6 Medical Billing Mistakes that Harm the Healthcare Revenue Cycle

Medical billing is such a vast and convoluted process that many healthcare providers have begun outsourcing medical billing companies for extra support. Hiring professional billers to act as an extension of your team is one of the many medical billing solutions that has improved the quality of the overall healthcare experience. Any inefficiencies may be avoided by working with dedicated medical billers to assist healthcare facilities and reduce errors significantly.  

ECLAT Health Solutions provides the offshore medical billing solutions you need to maintain a healthy revenue cycle as our team is highly trained to help you navigate the healthcare industry efficiently. We focus on providing our clients with the most accurate and affordable billing solutions possible. Here are some of the factors that cause the medical billing process to be so intricate.  

1. Slow Accounts Receivable (A/R) Follow-Ups

Accounts receivable or A/R is when an organization owes a designated amount of fees in regards to medical treatments and services their patient received. The payer, patients, and guarantors may make these payments, which are measured as A/R. Every healthcare organization has to ensure these bills get paid accurately and on time. Having a slow turnaround time for A/R follow-ups causes the reimbursement process for denied claims to be inefficient.

2. Insufficient Documentation

One of the main medical billing errors that cause the process to be so complex is insufficient documentation. When a single detail is missing or if there isn’t enough information, this prevents health care providers from adequately billing for the provided services. Other details that can affect the billing process is illegible documentation, spelling errors, incorrect date and so on. Once these errors occur, claims can quickly be denied making the billing process much longer than it needs to be.

3. Inaccurate Records

When it comes to medical billing, accurate documentation of patient records are very important. The claims and medical records associated have to align with the rules for Medicare coverage, coding, and billing. Medical records allow billers to see what the procedures and treatment a physician carried out during the visit. Whether the service provided was billed improperly or the services were medically necessary, records have to be signed by a variety of specialists before being passed onto the billing process. If they are not signed appropriately, they will be deemed inaccurate.

4. Physicians Aren’t Included in Patient Network

Patients often receive surprise medical bills after they have visited the hospital. This is due to the complexity of the network system that controls which physicians are covered under certain insurance plans. For example, often times the hospital is within the network of places their insurance will cover, but the doctor treating the patient is out of the patient’s insurance network. The insurance company will pay for the hospital bill but the patient will have to pay out-of-pocket for the doctor’s treatment portion of the bill, which is a fact that they often find out after they have received the medical bill. When this occurs, patients aren’t able to pay their bills in full, which may lead to bad debt.

5. Bad Debt

Bad debt occurs when bills are sent to patients for the services and treatments they received at their healthcare facility and they are not paid in full. As this is a frequent occurrence, it can be only be fixed with consistently accurate medical coding documentation.

6. Claims & Denials

Most medical billers have a specific standard when it comes to submitting claims and denials. However, there are still payers that may not have a standard of submitting these claims. Hiring experienced medical billers will allow your claims and denials to be processed and appealed close to the date the service took place. Collecting these in a timely manner will allow a steady cash flow.

ECLAT Health Solutions: Offshore Medical Billing Services

The offshore medical billing process is an obscure system of coding, guidelines, and procedures to ensure that claims are paid. Many companies have started outsourcing medical coding to secondary locations to improve efficiency. ECLAT Health Solutions is available to offer coding support to our clients so they can navigate the current entanglement of medical billing to make the entire healthcare billing process easier for patients and providers.

Contact us at 703-665-4499 to receive more information on all of our healthcare support services!

Hospital Chargemaster

The Importance of Entering Correct Medical Codes to A Hospital Chargemaster

Many healthcare facilities utilize a hospital charge description master, or hospital chargemaster (CDM), for billing patients and health insurance companies. When a chargemaster isn’t performing as it should, it negatively affects the overall healthcare experience. Accurate coding is important and must be documented precisely as it represents every healthcare service provided to the patient. Due to the constant updates of the medical coding classification system, occasional mistakes are made. It is recommended that healthcare providers work with professional international medical coding companies to ensure that the correct codes are entered into the hospital chargemaster so patients receive the proper health services needed to live a quality life.

When it comes to health service costs, healthcare facilities around the world are working on becoming more transparent. Professional medical coders play a significant role as they act as the bridge between the hospitals and patients or payers by sending accurate codes to the chargemaster, which then processes the claims made. Medical coding companies, like ECLAT Health Solutions, make it their mission to remain up-to-date with every change in the medical coding classification system so that health care providers can focus on providing quality patient care and that patients and payers are billed accordingly. To help you understand the importance of entering correct medical codes into a hospital chargemaster, we have provided more information below.

What is a Chargemaster?

A chargemaster, otherwise known as a Charge Description Master (CDM) or hospital chargemaster, is a vital component of the healthcare revenue cycle. A chargemaster serves as a medium between a healthcare facility and for billing their patients and insurance companies. This system contains a list of all the billable services and/or items to a patient or the patient’s insurance company. Examples of what a chargemaster may track include various medical procedures, diagnostic tests, medicine prescribed, and non-physician services. The data collected from a chargemaster can be used to track service volume, revenue, and costs.

Why Medical Codes Must Be Entered Accurately

When hospitals begin their billing process, a chargemaster uses charge captures to close the gap between the hospital and the patient. For example, after a patient receives the services they need, medical providers make note of the service in the patient’s medical record. From there, professional medical coders assign codes so that claims can be accurately submitted to payers. The charges are then used to bill or create claims for patients. If there are any coding mistakes in this process, it can affect everything that relies on the chargemaster. This includes data the chargemaster retrieves as well as the claims and bills sent to patients and insurance companies. To make sure that the CDM is working efficiently, it is reviewed annually for any additional service lines that have been added, which ensures the correct Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes are associated with the appropriate service description.

How to Correct Codes in the Chargemaster

Those in charge of their health facility’s chargemaster must enter correct medical codes because any errors could result in a lower quality of patient healthcare services. It is possible for errors to arise from what is captured in the Order Entry System (EHR) and what is being reported in the chargemaster. If your chargemaster has any inaccuracies, it can result in issues with payment, claim rejections, and compliance violations.

Typical examples of code errors include:

  • Assigning a non-billable or nonexistent code
  • Missing or inaccurate HCPS code is entered when a specific code is available
  • Assigning the wrong type of code. (for  example, using CPT code when an HCPS code is necessary for Medicare billing)
  • Missing HCPS codes for separately paid drugs

It is imperative that chargemaster staff members coordinate with providers to ensure correct coding so that the chances of errors is reduced. This includes verifying the line-item descriptions match up with CPT/HCPCS and revenue codes. If codes do not represent the service provided by the hospital, then those codes need to be changed immediately.

ECLAT Health Solutions is Northern Virginia’s Top Medical Coding Company

Often times healthcare providers balance a variety of duties on their plates and are spread too thin. With the addition of inputting accurate medical codes and making sure they are correct, it can take more time than health providers can spare. ECLAT Health Solutions provides the best medical coding services in the Washington DC metro area  that will reduce the chances of coding and billing errors and upcoding occurrences. Our team of highly-trained medical coders are professional and dedicated to helping providers increase their coding accuracy and provide solutions to improving areas of inefficiency. Contact us to speak with one of our medical coding specialists today!

RCM Best Practices Your Facility Should Adopt in 2018

2018 has arrived, and many healthcare facilities are using the New Year as an opportunity to restructure and improve their practices to ensure a successful year. Some healthcare facilities’ new year resolutions may involve improving their revenue cycle management. This resolution is certainly important, as poor RCM can make hospitals and other facilities miss out on millions of dollars of revenue every year.

At ECLAT Health Solutions, we are dedicated to helping our clients improve their RCM to earn a better revenue flow. If your practice’s goal for 2018 is to earn a healthier RCM, here are a few of our suggested best practices you should adopt this year:


Promote Billing Transparency & Provide Payment Options

In recent years, the number of patients who must pay for healthcare out-of-pocket has increased. This larger burden on patients often results in facilities receiving late payments, or not receiving them at all. Although facilities cannot completely guarantee that a patient will end up paying their bill (even with collection notices), they can take two simple measures to help increase their rate of payments.

Both administrative and clinical staff should be transparent and open when it comes to explaining the medical bill. Administrative staff who handle collecting payments from the patient should especially be trained to communicate up front with the patient and make sure they understand what they owe. Your facility should also offer a variety of payment options. Providing patients with the ability to enroll in a payment plan, pay with cash, check or credit card, and/or use automatic payments helps make their medical bill much more affordable and increase the likelihood that they will pay on time.


Monitor the Claims Process

Claims denials are a common reason why many facilities do not have healthy RCM. Claims denials may occur as a result of a coding error, because a patient does not have the right insurance coverage, and more. Because claims may be denied for a variety of reasons, it is crucial that your facility closely investigates and watches the claims process at every step of the way. Understanding the status of each claim as well as identifying why your claims are denied can help your staff recognize patterns and learn how to prevent many claims denials. If your facility suffered a large number of claims denials in 2017, consider restructuring your claims processes this year.


Maintain HIPAA and HITECH Compliance

Today’s healthcare world is full of shifting regulations and, unfortunately, a rise of security breaches. After the Equifax breach flooded the news in 2017, many healthcare providers were left uncertain about the effectiveness of their own security processes and practices. Providers must always maintain HIPAA and HITECH compliance to ensure that their patients’ sensitive financial information remains safe. Confidentiality is not the only reason to obey HIPAA/HITECH guidelines, however. Healthcare facilities and practices can face significant penalties such as fines for failing to comply with these regulations. This harms the revenue cycle, and of course can lead to less revenue at year’s end. Learn more about the importance of compliance in our post “Why HIPAA & HITECH Compliance Is Increasingly Crucial in Today’s World.”


Hire an Expert Medical Coding Company

If your RCM could use improvement, partner with an expert medical coding and billing company. ECLAT Health Solutions offers comprehensive medical coding, medical billing, and ICD-10 auditing services to help your practice earn a healthier revenue cycle. We provide 24-hour turnaround on our services and we can guarantee a score of 95% or higher coding accuracy. Our billers and coders are highly trained and always maintain HIPAA/HITECH compliance, so you can be sure your facility will earn the high-quality service it requires. We work closely with you as an extension of your company and make your revenue goals our goals.

Make 2018 the year your revenue cycle thrives. Contact ECLAT today to get started.

Selecting the BEST Principal Diagnosis

Early on in our lives, our parents laid out choices surrounded by guidelines that they hoped would lead us to being able to make the best decisions.  Depending on how we truly understood our choices, sometimes coupled with the outcome, we were able to navigate growing up to be great decision makers.  As we transition those types of early learning skills to our coding professions, the same principles apply.  We need to know and understand our choices and based on the guidelines accompanying our choices, make the best decisions for optimal outcomes.

As I respond to coding questions and review records, the one key factor that continues in every chart whether inpatient, outpatient, emergency or ancillary is principal diagnosis or first listed condition.  In order to ensure “reason for admission after study”, medical necessity and reason for the encounter is accurately reflected, we look first to the Uniform Discharge Data Set (UHDDS) guidelines.

  • Principal Diagnosis (PDX):  The circumstances of inpatient admission always govern the selection of the principal diagnosis.  Coding directives in the ICD-10 CM classification take precedence over all other guidelines.  “…that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
  • Admission follow Medical Observation/Post- Operative Observation:  Report the medical condition that led to the hospital admission, which may be different from the reason the patient was admitted to observation.
  • Admission from Out- patient Surgery:  If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.  If the reason is a complication, assign the complication as the principal diagnosis.
  • Abnormal Findings:  When findings are clearly outside the normal range and the physician has ordered other tests to evaluate the condition or has prescribed treatment without documenting an associated diagnosis, it is appropriate to ask the physician whether a diagnosis should be added or whether the abnormal finding should be listed in the diagnostic statement.  Incidental findings on X-rays should not be reported unless further evaluation or treatment is carried out.

The UHDDS definition of PDX does not apply to outpatient encounters.  If the physician does not identify a definite condition or problem at the conclusion of the visit or encounter, report the documented chief complaint as the reason for the encounter/visit.

Just like our parents instilled in us the way to treat others, following rules and guidelines and making good decisions, ethics is essential to coding practices.  AHIMA Standards of Ethical Coding was recently updated, reiterating that in all decisions we make as coders, we apply the highest level of accuracy according to the documentation.  Other third-party payers may follow slightly different reimbursement methods, but the accuracy of the ICD-10 CM and ICD-10-PCS and CPT/modifiers coding is always vital.  Failure to include all diagnoses or procedures documented that meet reporting criteria may result in financial loss for the health care provider.

As we adapt the value based purchasing model, moving from paying for volume to paying for value, we need to read and understand the “clinical truth” in the records, sometimes referred to as clinical indicators.  Let’s take a look at some examples:

  1. Patient is admitted with CHF and pneumonia. Patient is given IV Lasix and IV antibiotics.  Either may be sequenced as the PDX.
  2. Patient is admitted to the ICU with respiratory failure due to severe exacerbation of COPD.  A pulmonary consultant is involved.  Treatment includes IV antibiotics, steroids, oxygen, pulse oximetry, and aggressive respiratory therapy modalities.  Either may be sequenced as PDX.
  3. Patient presents with syncope.  Syncope is due to arrhythmia.  Cardiac arrhythmia is the PDX/first listed and syncope is a secondary diagnosis.
  4. Viral gastroenteritis with fever, abdominal pain, nausea, vomiting, diarrhea.  Code only viral gastroenteritis.
  5. A patient with cholecystitis was admitted to the hospital for a cholecystectomy.  Prior to surgery, the patient fell and sustained a left femur fracture.  The surgery was canceled and a hip pinning was carried out on the second day of the hospital stay.  The PDX remains cholecystitis since it was the diagnosis that occasioned the admission.
  6. A patient was discharged two days following a hysterectomy. On the second day at home, she strained lifting a small child.  She was readmitted with wound dehiscence. The wound dehiscence is the PDX.
  7. A patient is admitted with respiratory failure and a large iatrogenic pneumothorax three days following outpatient thoracentesis for malignant pleural effusion.  Iatrogenic pneumothorax is the PDX.
  8. A patient is treated in an observation unit for 16 hours with an exacerbation of COPD, then admitted as an inpatient for treatment of a pulmonary embolism discovered on chest CT.  Pulmonary embolism is the PDX.
  9. Patient is admitted following TURP as an outpatient for post- operative bleeding uncontrolled in the PACU.  The post-operative bleeding is the PDX.
  10. Patient is being observed for 24 hours following lumbar kyphoplasty develops rapid atrial fibrillation requiring admission; atrial fibrillation is the PDX.
  11. An elderly patient with chronic cholecystitis is admitted for 3 days following an uncomplicated elective laparoscopic cholecystectomy without further explanation before being transferred to a SNF.  Chronic cholecystitis is the PDX.
  12. A patient is admitted with right lower abdominal pain. Abdominal x-ray on admission indicates an ileus pattern. The patient has intravenous fluids, multiple tests   and the discharge diagnosis is given as RLQ pain, unknown etiology.  We should query for whether the ileus pattern identified on the abdominal x-ray is possibly the cause of the RLQ abdominal pain.  When a condition is introduced and not ruled out by the documentation, we should query for any possible relationship.
  13. A patient is admitted with fever, cough and treated with antibiotics and steroids.  The diagnostic statement is COPD exacerbation and pneumonia.  Using Coding Clinic guidelines, the PDX is the COPD exacerbation followed by the pneumonia.

We have navigated through several scenarios today regarding selection of the PDX/first listed condition that I hope you find validation in your current practices or understand better the correct method of PDX/first listed selection.

References: UHDDS guidelines referenced via, and Pinson, R.D.,MD, Tang, C.L. “2017 CDI Pocket Guide”, ACDIS, and AHA 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 email us at

Beginning the New Year revisiting HIV/AIDS


“Think like a wise man but communicate in the language of the people.”

– William Butler Yeats – Irish poet


Just as cleansing snowfalls, cooler breezes and overcast skies accompany January into the New Year, revenue cycle change is sure to follow.   All of us play a valuable role in the success of increasing quality while decreasing cost as we analyze documentation and assign appropriate codes. Centers for Medicare and Medicaid Services (CMS) have provided the healthcare road map.  It is up to us to understand, communicate and carry out the plan.

As we march forward together, clear, concise, crisp, timely, communication is necessary.  The tasks are requiring more detail and the skills are becoming more defined.  We seek 100% accuracy and learn daily from feedback to be the best we can be.   Resolve in 2017 to thrive with the flow of information and ideas that catapult us into new revenue cycle horizons as we collaborate and communicate together.

Beginning the New Year revisiting HIV/AIDS:

  • Human immunodeficiency virus (HIV) is a virus transmitted through contact with bodily fluids (blood, semen, vaginal secretions, breast milk) containing infected plasma or cells. Being HIV positive from a blood test showing HIV antibodies is not the same as having human immunodeficiency virus disease (AIDS).  “Do not use [code Z21] Asymptomatic human immunodeficiency virus infection status if the term ‘AIDS’ is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV-positive status; use [code B20] human immunodeficiency virus disease in these cases.”
  • “When and OB patient is identified as having any HIV infection a [code from subcategory O98.7] is assigned with [code B20] assigned as an additional code. If an OB patient tests positive for HIV but has no symptoms and no history of an HIV infection, [codes O98.7- and Z21] are assigned rather than [code B20].”
  • 4 encounter for screening for HIV
  • 7 HIV counseling
  • 89 other problems related to lifestyle (high risk group for HIV infection)
  • 6 contact with and suspected to HIV
  • [Code B20] is NOT assigned when the diagnostic statement indicates that the infection is “suspected,” “possible,” “likely,” or “questionable”. This is an EXCEPTION to the general guideline that directs the coder to assign a code for a diagnosis qualified to ‘suspected” or “possible” as if it were established.  Confirmation in this case does not require documentation of a positive serology or culture for HIV, the provider’s diagnostic statement that the patient is HIV-positive or has an HIV-related illness is sufficient.  The provider should be asked to state the diagnosis in positive terms.
  • Once the patient is diagnosed as AIDS, HIV related disease [code B20], the patient is always reported as AIDS, HIV [code B20] related disease; not returned to the HIV status [code Z21]. “Patients with any known prior diagnosis of an HIV-related illness should be [coded to B20].  Once a patient has developed and HIV-related illness, the patient should always be assigned [code B20] on every subsequent admission/encounter.”

Additional Information:

  • Q: A patient with AIDS was treated in this hospital last year for AIDS-related histoplasmosis.  He is now admitted for acute nephritis.  In the record there is no clear statement that the nephritis is due to his AIDS.  What is the PDX?
  • A: Assign [N00.9] nephritis NOS as the PDX as there is no clear statement that the nephritis is an HIV-related disease.  The coder should not make such assumptions without clear indications within the record.  [Code B20] should be listed as an additional diagnosis. Coding Clinic 4Q 1994 p.35
  • Q: An AIDS patient is admitted for treatment of severe diarrhea and dehydration.  He is diagnosed to have Cryptosporidiosis with dehydration.  How should this be sequenced?
  • A: Assign [B20], [A07.2], [E86.0].  Coding Clinic 4Q 1997 p. 30,31
  • When documentation is unclear or conflicting, the provider must be queried for clarification.

I look forward to working alongside each of you, researching and supporting all the efforts that go into fulfilling a valued and respected profession, coder.  Greet each day with a smile of exhilaration and passion.

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 email us at


In-house medical coding and outsourcing with ECLAT


Embracing new coding concepts and guideline changes can sometimes overshadow established policies that we use daily, prompting a need to revisit.  Recently, while researching a concept I felt was clear to me, I realized that depending on the circumstance, the clarity may not be so apparent.  All of us are vulnerable to being lulled into a false sense of coding satisfaction.  Take for instance the 7th character assignment of injuries and conditions.  Many of us learned this coding concept from the very beginning of ICD-10-CM training.

  • Initial = A “used for the initial encounter for the injury or condition while the patient is receiving active treatment for the injury”

A patient presenting to the point of care for the very first time to be examined and/or treated for a condition or injury that just occurred; assigning the seventh character “A” is a straightforward coding decision.

Example:  Forty-seven year-old male presented with a 10 cm. laceration of the right forearm following a chain saw accident in his yard, trimming his tree.  The laceration required layer closure in the Emergency Department. (S51.811A)(W29.3XXA)(Y93.H2)(Y92.017)(Y99.8)

Example:  Patient is admitted for acute care treatment for overdose of Advil, trazodone, lithium. (T43.212A, T43.592A, T39.312A (and the external cause codes)).

It is following the patient throughout the treatment process that can be puzzling.  One thing that helps me is to ask myself this question:

  • Has the patient previously received any active treatment for this particular injury or condition in any other setting (ED, provider office, hospital, clinic, etc.) or by any provider of care?

If the answer is no, then you have no question that the seventh character is “A” initial.  If the answer is yes, we have a decision to make and it helps to understand our choices.

  • Subsequent = D “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase”

Seems simple doesn’t it, and for injuries and conditions that follow the “routine course of healing” coders should have no problem with this concept.  It is when the “routine” is interrupted with an infection, or dehiscence or complication that causes the injury or condition to be readdressed that a true understanding of the seventh character assignment is required.  Anytime an injury or condition that was in the ‘routine’ healing phase requires attention, the seventh character “A” is reinitiated.  A new treatment plan is developed, the patient is no longer in the ‘healing’ phase, but rather is on a new “initial” phase.

Example:  Forty-seven year-old male presented following repair of a 10 cm. laceration of the right forearm following a chain saw accident in his yard, trimming his tree.  The laceration was closed and seemed to be healing well until the patient was changing the car tire in his home garage and the wound opened.  Upon presentation to the provider, a decision was made to admit the patient to the hospital for debridement, washout and closure of the wound dehiscence.  (T81.33XA)(X50.0XXA)(Y93.89)(Y92.015)(Y99.8)

Example:  Patient is accepted to the Psychiatric Center follow treatment for an overdose with Advil, Trazodone and lithium for evaluate and treatment of the major depressive disorder and post-traumatic stress disorder. (MDD and PTSD are PDX/sec dx, with (T43.212D. T43.592D. T39.312D).

Same wound, but requiring a new care plan; the seventh character is appropriately assigned “A” initial.  This is not aftercare; this is a new problem impacting a previous injury.

Following the phase of injury and/or condition healing is the state of healed/recovered.  When a late effect occurs directly resultant from the previous injury or condition, the following seventh character should be assigned:

  • Sequela = S “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn.  The scars are sequelae of the burn”

Example:  Chronic pain due to low back injury

(G89.21) chronic pain due to trauma (S39.002S) unspecified injury of muscle, fascia, and tendon of lower back, sequela

Coders need to use caution when coding fractures as there are more choices:

  • A – initial encounter for closed fracture
  • B – initial encounter for open fracture
  • D – subsequent encounter for fracture with routine healing
  • G – subsequent encounter for fracture with delayed healing
  • K – subsequent encounter for fracture with nonunion
  • P – subsequent encounter for fracture with mal-union
  • S – sequela

Coders may be tempted to assign the nonunion and mal-union fractures to acute as the treatment plan has changed to require additional treatment.  However following the initial treatment the fracture, during the healing phase, develop unique conditions.  In mal-union, the bony healing is occurring but the fracture fragments are in poor position.   In nonunion, healing is also taking place, but there remains a gap between the bony structures at the fracture site.  In these cases, the appropriate seventh digit for subsequent encounter is assigned (K/P).

Applying the guidelines to daily coding can be difficult; I’m hopeful this information will provide you with clarity regarding the characters representing initial, subsequent and sequela.

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 email us at

An Ever-Changing Healthcare Environment

Across the country and around the world, healthcare organizations are feeling the winds of change.  Political, restructuring, budgetary, regulatory breezes all blow in different waves of change to our daily tasks as healthcare professionals that impact us.  Often I think of how as a child I feared change.  Whether it was moving to a new town, getting introduced to a new teacher, meeting new classmates, it wasn’t long until I realized the opportunity that change afforded me.  Then I wondered why I had spent so much energy on fear.

One of the biggest cheerleaders for change in my life is my mother who believes the reality of change is acceptance.  Before you can turn the corner for true change, you must accept the components of whatever is changing.  Many of us have planned, taught and worked with ICD-10 to the point of acceptance and we now are beginning to reap some of the rewards of specificity in reporting service line disease processes.

The Official Coding Guidelines implemented October 1, 2016, reiterated in Coding Clinic 4th Quarter 2016, included some changes that cannot be overwritten by facility-specific policy and warrant a closer look.

Zika virus infections (A92.5 Zika virus disease) requires the provider document a confirmation statement that the patient zika mosquitohas Zika virus infection.  Possible, probable, suspected, terminology do not apply.  Much like HIV that must be confirmed before coding, avian flu must be confirmed before coding, so now is true for Zika virus infection.  Lots of people are being tested for such viruses, but only those confirmed by the provider are coded.  Non-confirmed cases may be coded to Z20.828 Contact with and suspected exposure to other viral communicable diseases.


  • 84 long term use of oral hypoglycemic drugs
  • – or I51.4- – I51.9 included in the I11 category of hypertensive heart disease
  • Use additional code from category I50 heart failure for type of heart failure
  • Sequence according to the circumstances of admission/encounter
  • I12 category represents Hypertensive CKD
  • Use additional code from category N18 for stage of CKD
  • I16 hypertensive crisis (urgency, emergency), category I10 – I15 also
  • STEMI/NSTEMI meeting secondary diagnosis criteria may be assigned within 4 weeks of the diagnosis when readmitted or transferred
  • Pressure ulcers that heal during a visit, assign the code of site/stage upon admission
  • Evolving pressure ulcers, assign one code for site and stage on admission (POA Y) and another code for site and stage for the same ulcer that progressed during the stay ( POA N)
  • Assign O09 supervision of high-risk pregnancy only during the prenatal period, if there are no applicable complication codes form Chapter 15, O80 is assigned
  • Assign the reason that prompted the admission when delivery occurs as the PDX
  • When multiple conditions are present at the time of admission on a delivery encounter; assign the PDX as the one that relates to the delivery.
  • Observation and evaluation of newborns for suspected condition not found assign Z05 (ie. Ruled out sepsis)
  • Poisoning when the intent is not known defaults to accidental intent, only assign undetermined when the documentation specifies the intent cannot be determined
  • Category Z3A is only applicable to deliveries, not applicable for abortion, termination of pregnancy or postpartum conditions.
  • A condition that the entire code component is not POA, is assign N, (acute exacerbation of COPD, however, the exacerbation occurred on day three of the hospital stay) The COPD was POA, however, the exacerbation was POA = N so the code is assign POA = N

The more we revisit these changes and put them into practice, the easier the changes are to accept and soon they become the new reality.  As we approach the season that reminds us to be thankful for all our blessings, let us appreciate the opportunities that change presents and work together to be the very best we can be.

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 email us at

What’s up “with” Diabetic Coding?

Responding to coder questions has always been one of my great joys.  The challenge of searching for the underlying cause or the analysis of a detailed operative note is second only to a Dr. Seuss favorite with my Grands.  Lately, diabetic coding has been a frequent topic for clarification.

According to the American Diabetes Association,“29.1 million Americans have been diagnosed with diabetes with another 86 million identified with pre-diabetes.”  The manifestations and associated conditions are staggering, as this disease impacts many body systems.  In ICD-9-CM code assignment with the designation of primary or secondary whether type I or II, controlled, uncontrolled and with a documented association of manifestations common to diabetes was the guidance. ICD-10-CM implementation eliminated the controlled and uncontrolled designation, opting for a more robust manifestation instruction.

The American Hospital Association (AHA) Coding Clinic publications for first quarter 2016, again second quarter 2016 reiterate the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 I.A.15 which says:

“With”  the word “with” should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetic Index, or an instructional note in the Tabular List.  The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.  These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must like the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

As coders plunge into their daily coding process, there remain areas of concern in complying with the instruction that as written seems so clear.  In the setting of a type II diabetic patient presenting with nausea and vomiting, gastric emptying studies support the diagnosis of gastroparesis the diagnosis code assigned would be E11.43.  The proximity of the documentation in the record of the two conditions (diabetes type II) and (Gastroparesis) have no bearing on the expectation to assign one code, assuming the relationship between the diabetes type II and the gastroparesis.

The same is true for CKD, foot ulcer, gangrene, and the list goes on as the coder references the Index “Diabetes, diabetic (Mellitus)(sugar) “with” or enters the key word “diabetes” in the encoder.  Recent coder questions include the diagnosis of cataract.  When the provider has not documented the type of cataract, (nuclear sclerosis, age-related, etc.) the coder is instructed to assume a link between the diabetes and cataract, reporting as diabetic cataract.  This may be an area of concern for some facilities as their statistical analysis will shift from an “H” diagnosis in Chapter 5 diseases of the eye to an “E” diagnosis in Chapter 4 endocrine diseases.  In talking with a local ophthalmologist, this raised awareness for him as he shared he has many diabetic patients that he may perform cataract surgery that have no relationship between the two conditions.  It is important to inform the providers as guidelines change that may impact their patient population data so they understand the need for the appropriate level of specificity documentation.

Osteomyelitis is also causing some eyebrow rising among coders.  The coding book Index, Diabetes “with” includes osteomyelitis “E11.69”.  In the coding book Index, Diabetes Type I or Type II “with” does not include osteomyelitis.  So, what’s a coder to do?  The answer was provided today in the AHIMA October 15, 2016 Conference.  Everywhere in the ICD-10 CM index that “with” is a part of the indexed condition, the link between the condition referenced by the index and the “with” condition is to be made unless the provider has documented the referenced condition is not due to the “with” condition or is due to another condition.  That includes osteomyelitis in a diabetic patient.  Just to be sure we are clear, additional examples including osteomyelitis will be included in the Coding Clinic 4th Quarter 2016.

As we continue to work with providers with regard to their documentation it is important to share with them how their patient is reflected in coding as many of them are unaware of coding guidelines.  Documentation matters now more than ever.

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 email us at