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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....

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....

Where Bad Billing Can Lead You

Author: Potter, Jeanne

Source: AHIMA Convention

Publication Date: October 21, 2005

Overview

In this day and age, any company that does not have a process in place to ensure their business practices are compliant with federal and state laws and regulations are putting themselves at serious risk. A physician’s billing practices are subject to federal and state rules....

PEPP: Collaborating to Improve Quality

Author: Poole, Laurie

Source: Journal of AHIMA

Publication Date: April 2001




By collecting and analyzing information about Medicare payment errors, PEPP initiatives are making a contribution to healthcare quality efforts nationwide. Here's how one organization takes a collaborative approach to improving quality.
State Payment Error Prevention Programs (....

Myelodysplastic Syndrome

Author: Poland, Leigh

Source: CodeWrite | AHIMA newsletter article

Publication Date: November 2010



Myelodysplastic Syndrome (MDS) is a term that is used to describe a group of cancers of the blood and marrow. In 1989, the International Agency for Research Institute identified Myelodysplastic Syndrome as a neoplastic condition. Approximately 7,000 to 12,000 new cases are diagnosed annual....

Comprehensive CDI: Making it Happen

Author: Pinson, Richard D.; Tang, Cynthia L.

Source: AHIMA Convention

Publication Date: October 17, 2008

Introduction

MS-DRGs were introduced by CMS on October 1, 2007 in an effort to incorporate severity of illness in adjusting hospital reimbursement for inpatient acute care. In response, as CMS predicted, clinical documentation integrity (or improvement) programs [CDI] are springing up eve....

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....

Look at Modifiers for Hospital Use

Author: Philippou, Karla E.

Source: Brief Encounter

Publication Date: July 02, 2001


Modifiers have been a continuing problem in the hospital setting. Although modifiers were mandated for hospital use in June 1998, many hospitals were unable to comply until the implementation of Ambulatory Payment Categories, (APCs), on August 1, 2000. The initial problems were related to info....

CMS Responds to RAC Myths

Author: Phelps, Charles

Source: CodeWrite | AHIMA newsletter article

Publication Date: April 2013



There is a lot of information available about the Recovery Audit Contractor (RAC) program. Some of what you hear, though, may not be completely accurate. It is important that providers obtain their information from reliable sources. The Centers for Medicare and Medicaid Ser....

Ready, Set, Automate: Preparing for Automation in Coding Workflows

Author: Peterson, Kathleen; Smith, Gail I.; Phibbs, Kozie V.; Eminger, Heather; Giustina, Elizabeth

Source: Journal of AHIMA

Publication Date: July 2010



Coding departments are in training for a triathlon. They are swimming in regulations, cycling through changes in source documents, and running at breakneck speed to ICD-10-CM/PCS implementation. Luckily, new workflow “gear” is emerging that can help them improve endurance and e....

Screening for Colorectal Cancer

Author: Petersen, Darley

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Background  
Colorectal cancer (CRC) remains the second most common cause of cancer death in Western Europe and North America.
Screening for CRC has not worldwide popularity in spite of proven survival benefit in average risk persons. Incidence and mortality, both are worrying in E....

Transitioning Transcriptionists

Author: Person, Carol; Terlep, Minnette

Source: Journal of AHIMA

Publication Date: July 2013



Facing a diminished role, transcriptionists at Sanford Health worked with the organization to move into open, and in-demand, coding roles



The need for transcription was diminishing at Sanford Health, and transcriptionists needed to make a choice-transition into another....

MS-DRGs: One Year and Counting

Author: Perez, Mario A. III; Tully, Melinda

Source: AHIMA Convention

Publication Date: October 17, 2008




Introduction




The most important changes in the Medicare inpatient prospective payment system in 25 years were initiated October 1, 2007. CMS began paying for inpatient hospital services using the CMS-developed Medicare severity DRGs (MS-DRGs). MS-DRGs represent....

Malignancy: Aftercare or Follow-Up?

Author: Parman, Cindy C

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2015




Physician documentation has always supported accurate diagnosis code reporting, but never more so than with the transition to ICD-10-CM codes. Specific terminology and the use of key words and phrases is essential, especially with terms such as "aftercare" and "follow-up," which phy....

HIV/AIDS in ICD-10-CM

Author: Parman, Cindy C

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2014



Human immunodeficiency virus (HIV) attacks the immune system, the body's natural defense system. And of course, without a strong immune system the body has trouble fighting off disease. Both the virus itself and the resulting infection are called HIV. The final stage of HIV infection is a....

Benchmarking with National ICD-9-CM Coded Data

Author: Osborn, Carol E.

Source: Journal of AHIMA

Publication Date: March 1999


As HIM professionals, we want to be assured that we are providing the highest quality data for reimbursement and research purposes. We can review coded data internally, but this does not give us a clear picture of the total information that is being submitted to the Health Care Financing Admin....

CPT Code Updates for 2012

Author: O’Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012


The 2012 updates to the CPT code set include 278 new codes, 139 code revisions, and 98 code deletions. This brings the total number of CPT codes to 9,641.

All major sections of the CPT code set, as well as the introduction and appendix A, have undergone changes. Beginning with the i....

CPT Changes for 2001

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2001




CPT 2001 Professional Edition (CPT® 2001) is complete and should be landing on your desk soon. As an introduction to the new book, this article provides a brief summary of the changes in 2001. A complete listing of the code and guideline changes can be found in CPT Changes 2001:....

CPT Changes for 2002

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2002


Coders need to keep their resources current—including updating the Current Procedural Terminology (CPT) codes every year with the annual CPT book. This article provides a brief summary of the changes made to the CPT 2002 code set. The complete list of changes can be found in Appendix B of....

Overview of the ESRD PPS

Author: Nelson, Tanai S

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010


In August the Centers for Medicare and Medicaid Services established a new prospective payment system (PPS) for end-stage renal disease (ESRD) facilities. The ESRD PPS will provide a single payment to ESRD facilities for renal dialysis services and other items and services related to home dial....

CMS Eliminates Reimbursement for Consultations

Author: Nelson, Tanai S

Source: AHIMA newsletter

Publication Date: December 02, 2009


As proposed, the Centers for Medicare and Medicaid Services (CMS) finalized their decision to eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes). What does that mean? That means that CMS w....

APCs: A Hospital-wide Effort

Author: Neilson, Seana

Source: AHIMA Convention

Publication Date: October 10, 2001




For many healthcare providers, thriving under the Medicare outpatient prospective payment system (i.e., APCs) appears to be a distant goal not to be realized anytime soon. In fact, for the next year or so, most healthcare providers subject to APCs will most likely be satisfied with me....

A Little Coding Advice

Author: Nance, Kellie D

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2013



Following are four pieces of advice to help you through tough situations and keep your skills sharp throughout your coding career:


Take a Break



When you are working with a chart with multiple diagnoses and are struggling with what should go first and ha....

Time for Change - a Time for 10: Updating the Classification for Discharges On and After 1.1.05 to ICD-10-AM (The Australian Modification of ICD-10 and the Australian Classification of Interventions in Health)

Author: Murphy, Deirdre

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Introduction

The Hospital Inpatient Enquiry (HIPE) scheme is a computer-based health information system designed to collect clinical and administrative data on discharges and deaths from acute care public hospitals. HIPE was established in 1971 and is the principal source of national data....

Brief History of ICD-10-PCS

Author: Mullin, Robert L.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 1999


The International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) was developed as a replacement for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) volume 3, Procedures. This version of ICD, in use since J....

Data Warehousing: Myths, Pitfalls, and the Secret Weapon

Author: Moyer, Rich

Source: Journal of AHIMA

Publication Date: November 2003


Is your organization using its data warehouse to its fullest potential? The author provides some pitfalls to avoid and some tips that may help improve care and use resources more efficiently.
Most healthcare organizations have invested in building a data warehouse. But once the warehouse....

Implementation of ICD-10-CA and CCI in Canada

Author: Moskal, Lori

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Introduction

The Canadian implementation of The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) and The Canadian Classification of Health Interventions (CCI) began in 2001 with five provinces and one territory. In 2002,....

Clear Focus on Coding

Author: Moses, Rhona

Source: Journal of AHIMA

Publication Date: April 1999


For the past three years I have been manager of coding education and billing guidelines at Group Health Cooperative, a 600,000-member HMO. Group Health has 25 primary care clinics, four specialty centers, an ambulatory surgical center, and two hospitals. We have about 700 staff physic....

Getting the SNOMED Ball Rolling in Australia

Author: Moore, Helen

Source: Journal of AHIMA

Publication Date: November 2004

Letter to the Editor, Journal of AHIMA


After reading the July-August 2004 Journal of AHIMA, I wanted to express my interest in the article by Jack Bowie, “Four Options for Implementing SNOMED.” It was pleasing to read an article on SNOMED that focused on HIM operatio....

Re-abstraction Studies to Assess Data Quality for Use in the Development of a Grouping Methodology

Author: Mitchell, Sandra; Bartoli, Holly

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Purpose

The purpose of this paper is to provide an overview of the data quality re-abstraction studies that have been conducted in Canada. These studies provide a baseline of reliability for clinical administrative data submitted to the Discharge Abstract Database (DAD). Canada began a s....

Clinical Documentation Improvement Program Strategies

Author: Mills, Mary

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction
What Is CDIP?

Aclinical documentation improvement program (CDIP) is a program focused on improving clinical documentation on a concurrent basis where a coder or documentation specialist, such as a nurse, reviews the medical record and consults with physicians regarding....

HIPAA Electronic Transactions

Author: Miller, Susan A

Source: HIPAA Conference 2000

Publication Date: March 14, 2000

2000 HIPAA Conference Presentation
HIPAA Electronic Transactions
Presented by Susan A. Miller, Esquire, Corporate Regulatory & Compliance Manager, IDX Systems Company HIPAA Summary
Title II, Subtitle F—Administrative Simplification of the Health Insurance Portability and Accoun....

CPT Code Updates for 2013

Author: Miller, Jackie

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013



The CPT code set has undergone extensive revisions for 2013, with codes, guidelines, and modifiers being revamped and updated. HIM coding professionals should download and review the CPT 2013 errata on the AMA website before starting to use the new codes. This download can be accessed at w....

Strategies for Remote Coding Success: Remote Coding Program Helps Norman Regional Retain Quality Coders

Author: Miller, Amy; Ridpath, Debra

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2010


Remote coding is helping organizations attract and retain experienced coding professionals at a time when highly skilled coding professionals are in short supply. Successfully implementing a remote coding program requires that facilities have their entire clinical documentation online and qual....

Quick Take on Clearinghouses

Author: McLaughlin, Mark

Source: Journal of AHIMA

Publication Date: January 2001




HIPAA's provisions have brought healthcare clearinghouses into the spotlight. What is a clearinghouse, and how is its role affected by the new regulations? This article answers these questions.

A clearinghouse is typically used to collect, validate, and distribute insurance c....

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