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Quality Clinical Documentation—A Costly Challenge

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: September 2009


The debate continues over how to reform healthcare while controlling costs and spending. The options are complex and controversial, and after decades of failed cost and spending control efforts, it’s not surprising that there is skepticism.

Reforming one of the world’s mo....

Preparing for ICD-10-CM in Physician Practices

Author: Kuehn, Lynn

Source: Journal of AHIMA

Publication Date: August 2009




What will change under ICD-10-CM, and what must be done to prepare? This is the year for physician practices to get their ducks in a row: become informed, assess their IT and training needs, and make a plan that leads to the October 1, 2013, deadline.



On September....

Preparing for ICD-10-CM: A Clinician's Perspective

Author: Rose, Eric

Source: Journal of AHIMA

Publication Date: July 2009


America’s physician practices are facing the biggest change in healthcare coding in decades: the replacement of ICD-9-CM by ICD-10-CM. This article discusses ICD-10-CM from a clinical perspective and reviews how electronic health record (EHR) systems will need to adapt to the transition.....

Present on Admission: Where We Are Now

Author: Garrett, Gail S.

Source: Journal of AHIMA

Publication Date: July 2009


Hospitals have nearly two years of POA reporting under their belts. With time, effort, and updates, assigning POA indicators is becoming routine business for coding professionals.

For the past several years, HIM professionals have served as a conduit for a rapidly evolving pay-for-pe....

Mortality Coding Marks 10 Years of ICD-10

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2009


Morbidity coders rarely see a mortality code. But for 10 years the National Center for Health Statistics has been busy compiling mortality data coded in ICD-10.


There are a thousand ways to die in this life, and the National Center for Health Statistics tracks every one of the....

New Guidance for Home Health Coding

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2009


Sweeping PPS changes for home health went into effect January 2008, making much of the prior coding guidance issued by the Centers for Medicare and Medicaid Services (CMS) incompatible with changes in the revised data collection set. Home health coding professionals anxiously awaited further i....

Wider World of Coding

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2009


Coding reminds me of the parable of three blind men describing an elephant. Each one touches just one part of the elephant.

The blind man who examined the elephant’s tail likened it to a straw fan swinging back and forth; the man who explored the legs described the elephant as....

ICD-10-CM Official Coding Guidelines

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


One of the keys to a successful transition to ICD-10-CM/PCS is a thorough understanding of the ICD-10-CM Official Coding Guidelines, which were posted to the National Center for Health Statistics Web site in January 2009. Similar to the ICD-9-CM coding guidelines, the ICD-10-CM guidelines are....

Understanding National Coverage Policies: Navigating the Maze of HACs, Serious Reportable Events, and Wrong Surgical Sites

Author: Cook, Jane; D'Amato, Cheryl; Garrett, Gail S.; Ruhnau-Gee, Becky; Hyde, Linda A.; Novak, Natalie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


Present on admission indicators, hospital-acquired conditions, serious reportable events, and “wrong” surgical events are each hot topics. However, they also can be a hot topic together, because a number of these reporting requirements are interrelated. HIM professionals must under....

ICD-10 Reimbursement Mappings: New Mappings from CMS Help Organizations in the Transition to ICD-10

Author: Butler, Rhonda R.; Mills, Ronald E

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2009


Starting October 1, 2013, healthcare claims will be submitted to payers using ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. Some payers such as the Centers for Medicare and Medicaid Services (CMS) are converting their reimbursement systems to use ICD-10 codes directly. However, som....

Streamlining the Revenue Cycle Management Process

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 2009


Keeping an organization’s revenue cycle running smoothly is no small feat. But Patsy Hathorn’s team at Mississippi Baptist Medical Center in Jackson, MS, volunteered to take it on. Now the team is seeing results.

Hathorn, RHIA, who is director of clinical resource managem....

HIM Breakup: Changing Times Pull HIM and Coding Apart

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2009


Benefits can follow when coding packs its bags and moves to the revenue cycle. But all realignments have their opportunities and risks.

HIM and coding are breaking up.

Once a common couple, the two departments are beginning to split at some facilities, moving on to differen....

Key Issues in the 2009 OPPS Final Rule

Author: Clark, Andrea

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2009


The final rule for the 2009 Outpatient Prospective Payment System (OPPS) includes multiple revisions that hospitals must address in their practices, policies, and operations. Hospitals should develop strategies for analyzing the financial impact and operational challenges by reviewing the foll....

Screening Algorithms to Assess the Accuracy of Present-on-Admission Coding

Author: Pine, Michael; Fry, Donald E.; Jones, Barbara; Meimban, Roger

Source: Perspectives in Health Information Management

Publication Date: February 2009


Abstract

Present-on-admission modifiers for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes are rapidly becoming a standard coding requirement. Inaccurate coding of these modifiers can distort analyses of risk-adjusted outcomes....

2009 CPT Coding Update

Author: Majerowicz, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2009


Changes to CPT codes for 2009 include 293 additions, 133 revisions, and 92 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2009 CPT code manual. The changes took effect January 1.

E/M Codes


Nu....

RAC Ready: How to Prepare for the Recovery Audit Contractor Program

Author: Johnson, Kathy M; Bloom, Allison; Morris, Denise; Madamba, Roderick

Source: Journal of AHIMA

Publication Date: February 2009


The Centers for Medicare and Medicaid Services is expected to announce the official start date of the Recovery Audit Contractor program this month, but it is already time for providers to be preparing for a potential audit. Managing a RAC audit effectively and efficiently requires preparing de....

Universal Adapters: Terminology Standards Enable Meaningful Data Exchange

Author: Cook, Jane; Foley, Margaret M.; Giannangelo, Kathy; Paterno, Marilyn D.; Scichilone, Rita A; Schwarz, Kathleen M.

Source: Journal of AHIMA

Publication Date: January 2009


Standardized clinical terminologies are critical connectors that allow systems to exchange health information.

In the winter of 1904 a major fire broke out in Baltimore, MD. The resulting damage—an entire swath of the downtown destroyed—was blamed largely on a lack of uni....

Coding Radiology Services

Author: Walk, Gerri

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2009


Because coding and radiology departments often share accountability for the quality of outpatient radiology coding, it is important that coding professionals share coding issues and charge capture expectations with radiology staff. This article outlines methods to improve the quality of coded....

FY 2009 Hospital IPPS Final Rule

Author: Schwab, Linda

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008


The final rule for the FY 2009 hospital inpatient prospective payment system (IPPS) went into effect October 1, 2008. Although there are relatively few changes to MS-DRGs and the complication and comorbidity (CC) and major CC (MCC) lists, the final rule signals that the Centers for Medicare an....

ABCs of Medicare Advantage

Author: Hernandez, Jeannette

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008


Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.

By June 2....

Discover How to Survive Medicare Severity DRGs with a Successful Clinical Documentation Improvement Program and Present on Admission Indicators

Author: Blackford, Gwendolyn

Source: AHIMA Convention

Publication Date: October 17, 2008


Health Information Management Department at the University of Michigan Hospitals and Health Centers
Introduction

What changes will be next for the inpatient coding world? October 1, 2007 had a tremendous impact on hospitals as it relates to clinical documentation for facility re....

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