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Pneumonia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).
Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).
Describe preadmission treatment tha....

Operational Improvements in Chargemaster Management through Performance Mapping

Author: Hathorn, Patsy B.; Trusten, John T.; Grzybowski, Darice

Source: AHIMA Convention

Publication Date: October 05, 2009

..chargemaster management, Coding and auditing. The Charge.. ..ately. Those can include Coding mistakes, under-pricing .. .. IT liaison, and the HIM Coding manager. Other team memb.. ... We use our Billing and Coding Compliance (committee na.. .. the revenue held due to Coding edits, lack of medical n..

Computer-Assisted Coding at the Cleveland Clinic: A Strategic Solution: Addressing Clinical Documentation Improvement, ICD-10-CM/PCS Implementation, and More

Author: Hartman, Kathy; Phillips, Shannon Connor; Sornberger, Lyman

Source: Journal of AHIMA

Publication Date: July 2012

..e reform, ICD-10-CM/PCS, Coding shortages, and the resul.. ..Rs and computer-assisted Coding (CAC) can be leveraged t.. ..d improve documentation, Coding , data extraction, and ul.. .. documentation, clinical Coding , and financial performan.. .. as having documentation/ Coding opportunity but little c..

Impact of Creating a Pay for Quality Improvement (P4QI) Incentive Program on Healthcare Disparity: Leveraging HIT in Rural Hospitals and Small Physician Offices [Commentary]

Author: Hart-Hester, Susan; Jones, Warren A.; Watzlaf, Valerie J.M.; Fenton, Susan H.; Nielsen, Carol; Madison, Mary; Arthur, Chris; Marbury, David; Rudman, LeeAnn; Patterson, Randi; Reynolds, Rebecca; Rudman, William J.

Source: Perspectives in Health Information Management

Publication Date: September 2008

..ysician offices increase Reimbursement . This paper will be divi.. ..(RWJF). In general, P4P Reimbursement incentive programs are t.. ..41–44 The criteria for Reimbursement may vary from the percen.. ..infrastructure. However, Reimbursement incentives related to P4..

HIM & Ethical Decision Making: Complex Challenges

Author: Harman, Laurinda B.

Source: AHIMA Convention

Publication Date: October 10, 2001

..ty, and risk management; Coding , compliance, fraud, and .. ..iance, fraud, and abuse; Coding ; quality review; researc.. ..y for information Mis Coding (intentionally) to avoid.. ..r to engage in negligent Coding practices Hiding inc.. ..ocumentation to increase Reimbursement Having access to inf..

Outpatient Wound Care – Keys to Getting Paid

Author: Hapner, Peggy

Source: AHIMA Convention

Publication Date: October 02, 2011

..documentation to support Coding and billing. And increas.. ..ll clearly spell out the Coding and documentation protoc.. ..tanding national correct Coding initiative edits to dete.. .. rules for documentation/ Coding that was present in that.. ..tion to National Correct Coding Initiative (NCCI) edits ..

CAD vs. Angina

Author: Hansen, Abby

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2013

..rs, there have been many Coding Clinics to guide us in o.. ..al diagnosis. As in most Coding scenarios, the principa.. ..The advice published in Coding Clinic , Second Quarter.. ..n Hospital Association. Coding Clinic for ICD-9-CM, Se.. ..n Hospital Association. Coding Clinic for ICD-9-CM, Fi..

Constructing a Coding Compliance Plan

Author: Hanna, Joette

Source: Journal of AHIMA

Publication Date: July 2002

.. turned its attention to Coding compliance. Do you .. ..icle to build a Coding compliance program that .. ..tion. Coding compliance has become an.. ..ng an effective Coding compliance program. Each.. .. The most successful Coding compliance program is co..

Choosing Consultants Without Compromising Compliance

Author: Hammen, Cheryl

Source: Journal of AHIMA

Publication Date: October 2001

.. Auditing Coding and DRG accuracy has bec.. ..o contract with external Coding consultants to perform t.. ..ement or to misinterpret Coding rules and regulations to.. ..pliance efforts, such as Coding compliance reviews. Comp.. ..se in selecting external Coding consulting companies. It..

Developing Technical Applications for Coding Compliance

Author: Hammen, Cheryl

Source: AHIMA Convention

Publication Date: October 10, 2001

..ing to provide focus for Coding compliance activities. .. .. Background Up Coding , DRG creep, and other co.. ..preventing inappropriate Coding and billing that could r.. ..mine the accuracy of the Coding and billing. Audits of .. ..cumentation was used for Coding purposes. Is there a pat..

Perfect Time for Documentation Improvement

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: July 2006

.. better documentation to Coding professionals. This i.. ..uterized order entry for Coding purposes,” she says. “It.. ..many years as a hospital Coding director. “A best practi.. ..entation improvement and Coding efficiency, she says. .. ..hnson, RHIA, director of Coding consulting services at C..

The Good, Bad, and Reality of Offshore Coding: Some Turn to Distant Shores to Fill US Coding Demands

Author: Gurrieri, Joseph J; Karban, Karen M

Source: Journal of AHIMA

Publication Date: September 2013

..ors plan to expand their Coding labor, according to a re.. ..ow to meet the increased Coding demand wrought by ICD-10.. .. Though many offshore Coding centers first opened off.. ..ring primarily physician Coding and billing services, ma.. ..atic changes in offshore Coding capabilities. Many HIM p..

Here Comes Rehab PPS!

Author: Grzybowski, Darice; Draper, Skeeter

Source: Journal of AHIMA

Publication Date: January 2002

..ditionally been based on Coding , which depends on qualit.. ..he future against proper Coding , it is important that th.. .. Staff, Clinicians About Coding , Data Collection T.. ..is often confusion about Coding guidelines to be used fo.. .. rehab PPS. Two types of Coding are required. One..

Who Answers the Medical Necessity Question?

Author: Gregg, Cheryl A.; Mallett, Sherri

Source: Journal of AHIMA

Publication Date: June 2000

..programs, documentation, Coding , and reimbursement analy.. ..dgeable about outpatient Coding guidelines (in particula.. ..ssity issues can lead to Reimbursement and billing difficulties.. ..tory tests. As a result, Reimbursement specialists must stay cu.. ..r anyone involved in the Reimbursement process, a thorough know..

Seizing the Moment to Improve the Quality of Health Information Management

Author: Goshen, Naomi; Nachmani, Frances ; Sasson, Nadine ; Itzchak, Tzipi ; Sayfan, J; Kopelman, D; Kolton, L; Vigder, L; Almog, D; Tiosano, T

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

.. more resources into the Coding process, as also noted b.. ..medical information, the Coding staff tried to motivate .. ..lity and accuracy of the Coding process. Method.. .. the methodology used in Coding medical data. The WHO g.. ..nd the responsibility of Coding the procedure on the cod..

AHIMA Letter to Secretary Sebelius and Attorney General Holder Concerning EM Coding in EHRs

Author: Gordon, Lynne Thomas

Source: AHIMA testimony and comments

Publication Date: September 26, 2012

..ons regarding alleged “up Coding ” of hospital .. ..E/M Coding for Hospitals .. ..adopt a national set of Coding guidelines for hospital .. ..set of Coding guidelines for reporting.. ..spital-specific internal Coding guidelines is contrary t.. ..te adherence to national Coding guidelines as required u..

Implementing and Managing a Virtual Coding Department

Author: Glass, Sarah

Source: AHIMA Convention

Publication Date: October 31, 2006

..g and Managing a Virtual Coding Department Sara.. ..d retention tool for the Coding staff in the HIM departm.. ..ent and manage a virtual Coding department, and the resu.. ..ully implement a virtual Coding department. St. Luke&rsq.. ..stem’s centralized Coding department uses the EHR ..

Audit of Automated Code Assignment in Israeli Hospital's Computerized Medical Information Systems

Author: Gill, Rhonda; Hecht, Rivka

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

..using the same automated Coding program compared to that.. ..ty of the data. This new Coding environment challenged t.. ..dified for auto-assigned Coding program), with correspon.. ..purposes, this automated Coding program and its code tab.. ..ere to the same official Coding guidelines and rules, de..

Retooling Quality Measures for ICD-10

Author: Giannangelo, Kathy; Hyde, Linda A.

Source: Journal of AHIMA

Publication Date: June 2010

..ssification structure or Coding rules used to assign spe.. ..und in the measures. En Coding primary documentation of.. ..0-CM. Any changes in the Classification structure or coding rule.. ..easures with code set or Classification changes. While the.. ..recommendations to other Classification and terminology changes...

ICF: Representing the Patient beyond a Medical Classification of Diagnoses

Author: Giannangelo, Kathy; Bowman, Sue E; Dougherty, Michelle; Fenton, Susan H.

Source: Perspectives in Health Information Management

Publication Date: November 2005

..s, levels of detail, and Coding guidelines .. .. CCS, is the director of Coding and compliance for AHIMA.. .. The International Classification of Functioning, Disabili.. .. The International Classification of Functioning, Disabili.. .. of International Classification s (WHO-FIC). 1 The pur..

Changes Ahead in Data Standards

Author: Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: June 2011


HIM professionals are most familiar with the data standards mandated through HIPAA. However, the data standard adoption process is also now part of the requirements for EHR technology in the meaningful use program.

Understanding the data standards adoption process under HIPAA and th....

Reporting Codes Accurately

Author: Giannangelo, Kathy

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2005

..gelo, RHIA, CCS Coding professionals routinely .. ..rt the healthcare claim. Coding professionals know that .. ..gnosis codes reported by Coding professionals ar.. ..g Accuracy Coding professionals follow a s.. ..lity and completeness of Coding (e.g., inclusion..

Development and Use of Automated Coding Software to Enhance Antifraud Activities

Author: Garvin, Jennifer Hornung; Watzlaf, Valerie J.M.; Moeini, Sohrab

Source: AHIMA Computer-Assisted Coding Meeting

Publication Date: September 06, 2006

..ent and Use of Automated Coding Software to Enhance Anti.. ..ent and Use of Automated Coding Software to Enhance Anti.. ..ent and Use of Automated Coding .. ..study examined automated Coding software and how it coul.. ..s and users of automated Coding and antifraud software. ..

Present on Admission: Where We Are Now

Author: Garrett, Gail S.

Source: Journal of AHIMA

Publication Date: July 2009

..ing routine business for Coding professionals. F.. .. Official Guidelines for Coding and Reporting. The POA g.. .. changes to the official Coding guidelines clarified doc.. .. Official Guidelines for Coding and Reporting, including.. ..ss should be part of the Coding department routine. By n..

Three-Day Window Updates

Author: Garrett, Gail S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011

..h111-3962 . Coding and Reimbursement Resour.. ..ces For more Coding and reimbursement guidan.. .. AHIMA's "Medical Coding " Web site at www.a.. ..hima.org/ Coding AHIMA's ".. ..ssistant vice president, Coding compliance, at HCA in Na..

Save the Stamps: Health Information Handlers Offering Electronic Record Submission for CMS Audits

Author: Galterio, Louis

Source: Journal of AHIMA

Publication Date: January 2013

..tals in the US to ensure Coding was done correctly. The .. ..gateway. Not only is the Coding and programming maintena.. ..d not receive sufficient Reimbursement for their submission, ad.. ..cents per page. Recently Reimbursement has been capped, and the.. ..ed. The 12 cent per page Reimbursement does not apply to other ..

Hospital Authority Clinical Vocabulary Table: the Past, the Present, and the Future

Author: Fung, V.; Cheung, N T; Szeto, K; Ngai, L; Lau, M; Kong, J HB

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

..ded so as to incorporate Coding rules in the HAMDCT. Ali.. ..as concern that when the Coding system was changed, it w.. ..a due to mapping between Coding systems by removing the .. ..ocabulary upon any given Coding system Ch.. ..change in version of the Coding system. At present, diag..

External Cause Codes in ICD-10-CM

Author: Fuller, Jan C.

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2014



The increased specificity in ICD-10-CM is reflected in a substantial increase in external cause codes. The traditional “E code” has been replaced with V, W, X and Y codes. While the purpose of the codes remains the same, the ICD-10-CM codes provide a level of detail not possible in ICD-9-....

Problem List Coding in e-HIM

Author: Fraser, Greg

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2005

..ed to problem list Coding . 5 However, S.. .."Problem List Coding in e-HIM".. ..ning. 4 ICD-9-CM is a Classification rather than a re.. ..d in this way. A Classification is a system that categor.. .. have meaning. A Classification is designed to be used p..

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