This document provides details about an upcoming webinar on coding traumatic brain injuries using ICD-9-CM. The webinar will be presented by Amy Waller and will discuss defining TBI and brain anatomy, the importance of proper documentation and coding for compliance, and how to analyze TBI documentation and select accurate ICD-9 codes. It provides information on continuing education credits available for certain health professionals who participate in the webinar. The webinar aims to help coders and clinicians properly code and classify TBIs in military treatment facilities using ICD-9-CM codes.
Get medical billing and coding training at Southern California Health Institute (SOCHi) Medical Billing and Coding program. Start your new Career Today!
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the various levels of Provider Medicare appeal rights. The presentation further explains how facilities can thoroughly manage the appeal process and participate in a successful ALJ hearing.
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the level of Medicare appeal, how facilities can thoroughly and timely manage the appeal process, and how facilities can participate in a successful ALJ hearing.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends associated with Medicare Part B Claims. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
This presentation provides a comprehensive review and forecast of the trends in Medicare Medical Review by numerous Medicare Contractors and is appropriate for all SNF Management, nursing staff, and therapy professionals. The presentation provides insight on the tidal wave of newly exposed compliance issues at the eye of the storm, leading to remote and on-site audits in the long-term care industry. Presentation highlights the historical drought in audits and the tornado effect the current scrutiny is causing amongst the SNF providers. Learn strategies to prepare records before the impending audit storm. Avoid slip ups on the seemingly invisible black ice of Medicare non-compliance. Become aware of the most recent CMS updates impacting the RAI process and subsequently reimbursement. Create an anemometer for Managers and staff to read the winds of change and create clear visibility for accurate and compliant records.
1. Learn to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes.
2. Understand the trends and triggers in Compliance Audits and Common Provider Pitfalls.
3. Learn strategies for appealing Medicare Claim Denials.
The management of the Minimum Data Set (MDS) 3.0 assessment schedule is complex and time consuming. Combining scheduled MDS assessments with unscheduled Prospective Payment System (PPS) Other Medicare Required Assessments (OMRAs) correctly will lead to accurate reimbursement and can ease the MDS workflow burden on the entire team, and save the facility costly mistakes due to noncompliance. Practitioners need to know what to do if the MDS schedule is not followed correctly, and how to regain compliance with the schedule as quickly as possible. This presentation reviews the scheduled and unscheduled PPS assessment requirements and describe how to select and set Assessment Reference Dates (ARDs) strategically and accurately. The presentation also discusses implications of not following the assessment schedule correctly, and how to regain compliance once an error in assessment scheduling is discovered. The Correction Process of existing MDS assessments, including modification, inactivation, and manual correction request will be discussed. This all-important information will help the MDS coordinator to maintain and regain federal compliance with the PPS assessment schedule.
1. Learn to outline the scheduled PPS assessment schedule and unscheduled PPS assessment requirements and explain the correct Assessment Reference Date selection for each assessment type.
2. Learn to state the correct application of default or provider liable days for an early, late, or missed scheduled or unscheduled assessment.
3. Learn to identify the appropriate use of the Start of Therapy OMRA, End of Therapy OMRA, End of Therapy-Resumption OMRA, and Change of Therapy OMRA.
4. Learn the eight criteria for a Medicare Short-Stay assessment.
5. Learn to identify the difference between a MDS modification and a MDS inactivation and recognize when to choose modification or inactivation.
The Top 9 Questions Every Medical Coder Asks about Risk Adjustment and the CR...Laureen Jandroep
The Top 9 Questions Every Medical Coder Asks About Risk Adjustment and the CRC™ Certification was presented in a webinar by Certification Coaching Org (CCO), www.cco.us. A wealth of information was covered including: what Risk Adjustment (RA) entails, how this field is growing, and RA career opportunities. Also discussed was what to look for in a Risk Adjustment course. Attendees’ questions on careers in RA or preparing for the Certified Risk Adjustment Coder (CRC™) credentialing examination were answered. Presenters were Alicia Scott, CPC, CPC-I, CRC, and Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPC-I, CCS, CANPC, CEMC, CFPC, CIMC, CGSC, COSC, CRC, CCC. The host for the webinar was Boyd Staszewski.
Get medical billing and coding training at Southern California Health Institute (SOCHi) Medical Billing and Coding program. Start your new Career Today!
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the various levels of Provider Medicare appeal rights. The presentation further explains how facilities can thoroughly manage the appeal process and participate in a successful ALJ hearing.
A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the level of Medicare appeal, how facilities can thoroughly and timely manage the appeal process, and how facilities can participate in a successful ALJ hearing.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends associated with Medicare Part B Claims. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
This presentation provides a comprehensive review and forecast of the trends in Medicare Medical Review by numerous Medicare Contractors and is appropriate for all SNF Management, nursing staff, and therapy professionals. The presentation provides insight on the tidal wave of newly exposed compliance issues at the eye of the storm, leading to remote and on-site audits in the long-term care industry. Presentation highlights the historical drought in audits and the tornado effect the current scrutiny is causing amongst the SNF providers. Learn strategies to prepare records before the impending audit storm. Avoid slip ups on the seemingly invisible black ice of Medicare non-compliance. Become aware of the most recent CMS updates impacting the RAI process and subsequently reimbursement. Create an anemometer for Managers and staff to read the winds of change and create clear visibility for accurate and compliant records.
1. Learn to summarize the multiple types of Medicare Contractor Audits and associated Compliance themes.
2. Understand the trends and triggers in Compliance Audits and Common Provider Pitfalls.
3. Learn strategies for appealing Medicare Claim Denials.
The management of the Minimum Data Set (MDS) 3.0 assessment schedule is complex and time consuming. Combining scheduled MDS assessments with unscheduled Prospective Payment System (PPS) Other Medicare Required Assessments (OMRAs) correctly will lead to accurate reimbursement and can ease the MDS workflow burden on the entire team, and save the facility costly mistakes due to noncompliance. Practitioners need to know what to do if the MDS schedule is not followed correctly, and how to regain compliance with the schedule as quickly as possible. This presentation reviews the scheduled and unscheduled PPS assessment requirements and describe how to select and set Assessment Reference Dates (ARDs) strategically and accurately. The presentation also discusses implications of not following the assessment schedule correctly, and how to regain compliance once an error in assessment scheduling is discovered. The Correction Process of existing MDS assessments, including modification, inactivation, and manual correction request will be discussed. This all-important information will help the MDS coordinator to maintain and regain federal compliance with the PPS assessment schedule.
1. Learn to outline the scheduled PPS assessment schedule and unscheduled PPS assessment requirements and explain the correct Assessment Reference Date selection for each assessment type.
2. Learn to state the correct application of default or provider liable days for an early, late, or missed scheduled or unscheduled assessment.
3. Learn to identify the appropriate use of the Start of Therapy OMRA, End of Therapy OMRA, End of Therapy-Resumption OMRA, and Change of Therapy OMRA.
4. Learn the eight criteria for a Medicare Short-Stay assessment.
5. Learn to identify the difference between a MDS modification and a MDS inactivation and recognize when to choose modification or inactivation.
The Top 9 Questions Every Medical Coder Asks about Risk Adjustment and the CR...Laureen Jandroep
The Top 9 Questions Every Medical Coder Asks About Risk Adjustment and the CRC™ Certification was presented in a webinar by Certification Coaching Org (CCO), www.cco.us. A wealth of information was covered including: what Risk Adjustment (RA) entails, how this field is growing, and RA career opportunities. Also discussed was what to look for in a Risk Adjustment course. Attendees’ questions on careers in RA or preparing for the Certified Risk Adjustment Coder (CRC™) credentialing examination were answered. Presenters were Alicia Scott, CPC, CPC-I, CRC, and Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPC-I, CCS, CANPC, CEMC, CFPC, CIMC, CGSC, COSC, CRC, CCC. The host for the webinar was Boyd Staszewski.
Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.
1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.
2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.
3. Understand Performance Improvement Projects (PIPs).
4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.
1. Learn to describe the technical and clinical requirements for Medicare coverage.
2. Understand the goal of supportive skilled nursing documentation.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.
5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.
One of the major goals in MDS 3.0 is to give residents and families a more active voice in the care delivered. Interviewing processes are provided in the MDS 3.0 RAI user’s manual to help caregivers obtain quality, accurate information from patients with focused scripted interview questions. This presentation discusses techniques for interviewing that will assist with achieving more accurate data for physical therapy care and MDS coding. The presentation reviews key sections of the MDS that are coded based on direct patient interviews.
1. Learn to identify the MDS Sections which are coded based on scripted resident interview.
2. Learn to describe three specific techniques that can be used to achieve accurate interview results.
3. Gain an understanding of key RUG reimbursement and quality measure impacts of the resident interviews.
4. Learn to summarize strategies for utilization of resident interview data to drive quality of care and improve quality of life in the SNF.
The MDS 3.0 has an impact on every aspect of care in a LTC or SNF. Reimbursement, Quality Measures, Five Star rating, Care Planning, and resident-centered care all begin with an accurate, standardized, and reproducible assessment.
Download the MDS 3.0: A Guide To Coding Accuracy by Beckie Dow, RN, RAC-MT for an overview of MDS 3.0. Beckie reviews the MDS 3.0 sections most vulnerable to error, while highlighting strategies for increased accuracy. Beckie also provides the MDS scheduling clinical qualifiers for each of the 66 RUG-IV categories and examples of potential financial losses due to inaccurate coding.
Learn How To:
1. Identify three MDS 3.0 Sections vulnerable to error.
2. Identify strategies for accurate reimbursement through the MDS 3.0 process.
3. Articulate three recent MDS 3.0 Coding instruction updates.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends with examples of denial statements. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
As digitization of the healthcare industry increases, the need to safeguard electronic patient data is also becoming increasingly important. Electronic protected health information (ePHI) is not just in the electronic medical records (EMRs). It also resides in emails, in documents and images on computers, servers, printer hard drives and mobile devices like laptops, cell phones, tablets and USB memory sticks. Healthcare professionals are also using texting and online file sharing services to conveniently share confidential information. The loss of this confidential patient health information is disastrous for patients and healthcare organizations.
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. This presentation defines late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system is reviewed and implications of inappropriate coding will be demonstrated.
On July 31, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Final Rule under the Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities to be implemented on October 1, 2014. This seminar will discuss the impact of Fiscal Year 2015 Medicare payment rate increases for Skilled Nursing Facilities (SNFs) and will review the most recent Office of Management and Budget (OMB) statistical area delineations affecting the SNF PPS Wage Index. Learn about the revision to the existing COT OMRA policy. Additionally attendees will be apprised of updates to Chapter 8, Section 30 of the Medicare Benefit Policy Manual (Pub. 100-02) which directs providers on coverage decisions for reasonable and necessary treatment of patient’s illness or injury.
Cpc certification training in hyderabad | medical coding cpc certification training in hyderabad, best medical coding training institute for classroom training and placement with internship class,medical coding training hyderabad
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. Join Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, in this in-depth interpretation of the elements of the PEPPER. Keri will detail how to interpret your PEPPER and discuss the practical application of this critical information to your Skilled Nursing Facility’s practice. Follow along with your own PEPPER report to develop an action plan to ensure compliance with Medicare regulatory requirements and ensure accurate reimbursement for clinically appropriate care provided.
CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. During this session, the speaker will define the late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system will be reviewed and implications of inappropriate coding will be demonstrated. Using dollar-impact case studies, the attendee will learn why this section is critical for the facility’s financial success.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
A presentation designed to train individuals in the rationale and defense of Medically Necessary Documentation as it pertains to CMS guidelines in an Inpatient Rehabilitation Facility. Designing short and long term goals to improve documentation for defending Medical Necessity under RAC / MAC audits.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.
1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.
2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.
3. Understand Performance Improvement Projects (PIPs).
4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.
1. Learn to describe the technical and clinical requirements for Medicare coverage.
2. Understand the goal of supportive skilled nursing documentation.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.
5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.
One of the major goals in MDS 3.0 is to give residents and families a more active voice in the care delivered. Interviewing processes are provided in the MDS 3.0 RAI user’s manual to help caregivers obtain quality, accurate information from patients with focused scripted interview questions. This presentation discusses techniques for interviewing that will assist with achieving more accurate data for physical therapy care and MDS coding. The presentation reviews key sections of the MDS that are coded based on direct patient interviews.
1. Learn to identify the MDS Sections which are coded based on scripted resident interview.
2. Learn to describe three specific techniques that can be used to achieve accurate interview results.
3. Gain an understanding of key RUG reimbursement and quality measure impacts of the resident interviews.
4. Learn to summarize strategies for utilization of resident interview data to drive quality of care and improve quality of life in the SNF.
The MDS 3.0 has an impact on every aspect of care in a LTC or SNF. Reimbursement, Quality Measures, Five Star rating, Care Planning, and resident-centered care all begin with an accurate, standardized, and reproducible assessment.
Download the MDS 3.0: A Guide To Coding Accuracy by Beckie Dow, RN, RAC-MT for an overview of MDS 3.0. Beckie reviews the MDS 3.0 sections most vulnerable to error, while highlighting strategies for increased accuracy. Beckie also provides the MDS scheduling clinical qualifiers for each of the 66 RUG-IV categories and examples of potential financial losses due to inaccurate coding.
Learn How To:
1. Identify three MDS 3.0 Sections vulnerable to error.
2. Identify strategies for accurate reimbursement through the MDS 3.0 process.
3. Articulate three recent MDS 3.0 Coding instruction updates.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends with examples of denial statements. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
As digitization of the healthcare industry increases, the need to safeguard electronic patient data is also becoming increasingly important. Electronic protected health information (ePHI) is not just in the electronic medical records (EMRs). It also resides in emails, in documents and images on computers, servers, printer hard drives and mobile devices like laptops, cell phones, tablets and USB memory sticks. Healthcare professionals are also using texting and online file sharing services to conveniently share confidential information. The loss of this confidential patient health information is disastrous for patients and healthcare organizations.
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. This presentation defines late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system is reviewed and implications of inappropriate coding will be demonstrated.
On July 31, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Final Rule under the Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities to be implemented on October 1, 2014. This seminar will discuss the impact of Fiscal Year 2015 Medicare payment rate increases for Skilled Nursing Facilities (SNFs) and will review the most recent Office of Management and Budget (OMB) statistical area delineations affecting the SNF PPS Wage Index. Learn about the revision to the existing COT OMRA policy. Additionally attendees will be apprised of updates to Chapter 8, Section 30 of the Medicare Benefit Policy Manual (Pub. 100-02) which directs providers on coverage decisions for reasonable and necessary treatment of patient’s illness or injury.
Cpc certification training in hyderabad | medical coding cpc certification training in hyderabad, best medical coding training institute for classroom training and placement with internship class,medical coding training hyderabad
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. Join Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, in this in-depth interpretation of the elements of the PEPPER. Keri will detail how to interpret your PEPPER and discuss the practical application of this critical information to your Skilled Nursing Facility’s practice. Follow along with your own PEPPER report to develop an action plan to ensure compliance with Medicare regulatory requirements and ensure accurate reimbursement for clinically appropriate care provided.
CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. During this session, the speaker will define the late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system will be reviewed and implications of inappropriate coding will be demonstrated. Using dollar-impact case studies, the attendee will learn why this section is critical for the facility’s financial success.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
A presentation designed to train individuals in the rationale and defense of Medically Necessary Documentation as it pertains to CMS guidelines in an Inpatient Rehabilitation Facility. Designing short and long term goals to improve documentation for defending Medical Necessity under RAC / MAC audits.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
Nace en Huánuco del 30 de mayo de 1842, su nombre fue Fernando, pequeño perdió a sus padres, queda a cargo de su tío Isidro Soler. A los 15 años entra en el Convento de los Franciscanos en Ocopa, después de la formación necesaria llegará ser hermano franciscano y luego sacerdote franciscano; por motivos de salud pedirá incorporarse al Convento de los Descalzos ubicado en el Rímac. Es allí donde concibe el proyecto de fundación. Poco tiempo después de la fundación de la Congregación de Religiosas Franciscanas de la Inmaculada Concepción será nombrado como II Obispo de Huánuco (1889); llegado a su diócesis se dedicará a custodiarla cual buen pastor. Murió en olor de santidad el 26 de junio de 1902.
Te presentamos nuestra empresa. Nos dedicamos a la ejecución de proyectos de cartografía y SIG y a la formación online en Tecnologías de la Información Geografica. Síguenos!
Running head 1-3 FINAL PROJECT MILESTONE ONE samirapdcosden
Running head: 1-3 FINAL PROJECT: MILESTONE ONE 1
PHE 330 FINAL PROJECT: MILESTONE ONE 5
1-3 Final Project: Milestone One
Artis Johnson
Public Health Education & Communication
Tami Ford
Southern New Hampshire University
September 4, 2022
I. Health Problem.
I have chosen to complete my final project discussing Human Immunodeficiency Virus (HIV). There are quite a few people that I know that are near and dear to my heart living with this virus. There are many misconceptions about HIV that the public has simply due to unawareness. With most common public health issues there are many questions that need to be answered to solve the myths. Mental health and substance use disorders can also make it difficult for people to take their medications as prescribed. When HIV is not treated or maintained, it can lead to the fatal diseases Acquired Immune Deficiency Syndrome (AIDS). Of note, you cannot have AIDS without being infected with HIV. According to the Center for Disease Control, HIV can affect anyone regardless of sexual orientation, race, ethnicity, gender, or age (CDC, 2022). However, certain groups are at a higher risk for HIV and weigh special considerations due to the specific risk factors. Gay and Bisexual men, pregnant women, infants, children, Transgender people, people who exchange sex for money, people who inject drugs, etc. These are all considerations of the causes for higher risk for being affected by HIV. However, with the modern medicines and treatments for HIV, many have been known to live long and healthy lives.
II. Organization.
The organization that I have chosen is the World Health Organization (WHO). WHO was founded in 1948 and is the United Nations Agency that connects nations, partners, and people to promote health, keep the world safe and serve the vulnerable – so everyone, everywhere can attain the highest level of health (WHO, 2022). My role in this organization will be a Public Health Physician. WHO works closely with United Nations Children’s Fund (UNICEF) on Elimination of Mother-to Child Transmission (EMTCT) of HIV and pediatric AIDS and works with United Nations Population Fund (UNFPA) on the integration of HIV and Sexual and Reproductive Health and Rights (SRHR). WHO considers the epidemiological, technological, and contextual trends of previous years, promotes learning with each disease area, and generates opportunities to leverage innovations and knowledge for efficient responses to HIV and sexually transmitted infections (STI). Thanks to awareness and past research, WHO is able to provide a in depth analysis of the past and current trends of HIV and other STI through multiple platforms.
References
Centers for Disease Control and Prevention. (2022, August 5).
HIV. Centers for Disease Control and Prevention. Retrieved September 4, 2022, from https://ww ...
DCoE_OPS_TBI_Webinar_14Aug_Presentation_v2-1_2014-08-14 FINAL
1. Breaking the Code: ICD-9-Clinical Modification
Diagnosis Coding for Traumatic Brain Injury
Aug. 14, 2014, 1-2:30 p.m. (EDT)
Presenter: Amy Waller, CPC, CPMA, CPCO
AHIMA Approved ICD-10-CM/PCS Trainer/Ambassador
Senior ICD-10 Trainer
Contractor, Team: Dynamics Research Corporation/Standard Technology, INC.
Arlington, Va./Bethesda, Md.
Moderator: Sherray L. Holland, PA-C
TBI Clinical Educator
Contract support to Defense and Veterans Brain Injury Center
Silver Spring, Md.
2. Webinar Details
2
Live closed captioning is available through Federal Relay
Conference Captioning (see the “Closed Captioning” box)
Webinar audio is not provided through Adobe Connect or
Defense Connect Online
- Dial: CONUS 888-877-0398; International 210-234-5878
- Use participant pass code: 3938468
Question-and-answer (Q&A) session
- Submit questions via the Q&A box
3. Resources Available for Download
3
Today’s presentation and resources are available for
download in the “Files” box on the screen, or visit
dvbic.dcoe.mil/online-education
4. Continuing Education Details
4
DCoE’s awarding of continuing education (CE) credit is limited in
scope to health care providers who actively provide psychological
health and traumatic brain injury care to active-duty U.S. service
members, reservists, National Guardsmen, military veterans
and/or their families.
The authority for training of contractors is at the discretion of the
chief contracting official.
Currently, only those contractors with scope of work or with commensurate
contract language are permitted in this training.
All who registered prior to the deadline on Thursday, Aug. 14,
2014, at 3 p.m. (EDT) and meet eligibility requirements stated
above are eligible to receive CE credit or a certificate of
attendance.
5. Continuing Education Details (continued)
5
If you pre-registered for this webinar and want to obtain
a CE certificate or a certificate of attendance, you must
complete the online CE evaluation and post-test.
After the webinar, visit
http://continuingeducation.dcri.duke.edu to complete the
online CE evaluation and post-test, and download your
CE certificate/certificate of attendance.
The Duke Medicine website online CE evaluation and
post-test will be open through Thursday, Aug. 21, 2014,
until 11:59 p.m. (EDT).
6. Continuing Education Details (continued)
Credit Designation – The Duke University School of Medicine
designates this live webinar for:
1.5 AMA PRA Category 1 Credit(s)
Additional Credit Designation includes:
1.5 ANCC nursing contact hours
0.15 IACET continuing education credit
1.5 NBCC contact hours credit commensurate to the length of the
program
1.5 contact hours from the North Carolina Psychology Board
1.5 NASW contact hours commensurate to the length of the program for
those who attend 100% of the program
6
7. Continuing Education Details (continued)
ACCME Accredited Provider Statement – The Duke University School of Medicine is accredited by the
Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
ANCC Accredited Provider Statement – Duke University Health System Department of Clinical Education &
Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing
Center’s (ANCC’s) Commission on Accreditation. 1.50 ANCC nursing contact hours are provided for participation in this
educational activity. In order to receive full contact-hour credit for this activity, you must attend the entire activity, participate
in individual or group activities such as exercises or pre/post-tests, and complete the evaluation and verification of
attendance forms at the conclusion of the activity.
IACET Authorized Provider Statement – Duke University Health System Clinical Education & Professional
Development is authorized by the International Association for Continuing Education and Training (IACET) to offer 0.15
continuing education credit to participants who meet all criteria for successful completion of authorized educational
activities. Successful completion is defined as (but may not be limited to) 100% attendance, full participation and
satisfactory completion of all related activities, and completion and return of evaluation at conclusion of the educational
activity. Partial credit is not awarded.
Duke University Health System Clinical Education & Professional Development has been approved as an Authorized
Provider by the International Association for Continuing Education &Training (IACET), 1760 Old Meadow Road, Suite 500,
McLean, VA 22102. In obtaining this approval, Duke University Health System Clinical Education & Professional
Development has demonstrated that it complies with the ANSI/IACET 1-2007 Standard, which is widely recognized as the
standard of best practice in continuing education internationally. As a result of Authorized Provider status, Duke University
Health System Clinical Education & Professional Development is authorized to offer IACET CEU’s for its programs that
qualify under the ANSI/IACET 1-2007 Standard.
7
8. Continuing Education Details (continued)
NBCC: Southern Regional Area Health Education Center (AHEC) is a National Board for Certified Counselors and
Affiliates, Inc.(NBCC)-Approved Continuing Education Provider (ACEPTM) and a cosponsor of this event/program. Southern
Regional AHEC may award NBCC-approved clock hours for events or programs that meet NBCC requirements. The ACEP
maintains responsibility for the content of this event. Contact hours credit commensurate to the length of the program will be
awarded to participants who attend 100% of the program.
Psychology: This activity complies with all of the Continuing Education Criteria identified through the North Carolina
Psychology Board's Continuing Education Requirements (21 NCAC 54.2104). Learners may take the certificate to their
respective State Boards to determine credit eligibility for contact hours.
NASW: National Association of Social Workers (NASW), North Carolina Chapter: Southern Regional AHEC will award
contact hours commensurate to the length of the program to participants who attend 100% of the program.
8
9. Questions and Chat
9
Throughout the webinar, you are welcome to submit technical
or content-related questions via the Q&A pod located on the
screen. Please do not submit technical or content-related
questions via the chat pod.
The Q&A pod is monitored during the webinar; questions will
be forwarded to presenters for response during the Q&A
session.
Participants may chat with one another during the webinar
using the chat pod.
The chat function will remain open 10 minutes after the
conclusion of the webinar.
10. Webinar Overview
10
The Defense and Veterans Brain Injury Center (DVBIC) reports an increase in traumatic brain
injuries (TBIs) in Defense Department numbers worldwide over the past two quarters.
All TBIs are to be documented or classified to a code from ICD-9-Clinical Modification. Proper
coding provides a detailed picture of a patient population, contributes to quality outcomes and
standards of care, permits correct reimbursements for clinical services and helps anticipate
demand for future services.
Medical coding professionals consider TBI coding to be “specialty” coding. Most lack experience
and clinical knowledge to code TBIs without guidance from coding specialists and clinical
colleagues.
Special rules apply to coding brain injuries in the Defense Department. Appendix G of the Military
Health System Coding Guidance: Professional Services and Specialty Coding Guidelines Version
3.6 contains rules that apply to coding brain injuries for both deployed and non-deployed settings.
These rules take precedence over any other coding guidance.
At the conclusion of the webinar, participants will be able to:
Discuss definitions, medical terms and basic brain anatomy specific to TBI.
Articulate the importance of correct documentation for TBI and correct ICD-9-CM coding and compliance.
Analyze initial and subsequent TBI encounter documentation and validate and/or identify appropriate ICD-9-
CM codes.
11. Presenter: Amy Waller, CPC, CPMA, CPCO
More than 20 years experience in health care
coding, auditing, consulting, compliance, billing and
management in both civilian and military settings
Certified Professional Coder, Certified Professional
Medical Auditor and Certified Professional
Compliance Officer
AHIMA Approved ICD-10-CM/PCS Trainer/
Ambassador
Currently responsible for the ICD-10-CM/PCS
Training Program for the Army
Has trained more than 2,000 providers, coders and
administrators on ICD-10-CM/PCS
11
Amy Waller, CPC, CPMA,
CPCO
12. Disclosures
12
The views expressed in this presentation are those
of the presenter and do not reflect the official policy
of the Defense Department (DoD) or the U.S.
Government.
The presenter does not intend to discuss the off-
label/investigative (unapproved) use of commercial
products or devices.
14. Polling Question
How are you involved with TBI at your Military
Treatment Facility (MTF)?
A. Medical Doctor (MD)
B. Doctor of Osteopathic Medicine (DO)
C. Physical Therapist (PT)
D. Occupational Therapist (OT )
E. Speech-Language Pathologist (SLP)
F. Registered Nurse (RN)
G. Nurse Practitioner (NP)/Physician Assistant (PA)
H. Social Worker (SW)
I. Case Manager
J. Inpatient Coder
K. Outpatient Coder
J. Other 14
15. What is ICD-9-CM?
The International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) is based on the World
Health Organization's Ninth Revision, International
Classification of Diseases (ICD-9). ICD-9-CM is the official
U.S. system of assigning codes to diagnoses and inpatient
procedures.
The National Center for Health Statistics (NCHS) and the
Centers for Medicare & Medicaid Services (CMS) are the
U.S. government agencies responsible for overseeing all
changes and modifications to ICD-9-CM.
15
16. History and Purpose
• ICD-9-CM has been in use since 1979.
• Statistical tracking of diseases was the intended
purpose of ICD-9-CM diagnosis codes (Volume 1
and 2).
• ICD-9-CM codes are used in the U.S. by payers for
billing and reimbursement purposes, not just for
epidemiological use.
Using a clinical system as a billing and reimbursement system has
many challenges. Many diagnoses do not have specific ICD-9-CM
codes. Changing to ICD-10-CM will alleviate some of these current
challenges, but it will add new ones as well, mainly for providers.
16
17. ICD-9-CM Classification
ICD-9-CM
consists
of three
volumes:
• Volume 1
• Tabular list containing a numerical
list of the disease code numbers in
tabular form
• Volume 2
• Alphabetical index to the disease
entries
• Volume 3
• Classification system for surgical,
diagnostic and therapeutic
procedures (alphabetic index and
tabular list)
17
18. ICD-10 Breakout
ICD-10-CM
• International
Classification of
Diseases 10th Revision,
Clinical Modification
– ALL Inpatient and
Outpatient Diagnosis
Codes
ICD-10-PCS
• International
Classification of
Diseases, 10th Revision,
Procedure Classification
System
– Inpatient Procedure
Codes ONLY
18
19. ICD-10-CM Facts
• Final rule for ICD-10-CM was implemented by
the United States Department of Health and
Human Services and published by CMS.
Who:
• ICD‐10-CM will replace ICD-9CM Vol. 1 & 2.
• ICD-10PCS will replace ICD-9CM Vol. 3.
• Both of these code sets will be unique to the
U.S.
What:
• ALL healthcare organizations within the U.S.
must make the transition.
• Workers Compensation Claims and Auto
Accidents are exempt.
Where:
• Currently, the new ICD-10-CM compliance date
is October 1, 2015.When:
19
20. TBI Definition
Centers for Disease Control and Prevention
A TBI is caused by a bump, blow or jolt to the head or a
penetrating head injury that disrupts the normal function of
the brain.
• Not all blows or jolts to the head result in a TBI.
• Severity of a TBI may range from “mild” (i.e., a brief change in
mental status or consciousness) to “severe” (i.e., an extended
period of unconsciousness or memory loss after the injury).
• Most TBIs that occur each year are mild, commonly called
concussions.
(Centers for Disease Control and Prevention, 2003) 20
21. TBI Definition
Department of Defense (DoD)
A traumatically induced structural injury and/or physiological
disruption of brain function as a result of external force that is
indicated by new onset or worsening of at least one of the
following clinical signs, immediately following the event:
• Any period of loss of or a decreased level of consciousness
• Any loss of memory for events immediately before or after the
injury
• Any alteration in mental state at the time of the injury (confusion,
disorientation, slowed thinking, etc.)
• Neurological deficits (weakness, loss of balance, change in vision,
praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may
not be transient
• Intracranial lesion
(Department of Defense, 2007) 21
22. External Forces
• External forces may include any of the following events:
– Head being struck by an object
– Head striking an object
– Brain undergoing an acceleration/deceleration movement
without direct external trauma to the head
– Foreign body penetrating the brain
– Forces generated from events such as a blast or
explosion, or other force yet to be defined
22(Department of Defense, 2007)
23. Basic Brain Anatomy
-Motor control
-Concentration
planning and
problem solving
-Speech
-Smell
-Hearing
-Facial
recognition
-Touch and
pressure
-Taste
-Body
awareness
-Vision
-Fine motor
(muscle) control
-Balance and
coordination
23
24. Brain Viewed from Above
Right Side Left Side
Judging the position
of things in space
Knowing body
position
Understanding and
remembering things
we do and see
Putting bits of
information together
to make an entire
picture
Controls the left
side of the body
Understanding and
use of language
(listening, reading,
speaking and
writing)
Memory for spoken
and written
messages
Detailed analysis of
information
Controls the right
side of the body
24
25. Brain Hemispheres
LEFT BRAIN DAMAGE RIGHT BRAIN DAMAGE
Problems seen on the right side of the body Problems seen on the left side of the body
25
27. Polling Question
A TBI is defined as:
A. A traumatically-induced structural injury and/or physiological
disruption of brain function as a result of external force that is
indicated by new onset or worsening of at least one of the following
clinical signs, immediately following the event.
B. A TBI is caused by a bump, blow, or jolt to the head or a
penetrating head injury that disrupts the normal function of the
brain.
C. Both A and B
D. Neither A nor B 27
28. Common Medical Terms
Agnosia Failure to recognize familiar objects
Agraphia Inability to express thoughts in writing
Alexia Inability to read
Aneurysm A balloon-like deformity in the wall of a blood
vessel
Anomia Inability to recall names of objects
Anosmia Loss of sense of smell
Anterograde amnesia Inability to remember ongoing events
Receptive aphasia Loss of ability to understand language
Expressive aphasia Loss of ability to formulate language
Apraxia Inability to carry out purposeful movement
Asterognosia Inability to recognize objects by touch 28
29. Common Medical Terms
continued
Ataxia Difficulty with muscle coordination
Clonus Rhythmic jerks following quick stretch of a muscle
Confabulation Verbalizations with no basis in reality
Convergence Movement of eyes inward to focus on closer object
Diplopia Seeing two images of a single subject
Dysarthria Difficulty in speaking due to muscle weakness
Dysmetria Inability to stop a movement at the desired point
Dysphagia Swallowing disorder
Echolalic Imitation of sounds or words without comprehension
Lability Drastic changes in emotions without apparent reason
Nystagmus Involuntary movement of the eyeballs
29
30. TBI Acronyms
• GCS - Glasgow Coma Scale
• HI - Head Injury
• ICP - Intracranial Pressure
• IED - Improvised Explosive Device
• JPTA - Joint Patient Tracking
Application
• LOC - Loss of Consciousness
• LRMC - Landstuhl Regional Medical
Center
• MACE - Military Acute Concussion
Evaluation
• MEDEVAC - Medical Evacuation
• MRI - Magnetic Resonance Imaging
• mTBI - mild Traumatic Brain
Injury/concussion
• NICoE - National Intrepid Center of
Excellence
• PDHA - Post Deployment Health
Assessment
• PDHRA - Post Deployment Health Re-
Assessment
• PDS - Pre-deployment screening
• PM&R - Physical Medicine and
Rehabilitation
• PTSD - Post-Traumatic Stress
Disorder
• PTA - Post-Traumatic Amnesia
• RCC - Regional Care Coordinator
• REC - Regional Education Coordinator
• RPG - Rocket Propelled Grenade
• SRC - Soldier Readiness Center
• SRP - Soldier Readiness Process
• TBI - Traumatic Brain Injury
• VTC - Video Tele-Conference
30
31. Documentation
The ICD-9-CM and ICD-10-CM Official Guidelines for
Coding and Reporting state:
“The importance of consistent,
complete documentation in the
medical record cannot be
overemphasized..”
31(Centers for Medicare & Medicaid Services, 2014)
32. Documentation Basics
Examples of
clinical
documentation
for outpatient
coding:
• An authenticated physician order for services
• Clinician visit notes
• A diagnosis or the reason the service was
ordered
• Test results
• Therapies
• A problem list
• Medication list
32
NOTE: Coders should not be coding from all test results in the outpatient
setting; they are allowed to code from test reports that have a physician
interpretation and are authenticated by the attending physician.
33. Encounter Documentation
Outpatient Diagnostic and Rehabilitative Services
• Coders review documentation of the following for both types of
services:
– Diagnosis, condition, problem or other reason for encounter/visit shown
in the medical record to be chiefly responsible for the outpatient
services provided during the encounter/visit
– Initial or subsequent visit
– Symptoms
– Deployment status
– Late effects
– Screening
33
Remember to always ask:
What is the reason for this
patient visit today???
Remember to include these
elements in all medical record
documentation, if applicable.
34. Other & Unspecified Codes
Other and unspecified codes are NOT the same!
“Other” Codes
– Codes titled “other” or “other specified”
• Usually a code with a 4th digit “8” or 5th digit “9” for diagnosis codes
• Use when the information in the medical record provides detail for
which a specific code does not exist
• Represent specific disease entities for which no specific code exists
so the term is included within an “other” code designation
“Unspecified” Codes
– Codes titled “un-specified”
• Usually a code with a 4th digit “9” or 5th digit “0” for diagnosis codes
• Use when the information in the medical record is insufficient to
assign a more specific code 34
35. TBI Level of Severity
35
The level of injury is based on observable signs at the time of injury.
Severity of injury does not predict functional or rehabilitative outcome of
the patient.
Mild Moderate Severe
Normal structural imaging
Normal or abnormal
structural imaging
Normal or abnormal structural
imaging
LOC = 0 – 30 min LOC >30 min and <24 hours LOC >24 hours
AOC = a moment up to 24
hours
AOC >24 hours. Severity based on other criteria
PTA = 0 – 1 day PTA >1 and <7 days PTA >7 days
AOC – Alteration of consciousness/mental state
PTA – Post-traumatic amnesia
LOC – Loss of consciousness
(Department of Defense, 2007)
36. Two Types of Encounters
Diagnostic Encounter
• ONLY medical providers can
diagnose a TBI.
• Initial or subsequent
• Codes types used:
– TBI diagnostic codes
– TBI V-codes
– Primary symptom codes
– Deployment status codes
– TBI screening code
– E-codes
– Other symptom codes
– Late effect codes
Rehabilitative Encounter
• Other privileged providers
MUST HAVE a medical
provider referral to treat.
• Initial or subsequent
• Code types used:
– Primary symptom code
– TBI V-code
– Late effect code
– Deployment status code
– Other symptom code
– Reason for visit code
36
37. Provider Visit Differences
Medical Provider
TBI Visits
• TBI screening, V80.01
Special screening for TBI:
– First positive screen:
• Initial encounter
– Seen again with
symptoms:
• Subsequent
encounter
Other Provider
TBI Visits
• Definitive TBI diagnosis by
Medical Provider:
– Receives referral:
• Initial encounter
– Seen again for e.g.,
therapy:
• Subsequent
encounter
37
38. Polling Question
Which of the following statement(s) is/are true?
A. When other and other specified appear in a code description, the
codes are assigned when patient record documentation provides
detail for which a specific code does not exist in ICD-9-CM.
B. Unspecified codes are assigned because patient record
documentation is insufficient to assign a more specific code.
C. Both A and B
D. Neither A nor B
38
39. TBI Diagnosis Codes
(850 Code Series)
39
TBI Diagnosis Codes (850 Code Series)
Concussion
4th Digit: presence of loss of consciousness (LOC) 5th Digit: duration of LOC (if present)
0 No LOC 0 Unspecified state of consciousness
1 Brief LOC (requires 5th digit) 1 LOC of 30 minutes or less
2 Moderate LOC (1-24 hours) 2 LOC of 31 to 59 minutes
3 Prolonged LOC and return to pre-existing condition
4 Prolonged LOC without return to pre-existing condition
850.12 Concussion with loss of consciousness from 31 to 59 minutes
NOTE: TBI DIAGNOSIS CODES MAY ONLY BE USED BY A
MEDICAL PROVIDER
40. TBI Diagnosis Codes
(851 Code Series)
40
TBI Diagnosis Codes (851 Code Series)
Cerebral laceration and contusion
4th Digit: cranial injury 5th Digit: duration of LOC
0 Cerebral contusion without open intracranial wound 0 Unspecified state of consciousness
1 Cerebral contusion with open intracranial wound 1 No LOC
2 Cerebral laceration without open intracranial wound 2 Brief LOC (less than 1 hour)
3 Cerebral laceration with open intracranial wound 3 Moderate LOC (1 – 24 hours)
4
Cerebellar or brain stem contusion without open
intracranial wound
4
Prolonged LOC (>24 hours) with return to
pre-existing conscious levels
5
Cerebellar or brain stem contusion with open
intracranial wound
5
Prolonged LOC (>24 hours) without return to
pre-existing conscious levels
6
Cerebellar or brain stem laceration without open
intracranial wound
6 LOC of unspecified duration
7
Cerebellar or brain stem laceration with open
intracranial wound
8
Other an unspecified contusion and/or laceration
without open intracranial wound
9
Other an unspecified contusion and/or laceration with
open intracranial wound
851.22 Cerebral laceration without open intracranial wound with brief (less than one hour) LOC
41. TBI Diagnosis Codes
(852 Code Series)
41
TBI Diagnosis Codes (852 Code Series)
Subarachnoid, subdural or extradural hemorrhage following injury
4th Digit: cranial injury 5th Digit: duration of LOC
0
Subarachnoid hemorrhage without open intracranial
wound
0 Unspecified state of consciousness
1
Subarachnoid hemorrhage with open intracranial
wound
1 No LOC
2
Subdural hemorrhage without open intracranial
wound
2 Brief LOC (less than 1 hour)
3 Subdural hemorrhage with open intracranial wound 3 Moderate LOC (1 – 24 hours)
4
Extradural hemorrhage without open intracranial
wound
4
Prolonged LOC (>24 hours) with return to pre-existing
conscious levels
5 Extradural hemorrhage with open intracranial wound 5
Prolonged LOC (>24 hours) without return to pre-existing
conscious levels
6 LOC of unspecified duration
Example: 852.33 Subdural hemorrhage with open intracranial wound and moderate LOC (1 – 24
hours)
42. TBI Diagnosis Codes
(800-804 & 853-854 Code Series)
42
TBI Diagnosis Codes (800 – 804 & 853 – 854 Code Series)
800 Fracture(s) of vault of skull
801 Fracture(s) of base of skull
803 Other closed skull fracture(s)
804 Closed fractures involving skull or face
853 Other and unspecified intracranial hemorrhage following injury (*only use 0 or 1 as the 4th digit)
854 Intracranial injuries of other/unspecified nature (*only use 0 or 1 as the 4th digit)
4th Digit: cranial injury 5th Digit: duration of LOC
0 Without mention of intracranial injury 0 Unspecified state of consciousness
1 With cerebral laceration and contusion 1 No LOC
2
With subarachnoid, subdural and/or extradural
hemorrhage
2 Brief LOC (less than 1 hour)
3 With other and unspecified intracranial hemorrhage 3 Moderate LOC (1 – 24 hours)
4 With intracranial injury of other/unspecified nature 4
Prolonged LOC (>24 hours) with return to pre-existing
conscious levels
5 With cerebral laceration and contusion 5
Prolonged LOC (>24 hours) without return to pre-existing
conscious levels
6 Without mention of intracranial injury 6 LOC of unspecified duration
800.12 Closed fracture of vault of skull with cerebral laceration and contusion with brief (less
than one hour) LOC
43. V-code Definition
43
• Encounters for circumstances other than disease or
injury
• V-codes (codes V01–V91) are used to describe
encounters with circumstances other than disease or
injury
• V-codes are used either as a first listed (primary) or
contributing (secondary) code depending on the
situation
V-Code Definition:
Index entries for V-codes are included in the
main Alphabetic Index in ICD-9-CM Volume 2.
44. DoD TBI Extender Codes
Some ICD-9-CM codes have been modified by
the DoD to meet the needs of the Services.
One-character extender is paired with a specific
ICD-9-CM code to acquire a unique meaning.
• Physicals
• Asthma
• Hepatitis
• Abortion
• Bacterial disease
• Gulf War-related diagnoses
Used to address a number of specific reporting
requirements
44
45. DoD TBI V-code Usage
If an extender has been established in accordance with specificity
guidelines, the root code is no longer valid for use without an
extender code.
This is crucial for TBI surveillance purposes.
Personal history of TBI codes (V15.52_x) must be used with any
diagnosed TBI encounter, initial or follow-up.
45
46. TBI V-codes
46
V-Code
(must be used with all TBI
encounters)
Injury related to Global
War on
Terrorism
Level of Severity
Unknown Mild Moderate Severe Penetrating
V15.52_0 Personal history of traumatic brain injury NOT otherwise specified
V15.52_1 Yes X
V15.52_2 Yes X
V15.52_3 Yes X
V15.52_4 Yes X
V15.52_5 Yes X
V15.52_6 No X
V15.52_7 No X
V15.52_8 No X
V15.52_9 No X
V15.52_A No X
V15.52_B Unknown X
V15.52_C Unknown X
V15.52_D Unknown X
V15.52_E Unknown X
V15.52_F Unknown X
47. Polling Question
Severity of injury can sometimes predict
functional or rehabilitative outcome of the
patient.
A. True
B. False
47
48. Coding Symptoms
• Code symptoms when:
• Cases for which no more specific diagnosis can
be made even after all facts bearing on the case
have been investigated
• Signs or symptoms existing at the time of initial
encounter that proved to be transient and whose
causes could not be determined
• Provisional diagnoses in a patient who failed to
return for further investigation or care
• Cases referred elsewhere for investigation or
treatment before the diagnosis was made
• Cases in which a more precise diagnosis was not
available for any other reason
• Certain symptoms which represent important
problems in medical care and which it might be
desired to classify in addition to a known cause
Codes that
describe
symptoms and
signs, as opposed
to diagnoses, are
acceptable for
reporting purposes
when an
established
diagnosis has not
been diagnosed (or
confirmed) by the
physician.
48
49. Common Symptom Codes
49
Cognitive/Linguistic
780.93 Memory loss
799.51 Attention and concentration deficit
799.52 Cognitive communication deficit
799.53 Visuospatial deficit
799.55 Frontal lobe and executive function deficit
799.59 Other signs and symptoms involving cognitive
Hearing
Location Codes: 0 = unspecified; 1 = external ear; 2 = tympanic membrane; 3 = middle ear; 4 = inner ear; 5 =
unilateral;: 6 = bilateral; 8 = combined types
388.30 Tinnitus
388.42 Hyperacusis
389.0 Conductive hearing loss (add location code as 5th character)
389.1 Sensorineural hearing loss (add location code as 5th character)
Neurologic
386.10 Peripheral vertigo
386.2 Central vertigo
784.0 Headache
339.20 Post-traumatic headache (unspecified)
339.21 Acute post-traumatic headache
339.22 Chronic post-traumatic headache
50. More Symptom Codes
50
Emotional/Behavioral
799.21 Nervousness
799.22 Irritability
799.23 Impulsiveness
799.24 Emotional lability
799.25 Demoralization and apathy
799.29 Other signs and symptoms involving emotional state
308.9 Acute stress reaction, unspecified
300 Anxiety/irritability
311 Depression
Sleep
780.52 Insomnia
327.23 Obstructive sleep apnea
327.3 Circadian rhythm sleep disorder: delayed type (327.31) or advanced type (327.32)
780.5 Sleep disturbance
Vision
368.13 Visual discomfort (e.g., photophobia)
368.8 Other specified visual disturbance
51. Late Effects
A late effect is the residual effect (condition produced) after
the acute phase of an illness or injury has terminated.
• Acute phase is not defined and is left to clinical judgment
• No time limit on when a late effect code can be used
• Residual effect may be apparent early or it may occur months or
years later
• Cerebrovascular accident
• Previous injury
• Never use the acute illness or injury code that led to the late effect
with a late effect code.
51
52. Late Effect Codes
52
Late Effect Codes
905.0 Late effect of fracture of the skull and
facial bones
906.0 Late effect of open wound of head, neck
and trunk
907.0 Late effect of intracranial injury without
skull or facial fracture
Coding of late effects requires
three codes sequenced in the
following order:
1. Condition or nature of the late effect
2. TBI V-code is sequenced second
3. Late effect code
Must be used with all follow up
TBI encounters!
53. Polling Question
Codes that describe symptoms and signs, as
opposed to diagnoses, are never acceptable
for reporting purposes even when an
established diagnosis has not been diagnosed
(or confirmed) by the physician.
A. True
B. False
53
54. Deployment Codes
54
Deployment Status V-codes
V70.5_4
Pre-deployment encounter: Encounter related to a projected deployment. Could
include family members experiencing a condition related to the projected
deployment of the sponsor or other family member.
V70.5_5
During deployment encounter: Any deployment-related encounter performed while
individual (active duty [AD], contractor, etc.) is deployed. Could include family
members experiencing a condition related to the deployment of the sponsor or
other family member.
V70.5_6
Post-deployment encounter: Specifically performed because an individual was
deployed. Could include family members experiencing a condition related to a
prior deployment of the sponsor or other family member.
55. E-codes
• E-codes are supplemental codes that capture the external cause of
injury or poisoning, the intent and the place where the event
occurred.
• E-codes are intended to provide data for injury research and
prevention strategies.
• E-codes are never to be used as a primary diagnosis code.
55
E-codes
E979.2 Terrorism involving other explosions/fragments
E999 Late effects of injury due to war operations and terrorism
E993.3 Injury due to war operations by person-borne Improvised Explosive Device (IED)
E991.6 Injury due to war operations by vehicle-borne IED
E991.7 Injury due to war operations by other IED
56. Reason for Visit Codes
56
Reason for Visit Codes:
V57.1 Physical therapy
V57.21 Occupational therapy
V57.3 Speech therapy
Code the reason for the visit for all rehabilitative
encounters, both initial and subsequent.
Visit code is first listed for subsequent visits.
57. Code Sequencing
Medical Provider – Initial
57
Order Description Code Example
1 Primary TBI Diagnosis Code 8XX.XX
2 TBI V-code V15.52_X
3 Primary symptom code 780.93
4 Deployment code, if applicable V70.5_X
5 TBI screening code V80.01
6 Other symptom codes, if applicable 784.0
7 E-code, if applicable E999
58. Code Sequencing
Medical Provider – Subsequent
58
Order Description Code Example
1 Primary symptom code 780.93
2 TBI V-code V15.52_X
3 Late effect code 905.0
4 Deployment code, if applicable V70.5_X
5 Other symptom codes, if applicable 784.0
59. Code Sequencing
Rehabilitation Provider – Initial
59
Order Description Code Example
1 Primary symptom code 780.93
2 TBI V-code V15.52_X
3 Late effect code 905.0
4 Deployment code, if applicable V70.5_X
5 Other symptom codes, if applicable 784.0
6 Visit Code: reason for visit V57.3
60. Code Sequencing
Rehabilitation Provider – Subsequent
60
Order Description Code Example
1 Visit Code: reason for visit V57.3
2 TBI V-code V15.52_X
3 Late effect code 905.0
4 Deployment code, if applicable V70.5_X
5 Symptom codes, if applicable 780.52
62. Case Study 1
A soldier presents to the battalion aid station after convoy hit by IED per U.S.
Central Command (CENTCOM) policy. Other soldiers severely injured in same
incident. Soldier denies LOC, but reports seeing stars, stumbling around for a
few minutes, and he cannot account for approximately 15 minutes of activity
after the explosion. At time of evaluation, soldier is asymptomatic MACE score
30/30.
62
Code Description
Primary Diagnosis 850.0
Concussion with no loss of
consciousness
V15.52_2
Personal History of TBI, GWOT Related,
Mild
V70.5_5 During deployment encounter
V80.01 TBI Screening Code
E979.2
Terrorism Involving Other
Explosions/Fragments
63. Case Study 2
A soldier presents to the MTF stating she is suffering from headaches
which date back to an explosion occurring in Iraq two weeks ago.
Provider reviews AHLTA (electronic health record) notes and finds a
note written immediately after the injury that document the injury event
associated with an alteration of consciousness coded with 850.0. The
provider determines that the complaints are acute.
NOTE: V15.52_x associates the acute symptom (headache) with TBI. 63
Code Description
Primary Diagnosis 784.0 Headache
Secondary
Diagnosis
V15.52_2
Personal History of TBI, GWOT Related,
Mild
V70.5_6 Post deployment encounter
64. Case Study 3
A soldier presents to the clinic for evaluation of persistent headaches after she
answered yes to one of the TBI questions on the PDHA. Review of her AHLTA
notes reveals post-motor vehicle collision evaluation in theater with
documentation of right arm fracture and facial contusions six months ago, but
no documentation of TBI evaluation, no MACE, and no TBI diagnoses coded.
Follow up visits indicate complaint of headaches, but no documentation of
treatment. Patient interview reveals a history of headaches, tinnitus, intermittent
dizziness, and blurred vision since the accident. She also had grogginess and
poor recall of events for a few hours after the crash.
64
Code Description
Primary Diagnosis 850.0 Concussion with no LOC
V15.52_2
Personal History of TBI, GWOT Related,
Mild
784.0 Headache
V70.5_6 Post deployment encounter
65. Case Study 4
A family member presents to the MTF clinic complaining of persistent
headaches. Complains also of blurred vision, and dizziness
(unspecified vertigo) since being involved in a motor vehicle accident
with loss of consciousness for 15 minutes two months prior to this
encounter. Review of previous AHLTA notes reveals an emergency
room visit with a CT scan positive for frontal contusion and coded with
851.02 and V15.52_7.
65
Code Description
Primary Diagnosis 784.0 Headache
V15.52_7
Personal History of TBI, Not GWOT Related,
Mild
907.0
Late effect of intracranial injury without
mention of skull fracture
368.8 Blurred vision
780.4 Dizziness
66. Accurately document
traumatic brain injury
encounters with current
Defense Department codes
Department of Defense ICD-9
Coding Guidance for
Traumatic Brain Injury
To order hard copies or download
electronic copies, visit dcoe.mil
67. References
Centers for Disease Control and Prevention. International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM). Retrieved July 31, 2014, from http://www.cdc.gov/nchs/icd/icd9cm.htm
Center for Disease Control and Prevention, National Center for Injury Prevention and Control. (2003). Report to
Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem.
Retrieved from http://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf
Centers for Medicare & Medicaid Services. Coding. Retrieved July 31, 2014, from
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding.html
Centers for Medicare & Medicaid Services. International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM). Retrieved July 31, 2014, from http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
Centers for Medicare & Medicaid Services. International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM). Retrieved July 31, 2014, from http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
U.S. Department of Defense, Defense Health Agency, Unified Biostatistical Utility. (2014). Military Health System coding guidance:
Professional services and specialty coding guidelines (Version 3.6). Retrieved from
http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm
U.S. Department of Defense, Health Affairs. (2007). Memorandum from the Assistant Secretary of Defense S. Ward Casscells, M.D.
Retrieved from http://www.health.mil/~/media/MHS/Policy%20Files/Import/07-030.ashx
67
68. Access training materials, quick reference cards, patient self-report
measures and patient educational materials at dvbic.dcoe.mil
Learn how to evaluate and manage sleep
disturbances associated with a mild traumatic brain injury
69. Questions?
Submit questions via the
Q&A box located on the
screen.
The Q&A box is monitored
and questions will be
forwarded to our
presenters for response.
We will respond to as
many questions as time
permits.
69
70. Continuing Education Details
70
If you pre-registered for this webinar and want to obtain a
CE certificate or a certificate of attendance, you must
complete the online CE evaluation and post-test.
After the webinar, please visit
http://continuingeducation.dcri.duke.edu to complete the
online CE evaluation and post-test and download your CE
certificate/certificate of attendance.
The Duke Medicine website online CE evaluation and
post-test will be open through Thursday, Aug. 21, 2014,
until 11:59 p.m. (EDT).
71. Webinar Evaluation/Feedback
We want your feedback!
Please complete the Interactive Customer Evaluation
which will open in a new browser window after the
webinar, or visit:
https://ice.disa.mil/index.cfm?fa=card&sp=131517&s=10
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Or send comments to usarmy.ncr.medcom-usamrmc-
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71
72. Chat and Networking
Chat function will remain open 10 minutes after the
conclusion of the webinar to permit webinar attendees to
continue to network with each other.
72
73. DCoE Contact Info
DCoE Outreach Center
866-966-1020 (toll-free)
dcoe.mil
resources@dcoeoutreach.org
73
74. Save the Date
Next DCoE Psychological Health Webinar:
A Population Approach to Treatment
Engagement in Behavioral Health Care
Aug. 28, 2014
1-2:30 p.m. (EDT)
Next DCoE TBI Webinar:
Gender Differences and TBI
Oct. 9, 2014
1-2:30 p.m. (EDT)