Archive for Medical Transcription

ICD-10-CM Coding for Latrogenic Blood Vessel Injuries

Some of the more common causes of blood vessel injury include gunshot wounds, stab wounds, blunt trauma (including blunt trauma with fracture or dislocation) and iatrogenic injuries. With more procedures being performed using intravascular techniques of late, the number of iatrogenic injuries to blood vessels has increased. Understanding the differences between ICD-9-CM and ICD-10-CM coding for blood vessel injuries occurring as a complication of a surgical procedure will help with correct code assignment when ICD-10-CM is implemented.


In ICD-9-CM, codes for iatrogenic injuries of blood vessels are found in Chapter 17, Injury and Poisoning. An injury to a blood vessel complicating a surgical procedure is reported with one of three nonspecific codes, as follows:


998.11 Hemorrhage complicating a procedure; 998.12 Hematoma complicating a procedure; and 998.2 Accidental puncture or laceration during a procedure. 
It should be noted that no distinction is made in ICD-9-CM for intra-operative or postoperative hemorrhage or hematoma.


In ICD-10-CM, codes for intra-operative and post-procedural blood vessel injuries are found in Chapter 9, Diseases of the Circulatory System. ICD-10-CM classifies body system-specific, intra-operative and post-procedural complications within each body system chapter, rather than in Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes Medical Transcription).


While ICD-10 codes for intra-operative and post-procedural complications affecting blood vessels are not specific to the site of the injury, they are specific to the body system affected, which in the case of blood vessel injuries is the circulatory system. Codes are also specific to the type of injury – hemorrhage and hematoma or puncture and laceration. Hemorrhage and hematoma codes are specific to whether the complication occurs during a surgical procedure or postoperatively, and these codes are also specific to some types of procedures (including cardiac catheterization, cardiac bypass, other circulatory system procedure or other procedure). Puncture and laceration codes are specific to whether the blood vessel injury occurred during a circulatory system procedure or during a procedure being performed on another body system.


For intra-operative hemorrhage and hematoma of a blood vessel or other circulatory system organs or structures, the following codes apply:

I97.410 – Use when the hemorrhage or hematoma complicates a cardiac catheterization procedure.I97.411 – Use when the hemorrhage or hematoma complicates a cardiac bypass procedure.I97.418 – Use when the hemorrhage or hematoma complicates another circulatory system procedure.I97.42 – Use when the hemorrhage or hematoma complicates a procedure on a body system other than the circulatory system.

For post-procedural hemorrhage and hematoma of a blood vessel or other circulatory system organs or structures, the following codes apply:

I97.610 – Use when the hemorrhage or hematoma complicates a cardiac catheterization procedure.I97.611 – Use when the hemorrhage or hematoma complicates a cardiac bypass procedure.I97.618 – Use when the hemorrhage or hematoma complicates another circulatory system procedure.I97.62 – Use when the hemorrhage or hematoma complicates a procedure on a body system other than the circulatory system.

For accidental puncture and laceration of a blood vessel or other circulatory system organ or structure, the following codes apply:

I97.51 – Use when the accidental puncture or laceration occurs during a circulatory system procedure.I97.52 – Use when the accidental puncture or laceration occurs during a procedure on another body system.

Sustain Your Business Records by ChoosingBest Transcription Company

Today with the upcomingglobalization, the services of transcription are offered by many medium andlarge businesses. If you notice, there are vast numbers of establishedcompanies for Business Transcription available; theyare professionally trained to transcribe your desire needs at affordable rates.Generally, meaning of Transcription is the method of recording the audioinformation into a text format. These transcription services also include thewritten data that is once heard of the audio. All this is done under thesupervision of trained experts and professionals.


There are different forms ofTranscription available in various formats like Business Transcription, Audio Transcription Services, ConferenceCall Transcript, and Digital Transcription. This transcription alsomakes use of customized and optimized software, which controls thetranscriptionist to virtually create a flawless copy from the audiotranscription.


Many events pertaining tobusiness take place in big organization like seminars, business meets,conferences, which are recorded by various audio and videotranscription equipments like utilizing a small tape recorder etc.


A couple of significant data ormeetings might have been recorded in cassette tapes or gramophone, which arenow a days out of date. These cassette tapes requires to be digitalized intothe required format like utilizing  someequipments that contains some software like Audacity, which edits the sound andother audio encoders like MP3 etc.


What is required by the customersis they just need to discard the physical audio tapes at the premises of anybusiness transcription service provider’s office.


Today, we observe that as far asdigital era is concerned, every single business recordings are transcribed invarious modes of digital audio and video formats. Most of the digital transcription companiesoffering digital services accept almost all kinds of audio formats like .WAV,AIFF, real audio, midi ,Ogg etc along with different video formats likeAVI,MPEG/MPEG4,,MkV, RM/RMV,MOV, WMV etc. and this way they offer their digitaltranscription service solutions. What these companies do is ask the clients toupload the digital files directly into their safe FTP web server. Why does itbecome essential for any business company or organization to obtain the serviceof a good quality transcription company?


Many times it happens that, mostof the famous business companies, in spite of having in house transcriptionbusiness fail to meet the terms due to lack of professionals. The major reasonor cause of such failure maybe because they over burdened their employees withextra burden of transcribing the business activities.


Initially these unskilled or semiskilled staff met with difficulties in recording Moreover these semi skilledstaffs were encountered with difficulties in transcribing complicated accents,voice disturbance and long and hectic hours of editing process etc. All thesedifficulties form a major part of failing to provide good quality oftranscription services and solutions.



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

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 http://www.mediscribes.com



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

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 injuryDatais collected based on site rather than type of injuryMixtureof diagnosis codesCalculationof sixth character using some codes extended out o the seventh characterAddingV 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 careencountersByimplementing 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.

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 http://www.mediscribes.com

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Mediscribes is distributor of Provox products for speech-driven workflow

Mediscribes, Inc., a fast growing Medical Transcription provider, is a distributor for the Provox products for speech-driven workflow reporting.

Provox VoxReports is a front-end speech recognition system for radiology reporting and workflow management. VoxReports supplements radiologist dictation with front-end speech recognition and macros, automating the workflow between radiologists and transcriptionists. Provox VoxNotes, a front-end speech recognition system for clinical reporting, automates the workflow between clinicians and transcriptionists and includes capabilities for charting.

Based in Louisville, KY, Mediscribes is one of the fastest growing transcription and document management solution providers in United States. “The Provox products are a good fit for our provider clientele seeking a cost-effective dictation and workflow solution,” said Vatsal Ghiya, President and CEO of Mediscribes. “We will be offering a very competitive per-report pricing model that should be appealing to imaging centers looking to gain the advantages of turn-around time improvements at a very reasonable cost.”

“We’re excited that Mediscribes will be distributing the Provox products,” said Steve Backes, President and CEO of Atirix.

“Mediscribes specializes in small to medium sized hospitals and clinics, where Provox products have proven to be a good value. Compared to template driven documentation and EMRs, transcription combined with speech recognition captures the patient story in a more meaningful and comprehensive way and also significantly improves the productivity of the clinician. The Provox products will be a good strategic fit for Mediscribes and their clients.”

Mediscribes is an ISO 9000-2001 certified company, rendering cost-effective consolidated transcription solutions to major hospitals, clinics, and other healthcare facilities. The firm specializes in providing highly accurate Transcription Services, while adhering to the Association for Healthcare Document Integrity (AHDI) guidelines. Mediscribes has a wide network of highly-skilled transcriptionists, editors and quality assurance professionals servicing more than 2,000 providers and producing over 40 million lines of transcribed dictation.

Atirix Medical Systems, of Minneapolis, MN, develops quality assurance and workflow products for diagnostic imaging centers. The patented Provox software system features SmartMacros for dynamic report formatting and includes system management tools for workflow customization, administrative controls, and performance reporting.

For more information please contact Mediscribes at 866-473-5655 or http://www.mediscribes.com. Mediscribes and Atirix will be together at RSNA in the Atirix booth, South Hall, #4703.

About Mediscribes

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 major hospitals, clinics, and other healthcare facilities in United States. Mediscribes is the most value-providing organization in the market today with a strong presence in America and offshore locations. The firm specializes in providing highly accurate transcription adhering to ADHI guidelines in unbeatable turnaround time with robust & proven document management system as its vantage point to its esteemed clientele.

Mediscribes provides end-to-end transcription solutions as its primary offering. For our customers, we focus on dictation systems, both ASP as well as enterprise level solutions, with the help of our most valued asset   ezVoiceIntelligence (ezVI), providing specialty-specific qualitative transcription along with a “whole nine yards” document management system. Mediscribes specializes in EMR data integration as well. Our data dispatch department is highly proficient in integrating transcribed reports into any type of EMR. Healthcare facilities that do not have EMR get the option to use our web-based file monitoring interface called eTranscribe for 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 http://www.mediscribes.com

Tags: Cardiology Transcription, Medical Dictation, Medical Transcription, Medical Transcription Companies, Medical Transcription Service, Medical Transcription Services, Outsource Medical Transcription, , Transcription Service

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