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August 2010
In This Issue...
Other News
Medical Privacy at Risk in Georgia
In an opinion piece in the Atlanta Journal-Constitution, an attorney warns of the lack of medical privacy laws in Georgia.

New Rules Open Up HIT Market
The revised meaningful use rules open the door for market newcomers, according to Nextgov.

Ask the Expert
Have a coding or transcription question? Get an expert answer by sending an e-mail to

This month’s selection
I have a coding question regarding chronic pain. A patient has an admitting diagnosis of chronic pelvic pain and has a diagnostic laparoscopy done as an outpatient. The postoperative diagnosis is 1. chronic pelvic pain, 2. endometriosis.

I have read the coding guidelines, Chapter 6: Diseases of Nervous System and Sense Organs (320-389). A. Pain-Category 338 and I am still not positively sure what is the correct code to select for chronic pelvic pain.

Libby McCollough, RHIT
Medical Records Coding
Claiborne County Hospital and Nursing Home

Category 338 is reserved for pain not elsewhere classifiable, meaning that if there is no other ICD-9-CM code that applies, using a code from this section is OK; otherwise the coder is directed to find a better, more applicable code.

Code 625.8 is the code for other specified symptoms associated with female genital organs. I would review the documentation to reveal a possible link between the pain and endometriosis.

Typically, physicians do not diagnose the same way we code; therefore, making the connection between symptoms and associated conditions is important. Pelvic pain is often associated with endometriosis. This is similar to a physician documenting chest pain due to myocardial infarction. If the physician performs the laparoscopy due to pelvic pain and determines that the diagnosis is endometriosis, then the first listed diagnosis should be endometriosis.

Official Coding Guidelines, Section IV (Diagnostic Coding and Reporting Guidelines for Outpatient Services) Section E states that “codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has NOT been established (confirmed) by the provider.” That is the key to this case.

— Gail Smith, MA, RHIA, CCS-P, is director of the HIM program at the University of Cincinnati.

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Editor’s E-Note

A patient or law firm requests a medical record file, then a staff member gathers the info and ships it off. Sounds straightforward, but that’s hardly the case.

This month’s E-News Exclusive delves into the myriad complications involved in the release-of-information process.

— Lee DeOrio, editor
E-News Exclusive

EHR Implementations and the HIM Department
By Matt Rohs

The HITECH Act was created to modernize the healthcare industry by promoting and expanding the adoption of EHRs by 2015. However, many healthcare organizations have not done their homework before plunging into EHR implementations. In a rush to take advantage of the federal EHR financial incentives, hospitals are forgetting to determine what EHR implementations actually entail, such as two- to three-year implementations, lapses in data availability, glitches during software upgrades, and a learning curve for all staff to become knowledgeable of new applications. Given the many aspects of EHR implementations, hospitals may be in for more than they expected.

These long and multifaceted implementations will place further burden on many departments in healthcare organizations, including the HIM department. The added work associated with an EHR implementation may even compromise the proper and timely release of private patient information. As healthcare organizations try to get their EHRs up and running quickly, they need to keep in mind that the release-of-information (ROI) process must be carefully managed.

Full Story »

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Industry Insight

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