HCC Blog by Caridad

Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) Severe Sepsis Present Data Element Version 5.14a Questions and Answers Effective for July 1, 2023, through December 31, 2023 "Participants will be able to understand and interpret the guidance in Version 5.14a, effective for July 1, 2023, through December31, 2023 discharges, of the specifications manual, specific to the Severe Sepsis Present data element, to ensure successful reporting for the SEP-1 measure for the Hospital Inpatient Quality Reporting Program." A few highlights from the document include: To establish the presence of severe sepsis by clinical criteria , all three clinical criteria (a, b, and c) must be met within six hours of each other. The three clinical criteria do not need to be documented in any particular order.  a. Documentation of an infection  b. Two or more manifestations of systemic infection according to the Systemic Inflammatory Response Syndrome (SIRS) criteria  c. Organ dy...

The Medicare Program Integrity Manual contains the guidance around signature requirements.  They are  found in chapter 3. 3.3.2.4 - Signature Requirements  This material was also covered in the Part AB November 2025 webinar by Noridian entitled: Signature Requirements Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.

In ICD-10-CM code book, osteomyelitis, M86, is subdivided into these body areas:       shoulder      humerus      radius and ulna      hand      femur      tibia and fibula      ankle and foot      multiple sites then each is further subdivided by:   acuity (acute, subacute or chronic)  and  laterality (left or right) Use additional code (B95-B97) to identify infectious agent and any major osseous defect, if applicable (M89.7-) Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented h...

Depending on the reason a patient is being seen after a fall, here are two scenarios to consider.  Let's look at these two diagnoses - Fall, initial encounter vs. history of falls.  If clinician uses the diagnosis of "Fall, initial encounter"  then they need to add the date of the fall to the chart note. When using the code of W19.XXXA, a Date of Injury must be provided. Add the date of injury in the claim information record. As an example, this diagnosis can be used for worker's compensation visits.   Or, if appropriate, clinician can also consider using the diagnosis of 'history of falls' Z91.81. With this code, no date is needed. This can be used with quality reporting. Clinicians documentation of the reason for the fall will help with code selection. Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and compl...

  Dementia ICD-10-CM classifies dementia on the basis of: etiology, severity and associated behavioral disturbances.  Etiology  refers to the type of dementia. This can include:      Vascular dementia F01      Dementia in other diseases classified elsewhere F02      Unspecified dementia F03 Severity  includes mild, moderate and severe:                 Mild - Clearly evident functional impact on daily life, affecting mainly instrumental activities. No longer fully independent; requires occasional assistance with ADLs.                 Moderate - Extensive functional impact on daily life with impairment in basic activities. No longer independent; requires frequent assistance with ADLs.                 Sev...

For this diagnosis of diabetes with skin complications, the relationship between the two conditions must be stated by the provider in their documentation. There is not presumed relationship as with some other diabetes diagnosis. This can include: cellulitis and onychomycosis (fingernails and/or toenails) as well as other provider stated conditions. Codes include: E10.628 Type 1 diabetes mellitus with other skin complications E11.628 Type 2 diabetes mellitus with other skin complications E13.628 Other specified diabetes mellitus with other skin complications Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein ...