By Steven Andrews
HPI: This is a 68 yr old male who comes in for a chief complaint of rash, located on the axillae. The rash is itchy and red and moderate in severity. The rash has been present for weeks. Pertinent negatives include: no joint aches, no blisters, no diarrhea, and no cough. He reports no household contacts with similar rash, no new medications and no new personal care products. He is not currently on any treatment.
EXAM:An examination was performed including the scalp (including hair inspection), head (including face), inspection of conjunctivae and lids, lips but not teeth and gums, neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, left lower extremity, genitalia, groin, buttocks, and inspection and palpation of digits and nails.
General appearance of the patient is well developed and well nourished.
Orientation: alert and oriented x 3.
Mood and affect in no acute distress.
Findings in the above examined areas were normal with the exception of the following exam descriptions below:
1. Irritant Contact Dermatitis (L24.9)
I counseled the patient regarding the following:
Irritant Contact Dermatitis Skin Care: Avoiding harsh chemicals, prolonged water exposure and wearing gloves can all help improve irritant contact dermatitis. Applying moisturizers regularly will also help reduce irritation. Topical steroids can help in more advanced cases.
Expectations: Irritant Contact dermatitis can persist unless contact with irritants in the environment are eliminated. Sometimes, patch testing is necessary to exclude an allergic contact dermatitis. Contact office if: your dermatitis worsens or fails to improve despite several weeks of treatment.
betamethasone valerate 0.1% lotion TP Sig: Apply 2 times a day as needed (1 refill)
2. Dog Bite- dog bite occurred 6/2/17
Initial visit (W54.0XXA)
mupirocin 2% topical ointment TP Sig: Apply up to 3 times a day (1 refill)
Plan: MIPS Quality.
Quality 110 (Influenza Immunization): Influenza immunization not administered because patient refused.
Follow up PRN
Neulasta OnPro SQ
ondanestron IV Push
dexamethasone IV Push
NaCl IV Infusion started 0845 stopped 1730
mesna IV infusion started 0930 stopped 1730
ifosfamide IV infusion started 0930 stopped 1230
Thanks so much,
HIM Reimagined: Just the facts
by Sheila Carlon, Ph.D., RHIA, FAHIMA; Mary Beth Haugen, MS, RHIA; Connie Renda, MA, RHIA, CHDA; Linda Sorensen, MPA, RHIA, CHPS
The Health Information Management Reimagined (HIMR) taskforce is charged with envisioning for the HIM profession in 10 years. The HIMR vision was created to ensure current and future professionals are prepared for the future of HIM in the rapidly changing environment resulting from changes in healthcare, technology, and education. Under the direction of the Council for Excellence in Education (CEE), the taskforce comprises educators from all academic levels (associate, baccalaureate, and graduate) as well as HIM practitioners. The CEE oversight body comprises educators and practitioners who hold a variety of HIM credentials including Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and other specialty credentials.
When working to shape the future of the HIM profession, the HIMR taskforce worked (and continues to work) diligently to seek input from a variety of stakeholders. Members of the taskforce presented the HIMR recommendations to the boards of AHIMA and the Commission on Certification for Health Informatics and Information Management (CCHIIM) and at the AHIMA leadership symposium, Component State Association meetings, and Assembly on Education. In addition, HIMR sought direct comments from CAHIIM, external stakeholders (employers and professional associations), and the AHIMA membership at large.
Through the comment and discussion period, the taskforce received direct comments from 60 AHIMA members and interested stakeholders. The passion and commitment of those that commented has been acknowledged as well as the commitment and leadership of the HIMR taskforce as they seek to advance the HIM profession through this innovative vision. Members of the taskforce would like to take this opportunity to clarify the recommendations and address some of these comments.
HIMR fact and fiction
One noted interpretation of HIMR is the elimination of associate degree programs.
- Fact (as taken from the draft HIMR white paper, available at www.ahima.org/about/him-reimagined/himr?tabid=whitepaper): Program accreditation at the associate level continues, as does the associate level degree, but it is based on a condensed set of HIM core content and deeper specialty content.
- Rationale: The taskforce recognizes the critical importance of associate degree programs to the HIM profession. HIMR demonstrates commitment to this academic level through the plan to create specializations at the associate level in response to industry need.
Another common response to HIMR is that the industry changes noted in the white paper will not impact HIM professionals as significantly as suggested.
- Fact: While we cannot predict the future, we can look to the past, the experiences of similar industries, and to the well recognized changes proposed for the future by experts in healthcare and technology. All indicators point to significant changes in healthcare and health information technology that will impact the work of HIM professionals. The recommendations in HIMR are intended to reflect healthcare in 10 years and beyond, not healthcare today. Moreover, healthcare and other industries are requiring higher levels of academic preparation, particularly for key leadership roles. HIMR supports creating clear pathways for academic advancement to position HIM professionals for future success in the workplace.
In response to the HIM white paper, some have expressed concern with the notion of specialization, particularly with the impact on rural communities.
- Fact: The specialty tracks proposed in HIMR will include a HIM core curriculum that represents the HIM body of knowledge. This proposed core curriculum would cover content related to the existing HIM domains of knowledge while affording academic programs the flexibility to meet their local needs. It is the firm belief of the HIMR taskforce that having specialties at the associate degree level demonstrates the diversity of the HIM profession today and creates a multitude of opportunities for HIM professionals tomorrow.
Some have interpreted HIMR as promoting a reduction or elimination of the clinical knowledge component of HIM curricula.
- Fact: HIMR does not make any mention of reducing or eliminating the need for clinical knowledge among graduates of HIM academic programs. While HIMR reflects a transition in the roles associated with HIM practice, the members of the taskforce recognize, celebrate, and support the clinical knowledge that HIM professionals bring to managing health information. The taskforce also recognizes that the diversification of the HIM profession requires a balance of clinical knowledge based on specialty, academic level, and domain of practice. Clearly, the HIM professional’s ability to communicate effectively in any healthcare-related role is enhanced by a strong clinical knowledge base. Future curriculum development activities will continue to include clinical content requirements as appropriate for the academic level and specialty.
Respondents have expressed concern with the sunsetting of the RHIT credential at the end of the 10-year HIMR plan.
- Fact: HIMR includes a recommendation to phase in specialty programs and associated specialty credentials. At the end of the proposed 10-year implementation plan, the recommendation is to sunset the RHIT credential and replace it with specialty credentials. The intent is to also use the associate programs as a building block to baccalaureate programs and the baccalaureate programs as a building block to master’s programs, since the knowledge required in HIM continues to become more advanced and complex.
- When HIMR was introduced, it was as a draft document with the specific intent of gathering feedback and input. Input received during the comment period and ongoing discussion about the value of a strong RHIT brand has prompted ongoing dialogue on this topic with the HIMR taskforce. The taskforce members are currently considering options to retain the RHIT brand in combination with academic specializations. Feedback and discussion is planned for the House of Delegates at AHIMA’s annual convention in October 2016 and will serve as a sounding board related to this topic with final revisions to HIMR planned before the end of 2016.
Respondents have interpreted HIMR to allow individuals with less than a baccalaureate degree to earn the RHIA credential.
- Fact: This is in no way stated or implied by HIMR. However, HIMR includes a recommendation for individuals who hold a baccalaureate degree or higher who also hold a RHIT credential?a window of opportunity to attain the RHIA credential. A similar 1999?2004 initiative was instrumental in positioning HIM professionals with advanced degrees for recognition of their HIM knowledge and higher level education. Comments have been received about the need for more granular eligibility criteria should such an initiative be undertaken as part of the HIMR plan. The taskforce continues to discuss eligibility criteria around this recommendation based on feedback received to date.
Respondents have interpreted HIMR to downplay the importance of coding of health information.
- Fact: Coded health information has never been more important. HIMR recognizes this in multiple ways, such as coded data being a source of data that will offer increased opportunity for HIM professionals with analytics and other associated skills. In addition, HIMR also recognizes that coding knowledge and leadership will continue to be a pillar of the HIM profession. However, we anticipate the role of traditional coder will continue to evolve, requiring additional skills and education to be able to engage in higher level roles, such as auditing, compliance, and other coding related leadership roles.
Leading is not always easy, because if it is done right it almost certainly requires change. Change is difficult, and the story of HIM is a story of change. We can collaborate to construct a future for HIM that is different, hopeful, and innovative. John F. Kennedy said ‘And those who look only to the past or present are certain to miss the future.’ This message seems as appropriate today as when the words were first spoken. This journey will require leadership, political will, and compromise from all stakeholders to push the profession forward. Only through our joint willingness to accept this challenge can we succeed as united HIM professionals.
Carlon is the HIM department director for CC & IS/Regis University in Denver. Haugen is the president and CEO of The Haugen Consulting Group, Inc., in Denver. Renda is the assistant professor and program director of health information technology at San Diego Mesa College. Sorensen is the department chair for the health information management department and Allied Health College of Health Professions at Davenport University in Grand Rapids, Michigan. Opinions expressed are that of the author(s) and do not represent HCPro or ACDIS.
Claim was submitted as below. Line 2, 4, 5 and 6 denied. Invalid modifier, included in another procedure.
Line 1 99213 25 M76.52 Patellar tendinitis left knee, M25.362 Other instability left knee, M25.361 Other instability right knee
Line 2 20611 M76.52 Patellar tendinitis left knee
Line 3 20611 50 M76.51 Patellar tendinitis Right Knee
Line 4 29530 59 M76.52 Patellar tendinitis left knee
Line 5 29530 50 59 M76.51 Patellar tendinitis Right
Line 6 J2000 M76.52 Patellar tendinitis left knee
So I have the following procedure description during an office visit:
Patient presents for eval for left ear lesion. He has a hx of left auricular abscess that was previously I&D’d and placed on extended course of Abx. He secondarily developed a cauliflower ear deformity. His reports an 80% improvement to his abscess with only mild residual drainge. He also has a 5mm skin lesion at the root of the helix on the same ear that was biopsied by previous ENT and found + for SCCA. The lesion appears to be separate from the abscess. + smoker, currently on levaquin and has approx 1 week left. He denies any pain in the ear today. He has a longstanding hearing loss in that ear was well and wears a HA in the right ear.
biospy + SCCA excised on the superior helix. The second portion of the procedure was extensive and included complete de-epithelization of a subcutaneous fistulous tract and pocket that extended the entire length of the concha likely formed secondary to his previous infection/abscess and led to his persistent foul smelling drainage. The procedure was initially scheduled for 1 hour but took 2 hours to complete because of the unforseen extensive nature of the fistulous track and pocket.
I reviewed his post procedure instructions and precautions in detail and questions answered. He will follow up tomorrow for wound check.
Full procedure note:
After written consent was obtained from the patient, the skin overlying the 6mm lesion at the superior helix was cleaned with alcohol and injected with 0.5ml 1% lidocaine with 1:100,000 epinepherine. The neck was then draped with a sterile drape. The left ear was then prepped with betadine. 3mm margins around the skin lesion on the superior helix were then outlined with a marking pen. A scalpel was then used to make an elliptical incision around the lesion with a defect size of 1.4 x 2cm. Scissors were then used to dissect the lesion from its surrouding tissues until it was removed in its entirety. The specimen was marked long stitch as anterior and short stitch as superior.
Attention was then focused on the adjacent draining fistula at the helical root. The tract was probed and explored and found to be an extensive subcutaneous pocket with foul smelling dishwater like drainage. The ear was then incised along the scaphoid fossa elevating a skin flap over the outer ear over the superior portion of helix and concha cymba. Complete epithelialization of the subcutaneous tissues was extensive and present in the pouch. Foul smelling clear drainage was present. The entire area was carefully depithelialized. The fistulas tract was depithelialized and closed. The wound was irrigated copiously with half strength peroxide and then closed using 5-0 prolene sutures. The left ear was then dressed with dental bolsters soaked in iodine and xeroform gauze sutured to the ear with 2-0 prolene sutures. The patient tolerated the procedure well."
At first, I was thinking of going with 11602 & 12051 for the lesion excision + closure & an adjacent tissue transfer code for the mentioned cleaning of the abscess. I know that malignant lesion excision is included in tissue transfer on the same location, but the physician is addressing 2 separate issues here (cancerous lesion and infected abscess). So I’m not sure which way to go. Also, the provider is generating a service order for 69005 (Drainage of external ear abscess), so should this be considered as well since no measurements are given for the abscess pocket? Any advice here would be appreciated. Thanks.