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By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA I think the most powerful guideline is A11. While it uses the example of distinguishing between ICD-10-PCS root operations Excision and Resection, it is far more than that. This is the guideline that gives us coders the power to think for ourselves as we read and interpret clinical documentation and translate it into codes. With this great power comes great responsibility. Never is our coding responsibility greater than when we prepare for the code set updates each year, when there are all kinds of things to learn. - Coders have a responsibility to

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Hands-on experience with real inpatient records means everything if your dream job is “Inpatient Coder.” Wouldn’t it be nice to have a tutor while you learn? See for yourself!  Join Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA for a demonstration of  this online virtual tutor here. I had been wanting to tackle the problem of how to teach real hands-on inpatient coding skills for a while. The disruption of the last few years made this a much more urgent challenge. Practical Coding Experience (PCE) on the Coding Workspace™ platform was “born” with the help of

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Coding is important. It is how we track and quantify the health of individuals and our nation’s population as a whole. It is used to measure and improve the quality of the services our healthcare organizations provide. It becomes the data in the shared repository of health information to support research and advancements in medical science. Coding is essential to our efforts to improve the quality of health data and through that the quality of care and overall health of our country. It is also how healthcare organizations get paid. And because there

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA In the television series, The Crown, King George VI tells the Princess Elizabeth his approach to reviewing the documents received in the red box, that daily package of papers sent from the government to the sovereign. It could be an overwhelming task. His solution: he would flip the pile over and start at the bottom where more critical or even controversial information was sometimes tucked, in the hopes he might not see it. I have recently been working with coders who are transitioning from outpatient to inpatient coding. One theme that continues to

By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA One of the challenges of ICD-10-PCS coding is making sense of the documentation as it appears in the record in order to support accurate code assignment. When learning to code a procedure, wouldn’t it be nice if someone would just point out the important parts? It would be so much easier if you knew what to look for and which documentation gives the “secret” that unravels the mystery of the procedure. Sometimes, the answer is right there but we just can’t see it. I find this problem in students I am mentoring who

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA It is probably not news to any of you that medical documentation can be tricky. A question came to me recently that asked “Trying to code the percutaneous thrombectomy of SFA with insertion of stent.” Just like in documentation, sometimes you do not get all the information you would like to have so I had to guess what the coder’s real issue was. Here is my answer to the question: In PCS, the thrombectomy (extirpation) and the dilation with the stent are both coded. Stents are placed during a dilation procedure, not inserted,

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA The FY 2022 changes to Guideline B4.1c make me extremely concerned about data collection for coding of vascular procedures. Since its addition to the Guidelines for FY 2018, Guideline B4.1c has read “If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry.” For FY 2022, the guideline is radically changed. Guideline B4.1c will read “If a procedure is performed on a continuous section of a tubular body part, code the body part value

By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA For years, people have wondered why the zooplastic option was available in the Transplantation tables and now we know why. A Maryland hospital transplanted a pig heart into a human for the first time on January 7th. A lucky coder at that hospital will be the first to use the Zooplastic qualifier for heart transplantation when coding this case as 02YA0Z2, Transplantation of Heart, Zooplastic, Open Approach. The ICD-10-PCS code set is robust, with options for coding things that seem like they will never be done in current surgical practice. This tells us

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Learning to code from books is vital but hands-on experience with real inpatient records means everything if your dream job is “Inpatient Coder.” Wouldn’t it be nice to have a tutor while you learn? That’s how it was done years ago and even right up until COVID-19 turned our world upside down. In Spring of 2020, students were being displaced from in-person professional practice experiences (PPEs), and I became a virtual tutor overnight. I had been wanting to tackle the problem of how to teach real hands-on inpatient coding skills for a while.