Articles - The Gold Standard

Whether you are located in a community general hospital or a high powered Pediatric center, professional coders have to know that kids are not the same as adults – pediatric diseases may be totally alien to an acute care hospital coder, regardless of how many years you’ve had ...

Robert S. Gold, MD

There is something coming down the pike that will affect every one of you — a new coding system for epidemiology of disease: ICD-10.

The system for countries to communicate with each other regarding incidence of diseases, mortality statistics, and responses to treatment — the International ...

Sepsis is defined as a whole body inflammatory state (i.e., a systemic inflammatory response syndrome or SIRS) caused by ...

Robert S. Gold, MD

Cardiomyopathy is typically a long-lasting disease (-pathy) of the heart (cardio-) muscle (-myo-). The American Heart Association (AHA) and the American College of Cardiology (ACC) published the stages of heart failure in 2001. These stages are distinctly different from the classes of ...

Robert S. Gold, MD

Okay, here's a quiz for you. Name ten cause of anemia in a cancer patient. Ready? Go!

I would imagine that anemia of neoplastic disease, 285.22, was the first thing that came to your mind, right? Well, you have to get out of that mindset ...

Robert S. Gold, MD

During a recent HCPro audioconference, an astute coding professional questioned a statement I made while presenting a case study about a patient who underwent a vaginal hysterectomy. In my scenario, a surgeon performed a sponge count and ...

Robert S. Gold, MD

Coders come with varying levels of expertise, various levels of experience. We all know that there are Official Coding Guidelines, there are rules, there are Coding Clinic advisories - there are books and other references galore. We know that coders are under the gun to get bills out - to keep AR (Accounts Receivable) minimized and we know that coders have been educated or mandated ...

Robert S. Gold, MD

Although the concept of this level of care has been around for a number of decades, it had only been a short interval since the Federal government put these facilities in the Prospective Payment System (PPS) and had them held responsible for assigning codes and Diagnosis Related Groups (DRGs) - and many of them are doing it wrong - and they’re going to get into trouble. ...

Robert S. Gold, MD

CAN YOU ADDRESS THE DIFFERENCE BETWEEN V55.1 AND 536.42?

EX 1: PATIENT PRESENTS TO ED FOR REPLACEMENT OF TUBE BECAUSE PATIENT PULLED IT OUT. DX: REPLACE G-TUBE
EX 2: PATIENT PRESENTS TO ED WITH FEVER AND AREA AROUND THE G-TUBE IS RED, AND ED REPLACES G-TUBE. DX: REPLACE ...

Robert S. Gold, MD

Gastroenterologists and other physicians who admit patients to the hospital for work-up or treatment of gastrointestinal (GI) bleeding occasionally leave holes in their documentation.

Hospitals may admit patients because of weakness or "near-syncope."� Staff may encounter very low hemoglobin, leading to transfusion ...

Robert S. Gold, MD

The goal of a physician query is to achieve a better reflection of the true disease process by assigning the best code for the clinical situation. But this goal is better reflected by the term “clarification.”

Understanding the intent of physician clarification and doing it the right way should be the goal of every HIM professional. ...

Robert S. Gold, MD

Once in a while, the words used by physicians don't jive with a coder's mindset. And the physician isn't going to change his!

A coding professional knows how to assign ICD-9-CM codes to the documentation found in the medical record according to rules of ethical coding and according to the medical dictionary. But sometimes it just doesn't work. Here are a few examples.

Pneumonia? The notes in the ED talk about ...

Robert S. Gold, MD

Over the past few years, I have presented seminars on the clinical aspects of diseases and procedures and written this column and others. I have found most coders to be receptive to these presentations.

Recently, I spoke about the clinical aspects ...

Robert S. Gold, MD

Coding bowel resections can be tough. Coding Clinic has not published many rules, so you may
not understand when and how to assign codes.

Some of the concepts you need to understand involve anastomoses, colostomies, and resections of the bowel. Don’t unbundle these steps they form part of the procedure.

Which procedure? ...

Robert S. Gold, MD

There are certain words that physicians routinely use that have pretty important consequences. These are words that can affect how crucial information, such as medical necessity and severity of illness are documented. The use of such words can affect the accuracy of your data and make a difference ...

Robert S. Gold, MD

We are all probably in a kerfuffle (a disorderly outburst or tumult; "they were amazed by the kerfuffle they had caused" [syn: disturbance, disruption, commotion, flutter, hurly burly, to- do, hoo-ha, hoo-hah, kerfuffle] regarding ...

Robert S. Gold, MD

“Due to . . .” Using this simple phrase in medical record entries can directly aid your patient care, data, profile, risk containment, and professional reimbursement.

Medical decision-making (MDM) is the most important and valuable part of the evaluation and ...

Robert S. Gold, MD

The nomenclature of diabetes mellitus (DM) has been a constant source of clinical confusion. Classification systems based on the age of onset of illness have given way to those based on the need for insulin, and now to ...

Robert S. Gold, MD

Remember back a few years ago when I wrote about my delight with methods for mortality statistics and my dissatisfaction regarding complications? Of course you do!

In the beginning, there was raw data. One hospitals’ death rate was compared to another hospital’s death rate - and the hospital with the higher ...