FAQ's
Frequently Asked
Questions
Q1: Do I
always need to use secondary diagnosis codes with a
late effect
code?
A1: A late effect
describes a residual effect of an illness and usually requires two
codes. The first code identifies the condition followed by the
residual/late effect. Example: Late effects CVA with dysphagia
438.82 dysphagia 787.20(PPS category 6&7). When looking up Late
effects CVA with dysphagia 438.82, code instructions state to
identify the type of dysphagia, thus identifying the need for an
additional code.
Exceptions occur
when the ICD-9 code is expanded at the 4th or 5th digit that
includes the residual/late effect. Example: Late effects CVA
with hemiplegia 438.20
Q2: MO650 - upper body dressing.
We have some discrepancies about how you would score
a patient's ability for the following scenarios:
The
patient puts all of his clothes in a dresser because he can
no longer use the closet safely. This adaptation was made
by the patient prior to us doing the assessment.
Some of us say he is a "0" because his usual place
for his clothes is now his dresser and he can manage without
assist. Some of us say he is a 1
because he can not get his clothes out of his closet without
assist.
A2: MO
650 identifies the patient’s ability to obtain, put on &
take off clothing. Where the patient keeps his clothing,
closet or dresser, is not the issue. He currently keeps his
clothing in a dresser and is able to obtain, put on & take
off. Correct MO response would be “0”
Q3: We
have always used 414.00 for CAD but are now hearing that we
should be using 414.01.
A3:
414.01 describes CAD of the native coronary artery (the
patient's own original anatomy) 414.00 is used when the
patient had a bypass with CAD without mention of what
artery was bypassed. 414.02-414.05 are used for forms
affecting grafted tissue vessel.
Q4: Our
therapist sees things slightly differently than our nurse.
We have a patient that can walk indoors with a rolling
walker independently. On the stairs, they use a rail, cane
and supervision. They also need supervision when ambulating
outside. The therapist feels that 2 is most representative
of the patient and the nurse disagrees.
A4: To
be scored a 2, they walk only with the supervision or
assistance of someone at all times. In this case the
correct response would be 1.
Announcement
2008 MaHIMA’s Professional
Achievement Award Winner :
Joan L. Usher, BS, RHIA, COS-C, ACE
Given to
individuals who have worked tirelessly to support the HIM profession
by advancing American Health Information
Management Association's (AHIMA)
leadership position and/or who have developed or refined practice
theory, demonstrated leadership, or introduced innovation and
creativity to current practice. These are best characterized as
individuals who go above and beyond in their quest to make the HIM
profession thrive.
Announcement
Joan L. Usher, BS, RHIA, COS-C, ACE has
been appointed to serve on the Hospice & Palliative Care Federation
of MA Board of Directors, for the 2008-2009 term.
Helpful Resources
(for more
information click on link below)
updated 10/20/08
Massachusetts Medical Record
Copying Fee updated 2008
Effective October 1, 2008 Chapter 135 of the Acts of 2003 allows
Massachusetts medical record copying fees to be increased
for FY2008 by 4.9%. The maximum rate that providers may charge for medical records
starting October 1, 2008 is:
-
$18.04 base charge for the clerical and other
administrative expenses related to complying with the request
for making a copy of the record; (excludes requests made by a
patient) ****
-
$0.61 per-page charge of the first 100 pages
copied;
-
$0.32 per-page charge for each page in excess of
100 pages;
-
Provider is allowed to charge an additional fee
related to the cost of postage (regular or priority/next day
mailing);
-
The provider is allowed to charge for the cost of
developing a summary of the medical information if requested.
Providers should be aware that fees must be waived for any request
that is made by a patient for a record used for an administrative,
claims, or eligibility review with Medicare, MassHealth, or other
public assistance programs. Requests made by any party other than patient or patient’s personal
representative, may be charged the base free for administrative
expenses.
The law establishes basis for which the fees may be set and may be
set lower than base charge but not higher.
****Massachusetts Hospital Association recommends that providers
should only charge the per page rate as the base rate is preempted
by HIPAA provisions.
