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Guidelines to follow in Coding forPostoperative Pain in ICD-10-CM

7 Jan

Normally Postoperative pain is considered as a normal phase of healingmethod following many types of surgery. Such pain is frequently kept undercontrol using typical measures like pre-operative, non-steroidal, provocativemedications; local anesthetics that is injected into the operative wound beforesuturing; postoperative analgesics; and even intra-operative or post-operativeinjection of epidural analgesics, that form many kinds of surgeries.

When post operative pain is documented to the current, which is far awayfrom the routine and expected for the appropriate surgical method surgical, doyou think it is a reportable diagnosis. Also note that coding for Postoperative pain in ICD-10-CM, which is not considered on daily basis or expected further in future, iscategorized by whether the pain is pertaining with a definite, documentedpostoperative complication.

Extreme coding forPostoperative Pain in ICD-10-CM not reported due to a Specific PostoperativeComplication

Remember that Postoperative pain not related with a precisepostoperative complication is conveyed with a code from Category G89, This Painnot shown or classified anywhere else.

Postoperative pain in ICD-10-CM mainly has four codes as given below.

G89.12 Acute post-thoracotomy pain;

G89.18 Other acute post-procedural pain;

G89.22 Chronic post-thoracotomy pain; and

G89.28 Other post-procedural pain that is chronic

In any case, if the documents fail to mention whether the post-thoracotomyor post-procedural pain is acute or chronic, consider the default is acute.

Extreme level of PostoperativePain reported Due to a Specific Postoperative Complication

Any coding for Postoperative pain reported that is taking place due to a specific postoperative complication isalways documented with its specified code for that particular complication thatalso includes Injury, poisoning and many other consequences of external causes.There is an extra additional code from category G89 that may be documented todefine the pain more appropriately whether it is post-thoracotomy or otherpostoperative pain, which is acute or chronic in nature.

Before we get into any discussion of postoperative pain generating dueto a definite postoperative difficulty, it is very crucial to fully apprehendthe general guidelines pertaining to coding of complications of care, which aredescribed in Section I.B.16 of the draft version in year 2013 of the ICD-10-CMOfficial Guidelines and Reporting. All these guidelines are very much alike tothose that are present in ICD-9-CM. The main factors to bear in mind whencoding complications of care are given below:

  • Allotment of code depends on theprovider’s reporting of the relationship between the situation and the medicalcare or method used.
  • Remember, not all conditions occurringduring the course of medical care or carrying out procedures are considered ascomplications.
  • In any case, if you find the reportingdone is not clear, you reserve the right to question the person concerned whowrote it.


Mediscribes, Inc. is one of the fastest growing Medical Transcription & document management systems providers in United States,based in Metro Louisville. Mediscribes is an ISO 9000-2001 certified company,rendering cost-effective consolidated transcription solutions to majorhospitals, clinics, and other healthcare facilities in United States.Mediscribes is the most value-providing organization in the market today with astrong presence in America and offshore locations. The firm specializes inproviding highly accurate transcription adhering to ADHI guidelines inunbeatable turnaround time with robust & proven document management systemas its vantage point to its esteemed clientele.

Mediscribes provides end-to-end transcription solutions as itsprimary offering. For our customers, we focus on dictation systems, both ASP aswell as enterprise level solutions, with the help of our most valued asset   ezVoiceIntelligence (ezVI), providingspecialty-specific qualitative transcription along with a “whole nine yards”document management system. Mediscribes specializes in EMR data integration aswell. Our data dispatch department is highly proficient in integrating transcribedreports into any type of EMR. Healthcare facilities that do not have EMR getthe option to use our web-based file monitoring interface called eTranscribefor global access to their data. eTranscribe has special features of E-signing,E-faxing, auto-printing, and user-friendly document search criteria.

For additional information, please visit


ICD-10-CM Official Guidelines for Coding andReporting in 2013

26 Dec

Confront the latest medical coding challenge ICD-10-CM coming onOctober 1, 2014.

What is ICD-10-CM?

ICD-10-CM also known as “InternationalClassification of Diseases” is generally a set of codes largely utilized mainlyby the physicians, hospitals, Medical Transcription Companies andhealth care expertise or specialists in order to perform an analysis onpatients every visit. The ICD-10-CM system of coding contains approximately68,000 codes and these codes become essential when claiming for any type ofhealth insurance in the U.S.

If we compare ICD-9-CM, we find veryfew alterations are done with ICD-10-CMDraft code set for 2013 which will beeffect from 1st October, 2014. It was decided to make a few changesin the 2013 ICD-10-CM Draft code, by accumulating a couple of terms andrectifying typos in the Alphabetic directory.

Let’s check out the probableadvantages of implementing the latest ICD-10 medical coding system:

  • Applicationof this code gives expansion of injury
  • Datais collected based on site rather than type of injury
  • Mixtureof diagnosis codes
  • Calculationof sixth character using some codes extended out o the seventh character
  • AddingV and E codes into the main classification

The alterations done by medicaltranscription companies signify huge development over ICD-9-CM and ICD-10.

Some specific improvements done aregiven below:

  • Prolongedinjury codes due to adding up of data pertinent to ambulatory and managed careencounters
  • Byimplementing a new concept of combination diagnosis/symptom codes, the numberof codes actually needed to explain a condition lessens.
  • Accordingto the news, HHS on January 16, 2009, issued a final rule wherein it hasaccepted ICD-10-CM (and ICD-10-PCS) to replace ICD-9-CM in HIPAA transactions.

Impact On Your Medical Coding Employees

This latest system of ICD-10-CM medical coding will bringtremendous level of progress for all the medical transcription companies andU.S. health care system.  The presentsystem of ICD-9-CM is outdated for new codes and limits the coding process. Asmedical transcription person, you require, to familiarize yourself with thelatest system and get the significant training for the same to ensure a smoothtransition.

Ifyou are a medical coder or any professional pertaining to medical servicescompany then it is mandatory for you to get a comprehensive synopsis about theessential changes in store for both diagnostic and procedural coding.

  • Apartfrom this, you will be required to get information at length on the impacts ofthe coding changes. The reason behind following this procedure is becauseOctober 1st, 2013 is the last date for compliance. All medical serviceproviders such as Medical Transcription ServiceProviders be it doctors or any other personal offering his medicaltranscription services, it will become necessary for them to get acquaintedwith the new system.
  • Youwill need to register yourself in an ICD-10-CM medical coding course in orderto study the new medical coding system, containing approximately 55,000 morecodes. This is not it, a lot more is yet to follow thus, please keep updatedwith the latest and upcoming modifications.

Even supposingchanges done may be little to ICD-10-CM Draft system of coding for the nextcouple of years, we suggest you as a medical coder to study the guidelinescarefully and yearly. Aside from this, you can expect supplementary guidelinesand reporting coming up as we have additional coders training under ICD-10-CM.

About Mediscribes

Mediscribes, Inc. is one of thefastest growing Medical Transcription & document management systemsproviders in United States, based in Metro Louisville. Mediscribes is an ISO9000-2001 certified company, rendering cost-effective consolidatedtranscription solutions to major hospitals, clinics, and other healthcarefacilities in United States. Mediscribes is the most value-providingorganization in the market today with a strong presence in America and offshorelocations. The firm specializes in providing highly accurate transcriptionadhering to ADHI guidelines in unbeatable turnaround time with robust &proven document management system as its vantage point to its esteemedclientele.

Mediscribes provides end-to-endtranscription solutions as its primary offering. For our customers, we focus ondictation systems, both ASP as well as enterprise level solutions, with thehelp of our most valued asset  ezVoiceIntelligence (ezVI), providing specialty-specific qualitativetranscription along with a “whole nine yards” document management system.Mediscribes specializes in EMR data integration as well. Our data dispatchdepartment is highly proficient in integrating transcribed reports into anytype of EMR. Healthcare facilities that do not have EMR get the option to useour web-based file monitoring interface called eTranscribe for global access totheir data. eTranscribe has special features of E-signing, E-faxing,auto-printing, and user-friendly document search criteria.

For additional information,please visit

Medical Transcription and Coding demand will increase with ICD-10

5 Sep

Medical Coder and TranscriptionistThe world of medical transcription and medical coding is extensive and always changing. The change that has the medical field buzzing right now is the change from ICD-9 to ICD-10 (International Classification of Diseases – Version 10). Currently, health care facilities use ICD-9 for documentation and coding, but by October of 2014 every facility must abide by the new system. These new changes will increase the need for skilled medical transcription and medical coding. It will also bring these two jobs expertise closer and merge at some time in the future.

Why will demand for transcription and coding increase?

For healthcare employees already working as a medical transcriptionist or medical coder, they don’t need to worry about these changes affecting their chances of employment. The truth is that the need for these highly skilled workers will actually increase with the implementation of ICD-10.

One of the main reasons for the increase of work is that the new book of codes is a lot more specific than ICD-9. For instance, in ICD-9, the code for a burn on the left arm is the same code as a burn on the right arm. While this may not matter to the insurance company, it does matter to the treating physician, the patient and the transcription. There are not numerous new diseases in the new manual, but it will have over 70,000 codes listed. These are also going to be seven digits, instead of the five seen in the past. The increase in codes and length of codes will help the medical coder be more specific.

There is no substitute for an intelligent human mind, so the fear that medical transcription will be obsolete after the new implementation is unfounded. Both transcriptionist and coders will actually have to work harder and attend more training to become compliant. The new system may be confusing and overwhelming to those who have worked on ICD-9 for years. As these older employees leave the workforce, fresh new recruits will be needed.

Importance of Implementing Electronic Health Records (EHRs) from ICD-10 prospective

In order to be compliant with the new rules, healthcare facilities will find that having an efficient EHR (electronic health record) system in place first will be a huge benefit. There are still thousands of private practices that have not made the switch to electronic medical records, but this will hurt them when they must face compliance with the new coding regulations.

By implementing an easy to use and efficient EHR, the transition to ICD-10 will be a lot smoother. If a facility does not yet use computers for their records, they should consider doing this as soon as possible to be ready for the upcoming coding and documentation changes.

The reason an EHR is so important is because it helps streamline the coding process. It is much easier to use a search function on a computer than trying to pore through hundreds of pages in a patient’s chart to find information. To determine whether an injury was on the left or right side of the body, for example, the coder can simply search for this terminology within the patient’s electronic record. To find this information in a paper chart wastes hours of valuable time.

How will the New System Help Medical Transcription?

It may be true that the new system will mean less hours of transcribing work but it doesn’t appear transcription will be absolute. In fact, those that choose to stay in the field and learn ICD-10 coding will be rewarded with more hours than ever of transcribing work.

Because ICD-10 demands greater detail, physicians will have to begin giving greater detail in their records. This translates into more words for the transcription, which equals greater pay. Also, the increased need for transcription with coding expertise will mean better rewarding opportunities.