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Clinical Coding: Part of the HIM Mosaic

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2003


Many in healthcare today understand coding only in the context of billing, not recognizing that the very same coded data are used for important healthcare operations, policy, epidemiology, and many other uses. For 75 years, AHIMA has been the professional forum to advance the quality of health....

Sepsis, Related Terms Cause Confusion for Coders: Set the Record Straight About Sepsis, SIRS, Septic Shock

Author: Prophet-Bowman, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2003


Sepsis, severe sepsis, SIRS, and septic shock have long been a source of confusion for coders. New ICD-9-CM codes established recently for Systemic Inflammatory Response Syndrome (SIRS), and additional proposed code revisions have added to the confusion regarding the differentiation among these....

Fracture Treatment Poses Coding Challenge: Multiple Treatment Options Require Special Attention

Author: Hutchinson, Mark R.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2003


There are 206 bones in the human body and each is susceptible to fracture. The choices in fracture management are complex and based on a number of issues including fracture type, fracture pattern, specific bone, age of fracture, age of patient, associated injuries, and physician preference. Co....

Group Health Plan's Glossary

Author:

Source: AHIMA web extra

Publication Date: March 02, 2003


Administrative requirements of the privacy rule include those to have personnel designations, training, safeguards, complaint handling, sanctions, mitigation of harm, and current policies and procedures. These are not required if only summary information is exchanged between the GHP and plan sp....

Observation Services Present Compliance Challenges

Author: Prophet-Bowman, Sue

Source: Journal of AHIMA

Publication Date: March 2003


Observation services have been a top fraud and abuse target of the Office of Inspector General (OIG) of the Department of Health and Human Services, primarily due to the complexity of the Medicare billing regulations and the potential for abuse. New regulations regarding reimbursement for thes....

Documentation Issues

Author: Kennedy, James S.

Source: AHIMA community resource

Publication Date: March 02, 2003


Issues to Consider If you write: Consider this: Acute Coronary Syndrome: This is a great admitting diagnosis, however it is so broad that it doesn't tell us the exact pathophysiology of what we found after study, diagnosis, and treatment of our patient. Does the patient have a coronary thromb....

AHIMA Advantage E-alert [Special edition]

Author: AHIMA

Source: AHIMA newsletter

Publication Date: February 13, 2003

HHS to Release Final HIPAA Security Rule February 20; HIPAA Transaction and Code Set Standards Modifications Announced

Teach Your Attorney Healthcare Contracting

Author: Le, Huan N.

Source: Journal of AHIMA

Publication Date: February 2003


Medicare regulations, HIPAA compliance, and the threat of litigation have made it impossible to draft a one-page healthcare contract. Standard language alone now extends to up to four pages. It’s a good idea to hire an attorney for contract negotiations and drafting, but even then, you mi....

Major Changes for Heart Failure Codes in 2003: New Codes Put Sharper Focus on Diagnosing, Preventing Heart Failure

Author: Casey, Patricia E.; Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2003


Are you up to date with the latest revisions to the heart failure codes? A revision of the heart failure codes, effective October 1, 2002, was originally presented at the May 2001 ICD-9-CM Coordination and Maintenance Committee meeting. At that meeting, representatives from Kaiser Permanente e....

ICD-9-CM Coordination and Maintenance Committee Discusses Code Proposals for FY2004

Author: AHIMA Policy and Government Relations Team

Source: AHIMA Advocacy and Policy

Publication Date: December 13, 2002


The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS), met on December 5-6, 2002 in Baltimore, MD. Donna Pickett, RHIA, from NCHS, and Patricia Brooks, RHIA, from CMS, cochair....

Analysis of Final Rule for 2003 Revisions to the Medicare Hospital Outpatient Prospective Payment System

Author: AHIMA Policy and Government Relations Team

Source: AHIMA regulation analysis

Publication Date: November 24, 2002

The final rule regarding calendar year 2003 revisions to the Medicare hospital outpatient prospective payment system (PPS) was published in the November 1, 2002 issue of the Federal Register.   This rule becomes effective on January 1, 2003.   This analysis will cover significant....

Journal Q&A (11/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2002


Q: Where can I find federal regulations, interpretive guidelines, and Medicare manuals online?


A: The Centers for Medicare & Medicaid Services (CMS) has a number of manuals available online including the federal regulations for various settings, interpretive guidelines, Med....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

What Documentation Source Is Used to Assign Diagnosis Codes for Outpatient Testing?
A completed medical record is the best source of diagnosis coding, without regard to setting. However, recently there was confusion concerning whether the reason for testing found on a requisition for the test....

Web FAQ

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

What are the documentation requirements for Observation Patients?
It is interesting to note that the observation service (OBS) did not originate from the government but by the healthcare marketplace in response to PPS/DRG conditions. When hospitals are not sure whether a patient will meet admi....

Web FAQ

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

What guidance is available for determining an organization's definition of "attending physician" or "physician of record"?
The Department of Health, Education, and Welfare adopted the UHDDS (Uniform Hospital Discharge Data Set) as department policy for Medicare and Medicaid patient populations....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

What Is the NCCI and How Can I Get It?

The National Correct Coding Initiative is a huge set of edits to be applied to CPT codes for outpatient hospital claims in anticipation of the APC (Ambulatory Payment Classification) system. It was created by HCFA for use by carriers for processing P....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where Can I Find the Regulations on Medicare Payment Methodologies Used in Non-acute Care Settings?


http://www.hcfa.gov/medicare/payment.htm is a site that provides links to pages on Medicare payment methodologies. On these pages you will find helpful information on various payment....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where Can I Find Coding Guidelines for Use in Long Term Care or for Skilled Nursing Facility Reporting?

The official coding guidelines (see earlier question regarding who has the official guidelines for code assignment) are applicable in long term care. These guidelines have been develope....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where Can I Find a Sample Job Description and the Standard Productivity Rate for a Coder?

Because of the wide variety of duties included in the tasks for a coding professional, AHIMA does not publish a standard job description and has found it impossible to create meaningful coding produ....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Who Has the Official Guidelines for Interpretation of Coding Guidelines or Appropriateness of Code Assignment?
For ICD-9-CM coding questions and guidelines we look to Cooperating Parties for ICD-9-CM. The National Center for Health Statistics and the Health Care Financing Administration receiv....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where can I find the APC regulations?

The HCFA regulations are found in the November 13, 2000 Federal Register, Vol. 65. No.219 pp.67798-68005. Go to http://www.access.gpo.gov/su_docs/fedreg/a001113c.html, and scroll down to Health Care Financing Administration.

HCFA has impleme....

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