1874 results.
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Coding it Right: Coding Examples for the Device Character in PCS
Author: Zumar, Wendy
Source: CodeWrite | AHIMA newsletter article
Publication Date: May 2012
When reading the description of a procedure and translating it to the ICD-10-PCS coding system, selecting the correct value for the device character can be challenging. A sinus antrostomy using balloon dilation, for example, is done with an inflatable balloon catheter, which is inserted i....
Coding and Documentation of Traumatic Closed and Open Fractures
Author: Zumar, Wendy
Source: CodeWrite | AHIMA newsletter article
Publication Date: July 2012
Objective: Examine the differences between coding traumatic closed and open fractures in ICD-9-CM and in ICD-10 CM and is based on the injury codes found in Chapter 17 of ICD-9-CM and Chapter 19 of ICD-10-CM. External cause of injury codes would also be reported where applicable.
Coding and Documentation of Laceration, Bites, and Punctures in ICD-10-CM
Author: Zumar, Wendy
Source: CodeWrite | AHIMA newsletter article
Publication Date: June 2012
The objective of this article is to examine the differences between coding lacerations, bites, and wounds in ICD-9-CM and in ICD-10 CM. This article focuses on the injury codes found in Chapter 17 of ICD-9-CM and Chapter 19 of ICD-10-CM. External cause of injury codes would also be report....
Pitfalls in Endovascular Coding
Author: Zielske, David R.
Source: AHIMA Convention
Publication Date: October 15, 2004
Overview
Endovascular refers to those procedures that involve percutaneous access to the vascular system. Diagnostic angiography and interventional procedures, such as angioplasty, stent placement, embolization, and dialysis access maintenance, are some of the procedures performed. These....
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....
Maximizing Data Quality of the Minimum Data Set
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: June 1998
HIM professionals who work in long term care settings are well acquainted with the Minimum Data Set 2.0 (MDS). Since 1990, it has been part of the standardized assessments that nursing homes participating in the Medicare and Medicaid programs must complete. Starting this summer, updated submis....
Benchmarking Project Harvests Ideas for Network
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: November 1998
It started as a simple benchmarking project. But when Patricia Rhodes, RRA, Carol Keller, MPA, and their team finished, the project had taken them across the country, opened up lines of communication with staff members at nine other facilities, and helped them improve their....
Dot-com Coder
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: July 2000
For many people, working with artificial intelligence may sound like something out of a science fiction movie. But for Amy Davis, RHIA, it's just part of the job.
Davis is coding specialist and knowledge engineer at DocCode.com, a company based in Jacksonville, FL. Davis's....
From Coder to Knowledge Engineer
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: July 2003
“Find a job that really holds your interest and one that will challenge you. If you’re not challenged daily, there’s something wrong.” —Judy Sample, RHIT, CCS, knowledge engineer
at Inference Systems International, Inc.
Combining her interests in coding and tec....
Quality at the Core
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: March 2002
Is your hospital getting ready for the Joint Commission’s core measures project? Some hospitals are already transmitting the necessary data as part of the pilot project. Here’s how they are handling the challenges and deriving benefits.
If you’re an HIM director, you prob....
Where Are They Now? CPR Leaders Assess Their Progress
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: September 2000
Five years ago the first recipients of the Davies awards showed us successes of CPR systems across the country. Where are they now? This article catches up with these CPR leaders.
Is your job exactly the same as it was five years ago? For most HIM professionals, the answer....
No Uncertain Terms
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: May 1998
HIM professionals think of classification systems such as ICD-9-CM as tools for everyday use. But these familiar systems are evolving and changing rapidly—as Donna Pickett, RRA, is well aware.
Pickett is medical systems administrator for the Office of Data Standards, ....
Steps to Internal Audits for Physician Office Records
Author: Zeisset, Ann M.; Scichilone, Rita A
Source: Journal of AHIMA - Coding Notes
Publication Date: October 1999
Physician offices face the challenge of submitting correct coding information through the billing process. Ensuring timely reimbursement at the highest level for which services were provided, correct coding also proves there are no fraudulent activities occurring at the facility. Performing a....
Fiscal Year 2007 ICD-9-CM Changes
Author: Zeisset, Ann M.; Schraffenberger, Lou Ann
Source: Journal of AHIMA
Publication Date: September 2006
Editor's note: This article is an expanded version of the article "ICD-9-CM Coding Changes for Fiscal Year 2007" published in the September 2006 edition of the Journal of AHIMA.
Hematology Issues
Lymphatic and Hematopoietic Tissues
New codes were approved to uniquely....
ICD-9-CM Coding Changes for Fiscal Year 2007
Author: Zeisset, Ann M.; Schraffenberger, Lou Ann
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2006
The ICD-9-CM coding changes for fiscal year 2007 were released in the April 25, 2006, Federal Register (available at www.access.gpo.gov/su_docs/fedreg/a060425c.html). Additional code changes were included in the final rule released in August. Changes go into effect with discharges occurring on....
Taking a Closer Look at 2003 ICD-9-CM, DRG Changes
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2002
The ICD-9-CM coding changes and DRG changes for fiscal year 2003 include 106 new diagnosis codes, 41 new V codes, 16 new E codes, 25 new procedure codes, and 19 invalid diagnosis codes. Released in the August 1, 2002, Federal Register, these changes went into effect October 1, 2002, with disch....
Modifier Usage for Hospital Outpatient Services
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2000
Implementing the processes for CPT modifier usage in the outpatient hospital setting has been a topic on everyone's "to do" list since HCFA announced the change. There are many variables in executing this change, such as updating or changing computer systems, training staff, and developing chan....
Coding on the Home Front
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2002
Recently, a group of coders participated in a survey about their day-to-day experiences as remote, or at-home coders. The survey asked a series of questions related to the positives and negatives of coding at home versus coding in the more traditional office setting. Below is a summary of the....
Tips for TIPS: Transvenous Intrahepatic Portosystemic Shunt
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2004
Transvenous intrahepatic portosystemic shunt (TIPS) is a relatively new procedure used to treat complications of severe liver disease such as bleeding esophageal varices. This extensive procedure is typically performed by interventional radiologists and involves the placement of a stent in the....
ICD-10-PCS Root Operation Guidelines
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2010
ICD-10-PCS has a completely different structure than ICD-9-CM. Each ICD-10-PCS code consists of individual values rather than lists of fixed codes and text descriptions, with each value containing a unique definition. The objective of the procedure is identified in the third character, the roo....
ICD-10-PCS Root Operation Groups, Part 4
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2010
Root Operations That Always Involve a Device, Involve Examination Only, or Define Other Objectives
The medical and surgical procedure section of ICD-10-PCS contains most (but not all) procedures typically coded and reported in the hospital inpatient setting. There are 31 root operatio....
ICD-10-PCS Root Operation Groups
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2010
Root Operations that Take Out Some or All of a Body Part
The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically reported in the hospital inpatient setting. As with all codes in ICD-10-PCS, the medical and surgical procedure codes contain....
Testimony of the American Health Information Management Association to the National Committee on Vital and Health Statistics – Standards Subcommittee
Author: Zeisset, Ann M.
Source: AHIMA testimony and comments
Publication Date: June 17, 2011
Testimony by AHIMA staff member on what AHIMA and HIM professionals are doing toward the full implementation and use of the upgraded HIPAA transactions as well as ICD-10-CM and ICD-10-PCS
Much in Store for ICD-9, DRGs in FY 2004: 104 Diagnosis, 10 Procedure Codes, 13 DRGs Introduced
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2003
New ICD-9-CM codes and DRG changes for fiscal year 2004 were released in the August 1, 2003, Federal Register. These changes went into effect October 1, 2003, with discharges occurring on or after that date. There were 104 new diagnosis codes and 10 new procedure codes. Due to code expansions,....
Rooting Out ICD-10 Procedure Codes, Part 7
Author: Zeisset, Ann M.
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: September 02, 2010
Editor’s note: This is the final part of a series discussing the nine root operation groupings.
The medical and surgical procedure section of ICD-10-PCS contains most but not all procedures typically coded and reported in the hospital inpatient setting. This article is the seventh i....
Rooting Out ICD-10 Procedure Codes, Part 6
Author: Zeisset, Ann M.
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: August 02, 2010
Editor’s note: This is the sixth part of a series discussing the nine root operation groupings.
The medical and surgical procedure section of ICD-10-PCS contains most but not all procedures typically coded and reported in the hospital inpatient setting. This article is the sixth in a....
ICD-10-CM Enhancements: A Look at the Features That Will Improve Coding Accuracy
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2009
Although the ICD-10-CM/PCS final rule sets an implementation deadline of October 2013, facilities should start preparing now for the new code set. All facilities reporting ICD-9-CM codes for diagnoses must transition to ICD-10-CM for diagnosis reporting.
ICD-10-CM implementation will....
Coding Injuries in ICD-10-CM
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2011
Note: This article has been updated. The updated version is available here.
Coding Guidelines for Pain
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2007
New codes for generalized pain, central pain syndrome, and postoperative pain were approved for ICD-9-CM in FY 2007 and went into effect October 1, 2006. Previously codes for pain were found in the body system chapters and the symptom chapters. A new category was created in the nervous sys....
ICD-9-CM Codes Ready for 2002
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2001
For those reporting ICD-9-CM codes for all diagnoses coding, and hospitals reporting ICD-9-CM volume III for procedures, fall is the time to review and implement the changes and revisions for fiscal year 2002.
The ICD-9-CM coding changes for fiscal year 2002 were released in the Augus....
Hospice Coding Left Out?
Author: Zastoupil, Shawna
Source: AHIMA newsletter article | CodeWrite
Publication Date: October 2016
Like many other healthcare settings, hospices are starting their journey into coding compliance. Before the first Federal Regulation (FY 2013), which addressed diagnosis coding clarification, hospices typically reported one code on their claims. Since that time, the Department of Heal....
Communication, Collaboration, and Compliance
Author: Zarybnicky, Rosalie; Coltrin, Kaelyn; Colwell, Holly; Lam, Donna
Source: Journal of AHIMA
Publication Date: February 2001
Best practices are the result of professionals developing practical ways to improve processes and quality. Medicare peer review organization and state Payment Error Prevention Program (PEPP) organizer PRO-West recognized this when it looked to state hospitals for methods to improve do....
Coding for Renal Failure
Author: Zarick, Andrew Jr.
Source: AHIMA Convention
Publication Date: October 10, 2007
Acute renal failure is present in one to five percent of all hospitalized patients and as many as 20 percent of ICU patients. The causes may be pre-renal, intra-renal or post renal. Pre-renal causes are the most common. Lab findings will help identify the specific cause of acute renal failure.....
VA Program Bridges Skills Gap, Improves Performance
Author: Zangl-Milbrand, Evelyn
Source: Journal of AHIMA
Publication Date: April 2001
When I was hired as the assistant director of the HIM section with the Department of Veterans Affairs, Greater Los Angeles Healthcare System (GLAHS), I faced a major challenge. Congress had recently required the Department of Veteran Affairs (VA) to submit claims to third-party payer....
Another Look at Home Care PPS
Author: Youmans, Karen; Scichilone, Rita A; Dougherty, Michelle
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2001
In the October 2000 Journal of AHIMA, we outlined the new home health care prospective payment system (PPS).1 Coding professionals working with home health providers have learned new terms and additional guidelines for reporting. However, confusion remains concerning code assignments, because s....
Sorting Out the Inpatient Rehabilitation PPS
Author: Youmans, Karen
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2001
FRGs, RIC, CMGs, FIM, MDS-PAC, IRF, RPPS, UDSMR...What do these letters mean? They are all part of the inpatient rehabilitation prospective payment system (RPPS). This article will explain the history and key pieces of this system.
A Brief History of PPS
As we know,....
HIM Spin on the Revenue Cycle
Author: Youmans, Karen
Source: Journal of AHIMA
Publication Date: March 2004
HIM plays an integral role in an organization’s revenue cycle. That means health information managers have a role to play in revenue cycle management.
Is the following scenario familiar? The CEO is complaining about accounts receivable (AR) climbing to $10 million. The coders a....
Are Ethics Guiding Your Workplace?
Author: Yokubaitis, Pamela R.
Source: Journal of AHIMA
Publication Date: September 2003
Sanctions under the HIPAA regulations mean serious financial consequences for healthcare professionals who release protected health information to others without following proper disclosure protocols. But HIM professionals should not be motivated by fear of financial consequences alone. Ou....
How to Win the Outpatient Data Quality Challenge
Author: Yoder, M. Jeanne
Source: AHIMA Convention
Publication Date: September 23, 2002
Using CPT Modifier -25 for Professional Billing
Author: Yoder, Lois M.
Source: Journal of AHIMA
Publication Date: January 2000
You may want to consider a focused review of how your practice assigns CPT modifier -25, "a significant, separately identifiable Evaluation & Management (E&M) service by the same physician on the same day of the procedure or other service."1 The Health Care Financing Admini....
Yahoo Search for ICD-10
Author: Yahoo!
Source: External web site
Publication Date: December 01, 2007
Evaluation of Alternative Methods to Establish DRG Relative Weights
Author: Wynn, Barbara O.; Scott, Molly
Source: RAND Corporation
Publication Date: April 15, 2008
Monitoring and Evaluating Your Hospital's Inpatient Case Mix
Author: Wozniak, Lynn-Marie
Source: AHIMA Convention
Publication Date: September 23, 2002
Issues Surrounding the Proposed Implementation of ICD-10
Author: Workgroup for Electronic Data Interchange. Subcommittee on ICD-10
Source: External web site
Publication Date: October 16, 2003
This paper outlines the impact that implementation of ICD-10 would have on the healthcare industry in the United States.
Comparison of Two Approaches to Text Processing: Facilitating Chart Reviews of Radiology Reports in Electronic Medical Records
Author: Womack, Julie A.; Scotch, Matthew; Gibert, Cynthia; Chapman, Wendy; Yin, Michael; Justice, Amy C; Brandt, Cynthia
Source: Perspectives in Health Information Management
Publication Date: October 2010
Speeding Decisions: Social Security’s Information Exchange Program
Author: Winter, Kitt; Hastings, Bob
Source: Journal of AHIMA
Publication Date: May 2011
The Social Security Administration has plenty of reasons to streamline its records request process-more than 15 million reasons each year, in fact. That's why it has been pioneering information exchange projects with the private sector, including use of the Nationwide Health Informa....
Physician Liaison Program Brings Improvement
Author: Wilson, Valerie; Hammer, Juanita; Washburn, Daniel
Source: Journal of AHIMA
Publication Date: February 1999
St. Mary's Mercy Hospital is a 277-bed acute care facility in northwestern Oklahoma. Serving as a regional referral center, the facility provides acute medical and surgical services, critical care, neurosurgical services, inpatient rehabilitation, a skilled nursing unit, ambulatory sur....
LOINC as a Data Standard: How LOINC Can Be Used in Electronic Environments
Author: Wilson, Patricia S; Scichilone, Rita A
Source: Journal of AHIMA
Publication Date: July 2011
There is a growing need for document standardization in health information systems to facilitate efficiency and ensure interoperability. Terminologies enable collection of data that can be reused without recoding or data entry duplication.
The Logical Observation Identifiers Names a....
Role of Mapping and Modeling for the HIM Professional and Coder
Author: Wilson, Patricia S
Source: AHIMA Convention
Publication Date: October 31, 2006
What Mapping and Modeling Means to the HIM Professional
Pat Wilson, RT(R), CPC, PMP
Objective
The process of mapping and modeling is required to assist with the goal of interoperability for an electronic health record (EHR). This presentation explains the process of mapping....
Maintenance and Update Issues for Clinical Vocabulary Mapping
Author: Wilson, Patricia S
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Presentation for the Clinical Vocabulary Mapping Methods Symposium
AHIMA Conference, 2005
San Diego, California
October 15, 2005 Introduction
The Electronic Health Record (EHR) is no longer an option. It has become a necessity. It is essential to an enterprise to hav....
What Mapping and Modeling Mean to the HIM Professional
Author: Wilson, Patricia S
Source: Perspectives in Health Information Management
Publication Date: March 2007
New Focus on Process and Measure: Raising Data Quality with a Standard Coding Workflow and Benchmarks
Author: Wilson, Donna D; Hampton-Bagshaw, Kim; Jorwic, Therese M; Bishop, Jean; Giustina, Elizabeth
Source: Journal of AHIMA
Publication Date: March 2008
Establishing a standard coding workflow that incorporates continuous improvement and creating performance benchmarks is key to improving the quality of coded data.
HIM professionals who assign codes or manage coded data take responsibility for translating clinical....
Recovery Audit Program Changes
Author: Wilson, Donna D
Source: CodeWrite
Publication Date: February 2015
Editor's note: The Centers for Medicare and Medicaid Services (CMS) has delayed the commencement of work under the Recovery Audit contract for durable medical equipment (DME), home health (HH), and hospice reviews. For more information and further updates on this new development, please s....
Recoding Surgical Cases Denied by RAC: CPT Coding an Additional Step in the Rebilling Process
Author: Wilson, Donna D
Source: CodeWrite | AHIMA newsletter article
Publication Date: August 2013
On March 13, the Centers for Medicare and Medicaid Services (CMS) developed a short-term ruling (CMS-1455-R) which allowed Medicare Part A (inpatient) recovery audit contractor (RAC) medical necessity claims to be rebilled as Medicare Part B (outpatient). For claims processed after July 1,....
PEPPER Reports: a Looking Glass into Inpatient Coding
Author: Wilson, Donna D
Source: CodeWrite | AHIMA newsletter article
Publication Date: July 2014
Do you ever wonder how your Medicare coding quality compares to other hospitals in your state, jurisdiction, or even the nation? The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a free tool developed by the TMF Health Quality Institute, under contract with the Ce....
Revisiting Unrelated Surgical Procedures (MS-DRGs 981-989)
Author: Wilson, Donna D
Source: CodeWrite
Publication Date: February 2016
Make a fresh start in the new year by revamping coding compliance plans to include a second level review of all claims that group into MS-DRGs 981-989 (Operating Room Procedure/Unrelated to Principal Diagnosis). Historically, MS-DRGs 981-989 have been "low hanging fruit" for outside audito....
New Changes De-Spookify Modifier -59
Author: Wilson, Donna D
Source: Journal of AHIMA - website
Publication Date: October 30, 2014
The proper application of modifier -59 (Distinct Procedural Service) has mystified many a coder. The Centers for Medicare and Medicaid Services (CMS) has recently indicated that modifier -59 is the most commonly used and abused of all the modifiers—mainly due to the fact that it is used to....
Five RAC Coding Targets: Demonstration Program Identified Key Areas of Improper Payment
Author: Wilson, Donna D
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2009
The Centers for Medicare and Medicaid Services (CMS) expects to have four Recovery Audit Contractors (RACs) operating by 2010. Each RAC will be responsible for identifying overpayments and underpayments in a region of the country. Based on the results of the demonstration program, the permanen....
RAC Inpatient Coding Denials: Key Areas of Improper Payment in permanent program
Author: Wilson, Donna D
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2012
The Recovery Audit Contractor (RAC) demonstration program found that "most of the overpayment amounts collected by the RACs (about 85 percent) were from inpatient hospital providers," and "almost half of the improper payments were the result of incorrect coding."1 Things have changed with....
Can You Manage Managed Care?
Author: Willner, Sue
Source: Journal of AHIMA
Publication Date: July 2001
HIM professionals’ data management skills make them a hot property in many settings, but none more so than managed care. In this second installment of the Journal of AHIMA’s special series on managed care, the author describes the ways managed care organizations use data and how HIM....
Walking the Tightrope—Coding Compliance in the Electronic Age
Author: Williams, Vickie J.
Source: AHIMA Convention
Publication Date: October 17, 2008
Introduction
For at least the last ten years, the federal government and private whistleblowers have viewed improper diagnostic coding as fertile ground for major investigations and prosecutions of healthcare providers. Prosecutors use the civil False Claims Act, the Civil Money Penalties....
Making a Proactive Transition to APCs
Author: Willett, Lyn
Source: Journal of AHIMA
Publication Date: July 2000
There's no doubt APCs are going to change the way your facility operates, but do you know how? By taking a look at your existing systems, you'll get a better idea of how to prepare for changes. This article spotlights specific functions to consider and optimize for the new outpatient prospect....
2005 ICD-9-CM Codes and DRG Changes
Author: Willard, Dianne; Worthington, Debbie; Ashley, Patti
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2004
ICD-9-CM coding and DRG changes for fiscal year 2005 include 150 new diagnosis codes, 21 new V codes, 54 new procedure codes, 25 invalid diagnosis codes, and 3 new DRGs. The changes were released in the August 11 Federal Register and went into effect October 1, 2004, for discharges occurring o....
HCFA Requires Use of Modifiers for Hospital Outpatient Services
Author: Willard, Dianne
Source: Journal of AHIMA
Publication Date: June 1998
On January 7, 1998, the Health Care Financing Administration (HCFA) released the final instructions on hospital outpatient modifiers from Medicare Hospital Manual transmittal number 726 dated January 1998. These instructions were electronically released to the Medicare fiscal intermediaries,....
Laboratory Services Regulations Impact National Coverage Decisions, HIM
Author: Willard, Dianne
Source: Journal of AHIMA
Publication Date: October 2002
This is Part 2 of a two-part article on laboratory services regulations. Part 1, which appeared in the September Journal of AHIMA, dealt with the administrative policies contained in these regulations. Part 2 addresses the specific national coverage decisions that were developed as part of thi....
1999 CPT Revisions
Author: Willard, Dianne
Source: Journal of AHIMA
Publication Date: January 1999
This article will summarize some of the major additions and revisions in the 1999 Current Procedural Terminology (CPT). A complete review of all the code and guideline changes -- including the rationale for these changes -- can be found in the November 1998 issue of the CPT Assistant newslette....
Coding Preventive Care Services
Author: Wilkinson, Dianne
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2008
According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....
Choosing Modalities for Carotid Stenosis
Author: Wiley, Sean
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2003
One of the leading causes of stroke and transient ischemic attack (TIA) is carotid artery disease (CAD). With technology changing at such a rapid rate, it is difficult for physicians to decide on the gold standard of care when it comes to visualizing carotid stenosis. This article will explain....
2007 CPT Coding Update
Author: Wiedemann, Lou Ann; Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2007
A number of changes to the current CPT codes took effect on January 1, 2007. These changes affect categories I, II, and III codes, with a total of 258 additions, 308 deletions, and 79 revisions. A summary of all additions, deletions, and revisions can be found in appendix B of the 2007 C....
Coding Sepsis and SIRS
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2007
Coding a chart with a sepsis diagnosis can prove challenging for coders. The coding guidelines for sepsis as well as ambiguous provider documentation can often mean an extended length of time reviewing a chart only to place it on hold for a physician query. This column outlines the clinic....
Managing Physician Queries in the EHR
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2011
Federal incentives provided for the meaningful use program under the American Recovery and Reinvestment Act are encouraging hospitals to adopt electronic health records (EHRs). Eighty percent of hospitals are planning to become meaningful users of EHR technologies in 2011, and the healthcare i....
Seasoning Your Compliance Plan with PEPPER: How to Read PEPPER Data on Payment Errors
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: January 2007
PEPPER data help facilities compare their Medicare payments with state and national averages. Here’s how to read yours.
Hospitals can take advantage of a report that helps them compare their Medicare reimbursement to state and national averages. What they learn can help them....
Strategizing Clinical Documentation Improvement: Tracking the Right CDI Measures, Data Can Impact Multiple Healthcare Areas
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2013
Clinical documentation requirements are expected to increase as healthcare systems are challenged with complex new audits, ever-changing compliance rules, and a transition to ICD-10-CM/PCS. All of these initiatives will specifically challenge clinical documentation improvement (CDI) profes....
Preparing for POA Reporting: How One Facility Educated Its Staff on the Importance of the New Requirement
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2007
Section 5001(a) of the Deficit Reduction Act introduced a new data reporting standard for hospitals submitting Medicare claims. The present on admission (POA) indicator will be a requirement for inpatient Medicare claims submitted by all hospitals on October 1, 2007.
This a....
Using CDI to Meet Federal Quality Measures
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: January 2013
Clinical documentation is the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has been an ongoing challenge to health informati....
Data Quality Audit: Understanding Coding Variations
Author: Whittome, Helen; Crook, Gail
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
The Canadian Health Information Management Association (CHIMA) and the Ontario Health Information Management Association (OHIMA), with technical support from the Canadian Institute for Health Information (CIHI), conducted a pilot data quality audit (the Audit) of Ontario acu....
Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement
Author: Whittle, Kelly
Source: Journal of AHIMA
Publication Date: September 2016
It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....
Accountable Care and Data Analytics Emerging in Healthcare
Author: White, Susan E; Taylor, Lisa Brooks
Source: Journal of AHIMA
Publication Date: November 2012
Value-based purchasing of healthcare is transforming the US healthcare delivery system and payment methodologies. Spurred by commercial pay-for-performance initiatives and the roll out of the Centers for Medicare and Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP), accountable....
ACO Primer: Reviewing the Proposed Rule on Accountable Care Organizations
Author: White, Susan E; Kallem, Crystal; Viola, Allison F.; Bronnert, June
Source: Journal of AHIMA
Publication Date: June 2011
In April the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking for the Medicare Shared Savings Program. The program was mandated by the Affordable Care Act to encourage the development of accountable care organizations (ACOs) in Medicare.
The....
Role of Data Analysis in Revenue Cycle Improvement
Author: White, Susan E
Source: AHIMA Convention
Publication Date: September 27, 2010
Introduction
Data analysis techniques are becoming increasingly important for HIM professionals. The application of relatively simple and straightforward data analytics can identify significant opportunities for improvement in the revenue cycle. Traditional chart audits can be enhanced b....
Predictive Modeling 101: How CMS’s Newest Fraud Prevention Tool Works and What It Means for Providers
Author: White, Susan E
Source: Journal of AHIMA
Publication Date: September 2011
In July the Centers for Medicare and Medicaid Services (CMS) began applying predictive modeling techniques to Medicare claims data to detect fraud. CMS contracted with Northrop Grumman, an information solutions company, to develop the technology. Northrop Grumman partnered with Verizon and Nat....
Positioning Your Facility for Severity Adjusted Coding
Author: Whitaker, Paul
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2007
With the recent talk of implementing a severity adjusted payment methodology, facilities must begin considering how they will prepare for this transition. Some healthcare organizations are concerned that the process is resource intensive, time consuming, and tedious.
Organi....
Job Satisfaction among Clinical Coders in Ohio
Author: Wenning, Jay; Brodnik, Melanie S.
Source: AHIMA Convention
Publication Date: September 23, 2002
Managed Care: The Dominant Paradigm in US Healthcare
Author: Welch, Julie J.
Source: Journal of AHIMA
Publication Date: April 1998
What does "managed care" really represent -- and what effect has managed care had on the healthcare market? The author describes how managed care came to be a critical market force, offers a snapshot of its proliferation, and examines its effects on the traditional payment system.
It's....
Aligning Computer-Assisted Coding and Information Governance Efforts
Author: Weinberg, Jason; Peterson, Stephanie; Marc, David; Sandefer, Ryan
Source: Journal of AHIMA
Publication Date: October 2015
AHIMA defines information governance as “the enterprise-wide framework for managing information throughout its lifecycle and supporting the organization’s strategy, operations, regulatory, legal, risk and environmental requirements.”1 AHIMA recognizes that successful heal....
Critical Success Factors in Establishing the Electronic Health Record: the Experience of St. Michael's Hospital, Canada
Author: Wegener, John; Woodman, Anna Jane
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Overview
This presentation will provide insight into planning, implementing, and managing the transition of a health records department, moving from an overburdened and inefficient paper environment toward an automated electronic setting. This success story will look at how staff, work pr....
Results from the Veterans Health Administration ICD-10-CM/PCS Coding Pilot Study
Author: Weems, Shelley; Fenton, Susan H.
Source: Perspectives in Health Information Management
Publication Date: July 2015
Abstract
The Veterans Health Administration (VHA) of the US Department of Veterans Affairs has been preparing for the October 1, 2015, conversion to the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) for....
Data Standardization in the Veterans Health Administration
Author: Weems, Shelley
Source: AHIMA Convention
Publication Date: October 21, 2005
The Data Standardization Program is the cornerstone of the Department of Veterans Affairs (VA) plan to share computable health information between its medical care facilities. Data standardization establishes a consistent way of defining data, thereby enabling all sites in the VA health system....
HIPAA Implementation: the Case for a Rational Roll-out Plan
Author: WebMD
Source: External web site
Publication Date: July 19, 2004
HIPAA Acknowledgments: the Need for a Standard Transaction Acknowledgment
Author: WebMD
Source: External web site
Publication Date: November 24, 2004
Recognizing the ICD-10-GM, German Coding Guidelines, and German Coders
Author: Weber, Regina G.
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Note: The following abstract is prepared solely for the use of reporting and informing the general public and healthcare field of ICD-10-GM and German coding guidelines. This abstract does not contain a formal position on production, subject, or issue from any institution or organizatio....
Testimony of the American Health Information Management Association to the Standards and Security Subcommittee of the National Committee on Vital and Health Statistics
Author: Watzlaf, Valerie J.M.; Stanfill, Mary H
Source: AHIMA testimony and comments
Publication Date: July 26, 2005
July 26, 2005
Opening Comments
Chairmen Blair and Reynolds, members of the Standards and Security Subcommittee, and ladies and gentlemen, good afternoon. I am Valerie Watzlaf, associate professor within the Department of Health Information Management in the....
ICD-10 Coding Productivity Study Highlights Emerging Standards
Author: Watzlaf, Valerie J.M.; Nemchik, Scot; Hoerner, Mike; Sheridan, Patty Thierry
Source: Journal of AHIMA
Publication Date: August 2016
The implementation of ICD-10 has been compared to Y2K, with industry analysts noting that October 1, 2015 came and went with little fanfare. This commentary speaks volumes to the significant preparation that occurred in the months and years leading up to ICD-10. If you were in the trenches....
Final Report: Effective Public Health Reporting Using ICD-10-CM
Author: Watzlaf, Valerie J.M.; Garvin, Jennifer Hornung; Moeini, Sohrab; Firouzan, Patricia Anania
Source: AHIMA Foundation
Publication Date: June 02, 2006
This study investigates the completeness and measures the effectiveness and efficiency of ICD-10-CM and ICD-10-PCS in capturing and reporting public health information.
Effectiveness of ICD-10-CM in Capturing Public Health Diseases
Author: Watzlaf, Valerie J.M.; Garvin, Jennifer Hornung; Moeini, Sohrab; Firouzan, Patricia Anania
Source: Perspectives in Health Information Management
Publication Date: June 2007
This research study examined the usefulness of the ICD-10-CM system in capturing public health diseases (reportable diseases or the nationally notifiable infectious diseases, leading causes of death, and morbidity/mortality related to terrorism), when compared to ICD-9-CM.
It also examined agreement levels of coders when coding public health diseases in both ICD-10-CM and ICD-9-CM.
Effective and Efficient Public Health Reporting Using ICD-10-CM and ICD-10-PCS
Author: Watzlaf, Valerie J.M.; Garvin, Jennifer Hornung; Moeini, Sohrab; Firouzan, Patricia Anania
Source: AHIMA Convention
Publication Date: October 31, 2006
Effective Public Health Reporting Using ICD-10-CM
Valerie JM Watzlaf, PhD, FAHIMA, RHIA, Jennifer Hornung Garvin, PhD, FAHIMA, RHIA, CTR, CCS, CPHQ, Sohrab Moeini, BSIS, and Patti Firouzan, MSIS, RHIA
Impact
Introduction
The emergence of ICD-10-CM brings anticipation about....
Physicians' Outlook on ICD-10-CM/PCS and Its Effect on Their Practice
Author: Watzlaf, Valerie J.M.; Alkarwi, Zahraa; Meyers, Sandy; Sheridan, Patty Thierry
Source: Perspectives in Health Information Management
Publication Date: January 2015
Abstract
Background—The United States is one of the last countries to change from ICD-9-CM to ICD-10-CM/PCS. The compliance date for implementation of ICD-10-CM/PCS is expected to fall on October 1, 2015.
Objectives—Evaluate physicians’ perceptions....
Managing Clinical Data: A Cancer Registries Update
Author: Watkins, Sue
Source: Journal of AHIMA
Publication Date: July 1997
Introduction
The American Cancer Society estimates that about 1.38 million new cancer cases will be diagnosed, and about 560,000 Americans will die of cancer, in 1997.1 These estimates do not include carcinoma in situ or basal and squamous cell skin cancer. To monitor trends in cancer i....
Update on Standardized Nursing Data Sets and Terminologies
Author: Warren, Judith J.; Bakken, Suzanne
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2002
HIM professionals can learn a lot from the nursing profession’s development of classification systems, terminology models, and quality indicators. Compared to other healthcare classification systems such as ICD-9-CM or CPT-IV, the nursing systems have not been widely used for reimbursemen....
Will Natural Language Processing Help Coders Anytime Soon?
Author: Warner, Homer R. Jr.
Source: AHIMA Convention
Publication Date: October 10, 2001
Abstract
Natural Language Processing (NLP) systems that aid the process of coding medical records for billing purposes are beginning to appear on the commercial market. NLP systems have the potential to favorably affect the whole medical record coding cost and work-flow equation....
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