the ICD-11 transition. Also, the code structure itself is projected to be updated, so what many medical coders knew like the back of their hands will now need to be re-learned.

No need to panic

The preview of the ICD-11 transition, which is set to be released for adoption by member states of the WHO in May 2019, may seem like a daunting announcement to some. Medical coding companies and health care professionals as a whole have become so accustomed to ICD-10, that the thought of drastic system and structural changes involved in ICD-11 may cause stress and insecurity. However, NO NEED TO PANIC! ICD-11 is an exciting announcement, as it marks innovation and forward thinking in the world of disease classification. A lot has changed since ICD-10 was introduced, and the way we view certain diseases and disorders should evolve as well. Like with any new piece of technology or information, there is always a learning curve, however the light at the end of the tunnel is brighter than ever, the health information management world will continue to improve its practices to promote patient transparency and reduce unnecessary hospital costs.

ECLAT Health Solutions is Ready for ICD-11

ICD-11 goes into effect January 1, 2022. The World Health Organization offices are still working on a global implementation plan to do this, and our team will be standing by to respond and take action to update our medical coding processes as necessary when the plan and final release is announced. As a leading global medical coding company, ECLAT Health Solutions is looking forward to ICD-11 and the impressive impact it will have on health care and how we classify diseases, disorders, and other health issues. To learn about the ECLAT Advantage, and what sets our medical coding company apart from others, contact us today!

4 Places to Look for Missing Revenue

Hospitals and other providers miss out on millions of dollars of revenue each year due to inefficient RCM practices. Between administration, billing, and coding, there are a lot of moving parts that, when working together, foster a healthy revenue cycle. However, this also means that when best practices are not used, or mistakes are made in any of these areas, revenue can be lost and may not always be easily or immediately detected.

For hospitals and providers that don’t love their bottom line, there are a few places they can look to track down that missing revenue. As medical coding, billing, and auditing experts, we are skilled at helping our clients and partners understand why they are missing out on crucial revenue, and how to recover it. With accurate coding, efficient billing, and expert clinical documentation improvement (CDI), we offer a variety of services that improve our clients’ revenue. We work as an extension of our clients’ practices, which allows us to explore and assess RCM errors on a deeper level.

Here, we provide insight into where facilities should look for missing revenue:


1. Clinical Documentation

Providers who struggle to identify the root cause of missing revenue should assess their clinical documentation processes. Every piece of clinical documentation must be as accurate, descriptive, and comprehensive as possible to ensure proper reimbursement. When a provider fills out patient documents, they must describe the patient’s condition and requested treatment as accurately and thoroughly as possible. This description is used by coding staff to assign the proper ICD-10 code and process Medicare DRG or MS-DRG claims. Inaccurate documentation will lead to inaccurate code which, of course, leads to claim denials and delayed reimbursement.

ECLAT now offers clinical documentation improvement (CDI) services that ensure our clients do not miss out on revenue opportunities. We provide our clients with detailed, thorough feedback on their current documentation processes as well as concrete steps and solutions for improvement. We work closely with hospital CDI teams to generate the most accurate codes and DRGs, which translates to successful on-time reimbursement and increased revenue.


2. Patient Experience

When looking at their RCM practices and assessing how to improve, many facilities fail to factor patient experience into the equation. However, the experience a patient has at a facility, from signing in, to receiving their treatment, to paying their bill and everything in between can all affect incoming revenue. High-quality patient experience was proven to greatly improve hospital revenue in one study conducted by Accenture. Providing superior customer service to patients affects their perception of a facility and will play a role in whether they return or seek out other providers for their next treatment. Further, a facility that offers transparent billing options and practices through their billing staff’s interactions with patients is likely to increase on-time payments. We discuss this a little further in the next section.


3. Billing & Collections Processes

Many healthcare facilities can find causes of missed revenue in their billing department. One common billing error comes from failing to collect payments at point-of-service. Availity conducted a study and discovered that a surprising number of facilities do not enforce POS collections and therefore either receive delayed payments or no payments at all, negatively affecting the health of their revenue cycle. In addition, facilities that do not take the necessary steps to communicate openly with patients and ensuring they understand their medical bill are more likely to suffer delayed payments. In the day-to-day of a busy physician’s office, simply handing a patient a bill is easy and convenient, but a patient who does not thoroughly understand their charge and how to make payments likely will not make them. For facilities with lower revenue, a deep look into current billing practices may provide some answers.


4. Quality Assurance Processes

Quality assurance is crucial for ensuring facilities maintain a healthy revenue flow. Using quality assurance processes will help a facility identify and avoid common causes of RCM mistakes such as coding errors, patient coverage inaccuracies, administrative errors, and claim denials before they can contribute to diminished revenue. Even further, quality assurance will allow a provider to identify patterns of errors in their revenue cycle and learn to avoid them in the future. ECLAT performs a 3-tier quality assurance process for each client to ensure accuracy and excellence at every step of the way. We perform this process with a 24-hour turnaround time for each case to give our clients the tools they need to earn and maintain higher revenue. Providers suffering decreased revenue should closely review their current quality assurance processes and search for ways to improve and earn better revenue flow.


At ECLAT, our medical coding and billing experts provide our clients with accurate, efficient services that help them improve their bottom lines. Not only do we identify causes of our clients’ missed revenue opportunities, but we provide suggestions and resources for helping them improve. Our comprehensive medical coding, billing, and CDI services all work to ensure our clients earn the highest revenue possible. We have found that facilities that take a deeper look at their current quality assurance, coding, and patient experience processes earn more revenue and a healthier revenue cycle.

Why Your Facility Should Check Claims Daily

Claims denials are a big reason why many healthcare providers miss out on annual revenue, making it crucial that you closely monitor your claims process every day. Perhaps your facility does one large, overarching review of all claims submitted in a certain period, such as every week or even every month. This review of multiple claims at once can provide useful data and insight into how several claims affect your bottom line.

However, only checking individual claims as they are processed and conducting a daily review of all claims submitted in that day will ensure your facility gives the claims process the close, analytical attention it requires for earning a healthier revenue cycle. Establishing a daily claim-checking process will give your billing staff a better bird’s-eye view and understanding of your own claims submissions and reimbursement process.

Not only will a thorough daily review help catch claims denials, but it will help your facility notice patterns of why claims are being denied or reimbursements are often delayed. Although your facility may work on processing one claim at a time to ensure each individual claim is accurate, this can actually cause your employees to miss out on overarching trends within the claims process, and therefore repeat the same mistakes.


What Should Be Part of Your Claims-Checking Process?

Your facility’s daily checks should involve reviewing every step of the claims life cycle, including:


1. Checking Patient Insurance Eligibility:

Your claims-checking process should begin even before a claim is made! Your administrative and billing staff should check every patient’s insurance coverage prior to providing service. Many claims are denied due to discovering that a client doesn’t have the insurance necessary to cover the treatment provided. If your facility has not always checked patient eligibility before service—or at all—you must make this part of your daily practices. For more information about the importance of checking patient eligibility, check out our last blog.


2. Submitting Claims:

Before submitting a claim, of course, your staff should double check the claim’s information. This pre-emptive check will ensure your staff catches any mistakes and makes necessary edits. Does the patient in question’s insurance coverage line up with what is recorded in the claim? Does the given treatment have the proper ICD-10 code associated with it? Although it can be easy for double-checking to fall by the wayside in a busy medical office, taking the extra few minutes to review a claim prior to submission can mean all the difference between an easy, quick reimbursement and a costly denial.


3. Re-Submitting Claims:

When a claim is denied and must be resubmitted, your staff must first look into why the denial occurred before making edits. A claim re-submitted without investigating the cause for the denial may be incorrectly edited and therefore denied again. Without proper follow-up, your staff may misidentify the reason for the denial, or fail to realize there were multiple denial causes. Checking the cause of each denial as they occur will not only prevent the claim from being denied a second time, but also provide your staff valuable insight into common reasons for claim denials over time.


Improve Your Claims Process With ECLAT

With ECLAT Health Solutions, your billing goals become our billing goals. Our medical billing experts look closely at every step of your claims process to ensure that your practice sees less claim denials and more revenue. We work as an extension of your facility, and provide individual, customized attention that our clients call “The ECLAT Advantage”.

Partner with a company that will help your facility earn a healthier claims process. Contact ECLAT today to learn more about our medical billing services!

3 Medical Billing Best Practices for Receiving More On-Time Payments

Missing or late patient payments is one of the biggest problems facing medical practices today. The disconnect between providing a treatment and receiving payment may happen for a variety of reasons, either on the side of the healthcare provider or the patient themselves. Although healthcare providers can only do so much to ensure a patient ultimately pays his or her medical bill, making internal improvements to medical billing practices can help increase the rate of on-time payments. Here are 3 medical billing best practices your facility can use to boost patient payments:


Focus on Point-of-Service Collections

Requiring payment in-office directly after providing a patient with treatment seems like a straight-forward concept, but a recent study by Availity found that many providers collect only a small amount of patient fees at point-of-service. The study reported that physician practices collected only 35% of patient fees and hospitals collected only 19% of patient fees at or before service. These providers overwhelmingly agreed that it becomes increasingly difficult to collect payment later after treatment has been given.

There are a few reasons that point-of-service payments may not be collected. At many facilities, front office staff waits until after a patient is seen to collect co-pays or other required payments. In addition, busy office staff often get sidetracked and don’t see a patient walk out of the office without paying.

If your facility has a low rate of on-time payments, put priority on collecting payments at point-of-service. Train your administrative staff to require that all patients pay their copay as they sign in on the day of service. Have your staff follow up with any patients who do not or cannot pay in-office. Enforcing at least partial payment for the treatment immediately following service is another key method to increasing patient accountability and receiving more on-time payments.

Train your staff to be wary of and identify “dead beat” patients who will never end up paying their bill. Although clients may receive one or two collection letters, many patients are aware that pursuing legal action is too costly for the collection agency, and intend on ignoring all warnings. Your staff should closely follow up with these kinds of patients and offer a variety of solutions to try and encourage payment.


Communicate with Patients Proactively

With medical bills and the amount of out-of-pocket patient payments increasing over the years, paying medical bills can be an overwhelming and confusing process for many patients. For higher frequency of on-time payments, your administrative and billing staff should not simply hand patients a bill and send them on their way. Have your billing staff sit down with a patient and explain their charges, as well as review the available payment options. Many patients simply do not understand their bill or how best to pay, and opening direct communication can mean all the difference between an on-time payment and a drawn-out collections battle.


Keep Accurate Records

Some hospitals who suffer from high rates of late patient payments do not have good record-keeping practices in place. Your administrative staff should keep track of how much each patient pays and how often. Without up-to-date records, your administrative staff may not even know a patient is behind on payment or that a bill has been paid in full. If you’ve noticed multiple billing errors and/or past due payments, try giving your record-keeping an update.

Improve Your Medical Billing Processes With ECLAT

ECLAT Health Solutions, a health services support provider, can drastically help you increase your rate of on-time payments with our medical billing services. No Billing service meets with you face-to-face to walk you through your billing issues. ECLAT does.

Not only do our billing experts process your claims, but we work to identify and remedy any errors in your billing processes.

Our billers have at least 10 years of experience and are trained to comply with all HIPAA and HITECH, CMS guidelines, and In-Network, Out-of-Network regulations. We are EHR-friendly, meaning we are versatile to work on any EHR,and keep meticulous records of your payment records to ensure you can easily keep track of your various patients’ payments. With ECLAT, you will start to see increased revenue quickly, with a 15-day turnaround time.

Our Eligibility & Benefit Verification process helps your patients understand their bill and their payment options to increase patient accountability. We understand that one size does not fit all, which is why we offer customized billing options and services for our clients and their patients. We work as an extension of your practice, providing you with secure and accurate medical billing so you can focus on what you do best: provide quality healthcare.

To learn more about our medical billing services and best practices, contact us today!

revenue cycle management company

Why Collaboration Between Coding & Patient Financial Services is Essential for Healthy RCM

There are two key parts to any healthcare facility’s revenue cycle: patient financial services (including enrollment, appointment scheduling, collections, and more) and medical coding. For your employees who work in each department, these two may seem like entirely different worlds sometimes, but communication and collaboration between the two is crucial for effective revenue cycle management. Inaccurate coding can make your hospital lose out on thousands of dollars of revenue each year, so improving the collaboration between patient financial services and coding is the best way to maximize cash flow.

Below, we explain why maintaining a healthy revenue cycle depends on a smooth partnership between patient financial services and medical coding.


RCM begins and ends with Patient Financial Services

The revenue cycle begins and ends with patient financial services, from the moment a patient first picks up the phone to make an appointment all the way through when they’ve made their last payment; therefore, the accuracy of your patient financial services plays a big role in the health of your entire revenue cycle.

A common issue that plagues hospitals and other facilities is a high rate of claims denials, and one reason for so many claims denials is the failure of a facility to properly and accurately check a patient’s insurance eligibility before providing treatment. Medical coders rely on knowing what treatments will be provided in order to transfer these treatments into medical code and submit a claim. A hospital should make sure it properly checks a patient’s eligibility prior to offering treatment to ensure the right information gets to the medical coders.


Where Medical Coding Comes In

Medical coders receive a record of the treatments provided from patient financial services and then must, in compliance with the latest ICD-10 guidelines, accurately use the corresponding code to submit the claim. If your hospital’s medical coding staff makes clerical errors while coding, the claim is likely to be denied. If this claim is not re-submitted, the patient will likely need to pay for the treatment in full. Accurate medical billing relies on accurate medical coding.

Having the most accurate medical coding practices in place ensures efficient patient financial services, and vice versa. If your facility already exhibits accurate patient financial services, but you believe you are still missing out on revenue, you must refine your medical coding practices. Partnering with an expert healthcare support services provider is the best way to ensure you have truly accurate medical coding and a healthy revenue cycle.

ECLAT Health Solutions offers medical coding services that can complement your patient financial services and truly improve your RCM. Our coding experts are trained in ICD-10 procedures and always exhibit HIPAA compliance. We can guarantee a score of 95% or higher coding accuracy in our work. When we work with a client, their revenue goals become our revenue goals, and we work tirelessly to reach and exceed these goals. We are proud to offer this unique approach, which our satisfied customers call “The ECLAT Advantage.”

Make sure you have efficient and accurate medical coding to complement your patient financial services and earn you the most revenue possible. Learn more about ECLAT’s medical coding, medical billing, auditing, and consulting services by calling us at (703) 665-4499, or filling out our contact form!

Common Pitfalls You Can Avoid with Effective RCM

Healthcare policies and reforms always seem to be in motion, especially in today’s political climate, making it a challenge for health care providers to keep up. If they can’t adapt to the changing landscape, they miss out on significant revenue. Because the healthcare industry is always shifting and evolving, it’s crucial that your facility’s revenue cycle management evolves with it to maintain cash flow. Implementing effective RCM can also help your facility avoid a variety of common pitfalls. Listed below are some typical drawbacks we would like to highlight for your close attention.

Claim Denials

One of the largest issues plaguing health care providers’ revenue cycle processes is the increasing amount of claims denials. Human error during medical coding processes accounts for a large amount of claim denials. Often, undertrained staff members may select the wrong ICD-10 code while processing a claim, which leads to the claim being denied and means rework of the claim or the health care provider will not be reimbursed appropriately or at all for the patient’s treatment.

The recent increase in healthcare regulation has also led to more and more claims being denied. Insurance companies have been analyzing claims more closely, and organizations like Accountable Care Organizations (ACOs) have doubled down on efforts to reduce healthcare abuse or fraud. This closer inspection of claims, especially when paired with human error and improper ICD-10 coding, has led to a great increase in claim denials, which means health care providers, and their patients, must pay for more medical treatments out of pocket.

It’s important that your staff monitors your facility’s claims process and identifies where errors are occurring as part of your revenue cycle management process.

Delayed or Missed Payments

More and more financial responsibility has fallen to patients receiving treatment in recent years. If this is because inaccurate medical coding lead to a denied claim, the patient may need to pay a hefty sum for treatment that should have been covered. However, even when coding errors haven’t been made, many patients have trouble paying for their treatment, and will need to use credit or a payment plan.

Ideally, healthcare providers should collect patient payments before or immediately after treatment. This concept seems straightforward, but according to a study by Availity, some facilities have found it challenging to collect debts from patients without adding pressure and fear that may lead to dissatisfaction.

Health care providers should promote point-of-service payment collection as part of their RCM to avoid receiving delayed payments from patients. They should also educate patients to ensure they understand the necessary payment for their treatment and cut down on lost revenue.

Failing to Verify Patient Eligibility

Many healthcare providers don’t fully check a patient’s eligibility and insurance coverage prior to providing treatment. In fact, a study conducted by Capario reported that 25% of practices never verify patient eligibility at all. When a provider doesn’t check a patient’s eligibility, there’s a greater chance that the claim will be denied, and the patient is left with an intimidating medical bill. As mentioned, if the provider doesn’t enforce point-of-service payment collection, the patient is likely to take longer to pay, or may dodge paying completely.

Checking patient eligibility during the pre-registration state is a key part of effective revenue cycle management. It’s crucial to verify your patient’s eligibility at the beginning of the process before they make their appointment, not later when you’re trying to bill them for payment.

Repeating the Same Errors

For facilities that see a lot of business and have many administrative tasks to keep track of, it’s easy for the same mistakes to occur repeatedly when processing claims. Putting focus on and processing one claim at a time can keep your staff too close to an individual claim and miss over-arching patterns and errors that are affecting your claim approval rate. To fix this, it’s important that your facility monitors and reviews the entire claims process from beginning to end.

Revamping your revenue cycle management practices so that your facility performs this review will help your staff start to notice common patterns of errors in processing claims. Finding and stopping these errors can help reduce the number of claims that are denied, which in turn means more appropriate revenue for your facility.

Accurate Revenue Cycle Management is Essential

Accurate and effective revenue cycle management is an all-inclusive solution that can keep your facility ahead of the game in the ever-changing healthcare industry and earn your facility as much revenue as possible. To ensure your RCM can keep up with the changing times, you need to partner with an expert healthcare support service provider.

ECLAT Health Solutions can improve your RCM with Medical Coding, Medical Billing, Auditing and Consulting services. We are proud to provide medical coding and billing services to healthcare providers across the U.S.with our highly-trained team of medical coders, we can guarantee a score of 95% or higher coding accuracy in our work. We have a passion for helping your health care facility meet and exceed its revenue goals, even in our constantly evolving healthcare landscape.

Make sure your health care facility’s revenue cycle management can adapt and bring you as much revenue as possible. Learn more about our medical coding and billing services by calling us at (703) 665-4499, or filling out our contact form!

Post-Operative Respiratory Failure

Preparing the soil before I plant my vegetables and flowers will help ensure my family and I enjoy the delicious taste and beauty throughout the summer; payoff for my sore muscles.  The same is true for most things that are meaningful in our lives.  Taking time to prepare ensures the best outcomes.  Let’s take a look at respiratory failure, in particular, post-operative respiratory failure.

Understanding the definition for respiratory failure:

Acute respiratory failure may be life-threatening and correlates to abnormal blood gas measurements and develops within minutes or hours.

  •  Hypoxemic:  most common; can be correlated to most causative lung diseases and is indicative of a lower than normal arterial oxygen level (deprivation).
  • Hypercapnic:  high level of carbon dioxide (PaCO2) and is most often associated with drug overdoses, severe airway disorders (chronic obstructive pulmonary disease (COPD)), or neuromuscular diseases (myasthenia gravis, cystic fibrosis (CF)).

Chronic or long-term respiratory failure is often caused by various types of COPD, neuromuscular diseases, CF or even morbid obesity.  Chronic respiratory failure develops over a period of days or longer, worsens over time and triggers should be identified. Typically chronic respiratory failure correlates to superimposed infection.

Acute on chronic respiratory failure represents rapid deterioration of patients with chronic respiratory failure.  These are typically COPD patients or those with           neuromuscular disease or chest wall disorders.  These patients may require long-term mechanical ventilation.

Post-operative/post-procedural respiratory failure is defined by the need for ventilation     for more than 48 hours after surgery or reintubation with mechanical ventilation post extubation.  Comorbid risk factors include:  obstructive sleep apnea, COPD, congestive heart failure, advanced age, ASA class greater or equal to 2 and pulmonary hypertension.

Clinical Indicators for respiratory failure:

Acute Respiratory Failure

  • Moderate to severe respiratory distress
  • Elevated RR (> 32), use of accessory muscles, labored

Breathing at rest

  • Need for intubation, continuous nebs, bipap or cpap to

Control ventilation

  • In patients without preexisting lung disease, pCO2 > 50 or pO2 < 60 on ABG.
  • In patients with preexisting lung disease, pCO2   markedly elevated from baseline or pO2 markedly lower than baseline


Acute Respiratory Distress/Insufficiency

  • mild to moderate respiratory distress
  • Elevated RR (> 26), use of accessory muscles, labored

Breathing at rest

  • Need for continuous high flow O2 (> 3-4L NC in patient

Without known lung disease or hypoxia)

  • Use of frequent nebulizers (ie q 2 hour albuterol)

Chronic Respiratory Failure: Persistent decrease in respiratory function prior to admission suggested by the following:

  • Chronic continuous home O2
  • Chronic hypercarbia due to respiratory condition (ie: pCO2 > 40)
  • Use of chronic steroids for underlying lung pathology

Focusing on post-operative respiratory failure, we must consider the impact of PSI 11, a risk-adjusted measure evaluated using an observed over an expected ratio.  In order to qualify for PSI 11, the following must be present:

All elective surgical discharges treated at the hospital are evaluated, however there are some elective procedures that are excluded, therefore ensuring the coder assigns the appropriate diagnosis code for the documented condition in the post- operative setting is essential.  Examples of some excluded conditions include placement of a tracheotomy prior to the OR procedure, procedures for lung cancer and discharges grouped to (Major Diagnostic Categories (MDC)) 5 diseases of the circulatory disease.

Any discharge included in PSI 11 which has one of the following ICD-10-CM codes on the claim triggers a reportable actual – or observed – post-operative respiratory failure event:

Watch those POA = N… A secondary diagnosis which is NOT present on admission:

J95.821—acute post procedure respiratory failure

J95.822 – acute and chronic post-procedural respiratory failure

Watch for one of the following procedure codes:

Mechanical ventilation greater than 96 consecutive hours (5A1955Z)

  • Date of procedure MUST be zero or more days after the first major operating room procedure

Respiratory ventilation 24 – 96 consecutive hours (5A1945Z)

  • Date of procedure MUST be 2 or more days after the first major operating room procedure

Reintubation procedure codes (0BH13EZ, 0BH17EZ, 0BH18EZ)

  • Date of procedure MUST be 1 or more days after the first operating room procedure

Coders should not assign mechanical ventilation when the ventilation is a part of the normal surgical procedure.  A rule–of-thumb for assigning mechanical ventilation in the post procedure setting is when ventilation support exceeds 48 hours with the start time as the time of intubation for the procedure.  Watch the provider documentation that should indicate some condition as the reason for the extended time as it is unexpected/unanticipated.

There may be times when the rule-of-thumb does not apply. If the duration of the mechanical ventilation is less than 48 hours, however the provider documents this is prolonged and/or unexpected and states the condition that required the extension, the coder would assign the post- operative respiratory failure as documented.

A query opportunity may exist when the patient is extubated in the post-operative setting however, continues to need supplemental oxygen.  Watch your clinical indicators as this may represent a respiratory condition.

Be prepared; familiarize yourself with clinical indicators for respiratory failure, in particular post-operative respiratory failure as well as PSI 11.  Never assume a complication with respiratory failure or any post procedural condition as the condition may just be a condition in the post- operative setting; query when the documentation needs clarifying.


Just Coding HCPro, Coding Clinic, Official Coding Guidelines 2017, Robert Stein, MD, CCDS and Shannon Newell, RIA, CCS, Briefings on Coding Compliance Strategies

About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please comment below.

HIV and AIDS, Understanding the Disease and Documentation Requirements

Spring has finally arrived across most of the country. The landscape is taking on the colors of blooming flowers and trees. This time of year signals new opportunities so let’s revisit one of the diagnoses that can be confusing to coders –  HIV and AIDS.  We will endeavor to better understand the disease process and requirements for documentation.  In turn, as coders, we will be better prepared to analyze record documentation, assign the accurate code and identify when a query is needed.

Human Immunodeficiency Virus (HIV), is a retrovirus that destroys the immune system, disabling the body’s ability to fight infections causing some lymphomas, other malignancies and opportunistic infections to grow.  The Official Coding Guidelines that we followed for coding HIV/ Acquired Immune Deficiency Syndrome (AIDS) in ICD-9-CM have not changed for ICD-10-CM. The only difference is that the codes have changed:

  • B20 – AIDS (previously 042)
  • Z21 – asymptomatic HIV status, HIV + (previously V08)

Regardless of whether a patient is newly diagnosed or has had previous admissions/encounters for HIV conditions, is irrelevant to the sequencing decisions.

  • Code only confirmed cases of HIV infection/illness – Inpatient & Outpatient
  • Chart documentation with qualified diagnoses such as “possible”, “probably”, “rule out”, “suspected” or “suspicion of” are never reported as AIDS (B20) – Inpatient or Outpatient

This is an exception to the rule on the Inpatient side!

  • In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or has an HIM-related illness is sufficient.

HIV Positive:  Code Z21

Used when the patient has never been diagnosed with AIDS or an AIDS-defining condition.  Also called “asymptomatic HIV” in ICD-10-CM.

  • Documentation coded as Z21 (not AIDS) – HIV positive, HIV +, HIV Infection, asymptomatic HIV, known HIV, HIV test positive. Do not use if the term “AIDS” is documented for the patient or the patient has any HIM-related illness or has a history of any HIV-related conditions.
  • A diagnosis of HIV + (Z21) is not the same as a diagnosis of HIV infection, symptomatic HIV/AIDS and AIDS (B20)

Diagnostic Criteria

For adults, adolescents and children >18 months of age, the CDC defines AIDS as an HIV-positive patient with any one of the following:

  • Current or prior diagnosis of an AIDS-defining condition


  • Current or prior CD4+ T-Lymphocyte count <200
  • The CD4 Count is a clinical indicator, however the provider MUST document AIDS, HIV related illness, etc., or a query is necessary.

Coding for HIV

For inpatient coding, the physician must state the diagnosis, and if not clearly documented, there is an opportunity to query for clarification.  For outpatient coding, it is often challenging for coders to determine if the patient is just HIV + (Z21) or if the patient has ever had an HIV-related illness (B20).  As of now, most outpatient coders do not have the capability to query for OP coding.  If the coder is unable to determine which the patient has based on the documentation provided, we should default to asymptomatic, rather than assigning the patient a diagnosis of AIDS.

Opportunistic Infections (OIs)

Healthy immune systems can be exposed to certain viruses, bacteria, or parasites and have no reaction to them.  However, people living with HIV/AIDS may have serious health threats from what are known as “opportunistic infections (OIs)”.  These infections attack the weakened immune system and can be life-threatening.  OIs are signs of a declining immune system.  Most life-threatening OIs occur when the CD4 count falls below 200 cells/mm3.  The CDC developed a list of more than 20 OIs that are considered AIDS-defining conditions. Patients having laboratory confirmed HIV infections and one or more of these OIs, will be diagnosed with AIDS regardless of the CD4 count.

Acquired Immunodeficiency Syndrome (AIDS)

AIDS is the final stage of human immunodeficiency virus (HIV) infection, stage 4 by the World Health Organization (WHO) criteria (2007) and stage 3 by Centers for Disease Control and Prevention (CDC) (2008) criteria or clinical categories B or C (CDC). AIDS code (B20) applies if AIDS has ever been previously diagnosed.  B20 must always be coded on every single subsequent encounter and never again code Z21 once AIDS is assigned.

  • Documentation coded as B20 –AIDS: HIC illness, HIV disease, ARC (AIDS – related complex), HIV symptomatic (any current AIDS-defining condition), HIV currently being treated for an HIV-related illness or is described as having any condition resulting from HIV + status, Acquired immune deficiency syndrome.
  • Once a patient has any HIV-related illness (OI0, every subsequent encounter should be coded as AIDS (B20)
  • Asymptomatic HIV (Z21) and inclusive HIV R75) are never reported once a patient has a confirmed diagnosis of AIDS.

Major AIDS-Related Conditions

Therapeutic Treatment

  • Antiretroviral treatment: (HAART) combination of drugs recommended
  • Pre-Exposure Prophylaxis (PrEP)
  • Post-Exposure Prophylaxis treatment for occupational exposure (PEP)

-Zidovudine (Retrovir, ZDZ,AZT) and Lamivudine (Epivir, 3TC) = Combivir

-Lamivudine (Epivir, 3TC) and Stavudine (Zerit, d4T)

-Didanosine (Videx, Videx EC, ddl) and Stavudine (Zerit,d4T)

  • Fulyzag for treatment of antiretroviral treatment induced diarrhea

A lot of information is included that I trust will clarify the assignment of HIV and AIDS as well as opportunities for query.   Take time to enjoy the Spring!


  1. Reference: Optum: Guide to Clinical Validation, Documentation and Coding (2014) p.34
  2. References: 2016 CDI Pocket Guide by R. D. Pinson, MD, FACP, CCS & C. L. Tang, RHIA, CCS. p.87, 88.
  3. Reference: Optum: Guide to Clinical Validation, Documentation and Coding (2014) p.30.
  4. Reference: U.S. Department of Health and Human Services. Potential Health Related Problems: Opportunistic Infections. www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids  (2016).
  5. References: ICD-10-CM Official Guidelines and Reporting 2017 1.a.1.2


About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please comment below.


Anemia, coding, sequencing and more…

As coders we all face challenges when it comes to assigning codes that best describe anemia being treated.   Many times, anemia requires a query for the type being evaluated and/or treated.  Often once anemia has been stabilized, work up to identify the cause is undertaken. Let’s explore anemia, coding, sequencing and more.

Anemia in the truest clinical sense is when the blood lacks enough red blood cells (RBCs)/ hemoglobin or lacks healthy red blood cells/hemoglobin.  Symptoms of anemia include fatigue, pale skin, heart palpitations, dizziness and shortness of breath.  Some patients present for evaluation with one or more of the above symptoms, others may have no symptoms however anemia may be detected by a simple blood test called a complete blood count (CBC).

Sickle cell anemia/hemoglobin SS is an inherited type of anemia in which the red blood cells/hemoglobin are distorted or sickle-shaped making them fragile and prone to rupture.  Since the RBCs/hemoglobin are the oxygen-carrying protein within the RBC, the abnormal shape inhibits the function of the RBC.  Many sickle cell anemia patients suffer from pain syndrome and anemia symptoms.  Experimental gene therapy is being researched in clinical trials to relieve these patients from having to take daily hydroxyurea reducing the frequency of painful crises and need for frequent blood transfusions.

Blood loss anemia is either chronic or acute.  Acute blood loss anemia is a sudden loss of blood over a brief period of time.  Trauma, gastrointestinal bleed and intraoperative/postoperative events are the most common reasons for acute blood loss anemia.  Chronic blood loss anemia is a loss of blood over a period of time due to iron deficiency, condition of the bone marrow, or slow bleed of the gastrointestinal tract.

When the reason for the anemia is identified, sickle cell anemia, gastrointestinal bleed (ulcer, erosion, AVM, etc.). Trauma, etc., the cause/reason of the anemia is the PDX. 

Coding Clinic 2013 3Q page 8 describes a patient who presents with generalized weakness, severe hypochromic microcytic anemia and melena.  The provider described, ‘etiology of gastrointestinal (GI) bleeding resulting in anemia is to be established.”  The patient underwent EGD and colonoscopy with colon biopsy.  A fungating malignant mass in the right colon was identified.  The provider’s final statement indicated, “Adenocarcinoma of the transverse colon, acute microcytic hypochromic anemia secondary to blood loss due to GI bleeding”.

Assign the malignant neoplasm of colon transverse colon as PDX.  Secondary diagnoses include acute post hemorrhagic anemia and blood in stool (melena).  (Melena is not inherent to colon malignancy).

Coding Clinic 2013 3 Q page 4 describes a former 35 week premature infant now eight weeks old who is suffering from iatrogenic anemia due to blood loss due to frequent blood draws.  This condition could also be documented in older patients as well.

Assign the code for anemia secondary to blood loss (chronic).  This applies to both infants and adult patients.

Coding Clinic 2007 1 Q page 19:

If a physician documents postoperative anemia in the medical record, but does not label the condition as a complication, and does not specify acute blood loss, assign anemia unspecified.  When post-operative anemia is due to acute blood loss, assign acute post-hemorrhagic anemia.”

Only assign a complication code when the provider documents the anemia is a complication

Gastrointestinal hemorrhage manifests itself in several ways:

  • Hematemesis, indicting acute upper GI hemorrhage
  • Melena, indicating upper or lower GI hemorrhage
  • Occult, bleeding seen on laboratory examination only(not GI Bleed)
  • Hematochezia, usually indicating blood from the rectum

When a patient presents with signs and symptoms of anemia, treatment of the anemia is begun which may be oral therapy or transfusion, the thrust of care may be associated with the anemia.  However, when the patient, once stable, begins the evaluation and search for the source of the anemia and after careful study that source is identified, gastritis, esophagitis, erosion, ulcer, AVM, fungating mass…the identified source of the bleeding that caused the anemia is the PDX followed by the type of anemia documented.

When evaluation does not reveal a source or possible source of the bleed, the anemia is the PDX.

Coding Clinic 1991 1 Q page 15:

“If the physician documents this as a bleeding gastric ulcer based on history and /or physical examination, code it as such even if active bleeding is not demonstrated at the time of endoscopy.  Most gastric ulcers associated with bleeding will bleed intermittently so it would not be uncommon to find the ulcer not bleeding at the time of endoscopy.  Therefore, the fact the ulcer is not bleeding at the time of endoscopy should not preclude the coding of gastric ulcer with hemorrhage if it has been documented by the history and/or physical examination.”

Let us continue to work together, evaluating our resources to better understand anemia, coding, sequencing and more. My thanks to Coding Clinic.

About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please comment below.