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Clinical Coding Internationally: A Comparison of the Coding Workforce in Australia, America, Canada, and England
Author: McKenzie, Kirsten; Walker, Sue; Dixon-Lee, Claire; Dear, Gareth; Moran-Fuke, Judy
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
Recently, researchers in Australia, America, England, and Canada have conducted national surveys of clinical coders in their respective countries. In Australia in 2002, the National Centre for Classification in Health (NCCH) in collaboration with the Health Information Manag....
So What Exactly is Clinical Documentation Improvement?
Author: McDonald, Lori
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2015
There is a lot of talk in health information management these days about clinical documentation improvement (CDI). You may have questions, or you may be hearing questions around you. This short article answers three basic questions about CDI.
What is CDI?
Word is Collaboration: How HIM, Revenue: Cycle, and Compliance Team Up for Success
Author: McDavid, Jan P; Truscott, Tricia; Crump, Dawn; Brocato, Lori
Source: AHIMA Convention
Publication Date: October 02, 2011
Background:
The need for HIM, Compliance and Revenue Cycle Management to work together is more important than ever. New initiatives, regulations and more stringent compliance demands are crossing the lines of various departments throughout the healthcare continuum. Departments which may....
Coding Debridement Procedures
Author: McCullough, Dan
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2008
Coding debridement procedures can be difficult-even for the most experienced coding professional. Recent studies have documented inappropriate coding of debridement procedures that have resulted in millions of dollars in overpayments.
This article offers guidance on the app....
Data Mapping
Author: McBride, Susan; Gilder, Richard; Davis, Robert; Fenton, Susan H.
Source: Journal of AHIMA
Publication Date: February 2006
Exchanging health data electronically requires some cartography. HIM professionals not involved with data mapping now will be soon.
One essential component of health IT interoperability, and the improved care and efficiency it offers, is data mapping. Data mapping....
What is the Charge Description Master?
Author: Mays, Katherine E
Source: CodeWrite | AHIMA newsletter article
Publication Date: June 2011
The Charge Description Master (CDM), sometimes called the Chargemaster or Procedure Code Dictionary, is the database of all billable items that go on patients’ accounts. It contains all the descriptions, revenue codes, department associations, alternate CPT/HCPCS codes for different payer....
Hypertension: Cross Walking Between ICD-10-CM and ICD-9-CM
Author: Mathews, Tintu Elizabeth
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2013
After reading this article you should be able to understand the concepts of assigning ICD-10-CM and ICD-9-CM codes for hypertension.
Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure....
A Relook at POA Indicators
Author: Martin, Ginny
Source: CodeWrite | AHIMA newsletter article
Publication Date: May 2015
Accurate assignment of the present on admission (POA) indicator has new significance with the inception of value-based purchasing (VBP). Coding and the supporting medical record documentation are being used to identify the hospital-acquired conditions and patient safety indicators on whic....
Using Additional Diagnoses to Improve Productivity
Author: Martin, Ginny
Source: CodeWrite
Publication Date: February 2016
ICD-10 has now been in effect for several months and coding professionals have become more familiar with the new codes and guidelines. The initial training and education is complete and ongoing quality reviews are being done to analyze coding accuracy. But what else can this data tell us?....
MS-DRG Journey: How One Hospital Joined together to Successfully Implement MS-DRGs
Author: Martin, Ginny
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2008
The Centers for Medicare and Medicaid Services (CMS) surprised the coding world last year when it changed its 22-year-old reimbursement system to the severity-adjusted MS-DRG system. HIM departments anticipated the system would have a significant impact on operations—increasing demands f....
Coding Compliance Tips for Hospital Outpatient Observation Services
Author: Manning, Susan C.
Source: Journal of AHIMA
Publication Date: July 1999
The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) continues in its efforts to promote voluntarily developed and implemented compliance programs for the healthcare industry. Fundamentally, compliance efforts must be designed to establish a culture th....
Electronic Clinical Documentation System: the HIM Perspective
Author: Mangin, Wendy L
Source: AHIMA Convention
Publication Date: September 23, 2002
Reducing Outpatient Billed as Inpatient Errors
Author: Malone, Sue M.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2008
From 2006 to 2007, the Colorado Foundation for Medical Care (CFMC), the quality improvement organization (QIO) for Colorado, led a project to reduce the outpatient billed as inpatient billing error rate in five area hospitals. This article discusses the findings from the project, as well as be....
New Approach to Neonatal Hyperbilirubinemia
Author: Malone, Sue M.
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2009
Coders often believe that jaundice in newborns is expected, minor, and not of much concern. In general, they tend to add the unspecified fetal and neonatal jaundice code 774.6, when they code it at all. Additionally, documentation of hyperbilirubinemia is not always accurate. This article advo....
Sign of the Changing Times: CPT 1999
Author: Mallett, Sherri; Smith, Gail I.
Source: Journal of AHIMA
Publication Date: June 1999
This year brought with it 686 changes to CPT. While this is a moderate number in comparison to previous years, several of the changes have significant impact on code assignment. The purpose of this article is to highlight some of the areas of significant change. (See "1999 CPT Revisions" in t....
Telemedicine: Bridging Gaps in Healthcare Delivery
Author: Majerowicz, Anita; Tracy, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2010
Traditionally, healthcare has been provided in the physician’s office, hospital, or outpatient clinic. Patient care has been based primarily on face-to-face contact, with the exchange of information via conversation.
However, technology is changing how and where care is delivered. M....
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....
Developing an ICD-10-CM/PCS Coder Training Strategy
Author: Majerowicz, Anita
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2011
Although the ICD-10-CM/PCS implementation deadline is two and a half years away, it is not too early to begin planning coder training. Solid training plans will ensure a smooth transition and minimize the transition's impact on productivity. A well-planned training strategy will ensure that co....
Quality Queries for Quality ICD-10-PCS Codes
Author: Maimone, Carol
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2016
Physician queries have historically been an effective communication tool used by health information management (HIM) coding professionals to clarify documentation in the health record for accurate code assignment. The goal for any coding professional is to have all final coded diagnoses an....
Calendar Year 2015 OPPS Update
Author: Maimone, Carol
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2015
The Centers for Medicare and Medicaid Services (CMS) released a final rule providing required adjustments to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year (CY) 2015 on October 31, 2014.....
Trouble with DRGs
Author: Mahoney, Robert J.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2005
A major frustration among coding professionals, particularly in the inpatient setting, is the difficulty in translating physician documentation into diagnostic related group (DRG) data. Some hospitals have attempted to improve their coding effectiveness by establishing time-consuming physician....
Trouble with DRGs: Part 2
Author: Mahoney, Robert J.
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2005
Last issue’s article presented some ways that DRG criteria redefine well-established clinical entities such as respiratory failure and sepsis. This article will discuss two other incompatibilities between DRG criteria and clinical practice: the clinical distinctions required by the DRG s....
Better Coding through Improved Documentation: Strategies for the Current Environment
Author: MacDonald, Ellen
Source: Journal of AHIMA
Publication Date: January 1999
Now more than ever, HIM professionals must ensure that documentation of health information is thorough, clear, and accurate. Here are some strategies to solve problems and improve processes.
Health information managers and coding professionals have always played a vital role in adv....
Understanding The History Component of The E/M Code - Part 2
Author: Maccariella-Hafey, Patricia C
Source: CodeWrite | AHIMA newsletter article
Publication Date: January 2015
This is the second of a two-part series on the history component of the CPT Evaluation and Management code. The first part was published in the December 2014 issue of CodeWrite.
Levels of Evaluation and Management (E/M) services are based on four types of history (Problem F....
Understanding the History Component of the E/M Code (Part 1)
Author: Maccariella-Hafey, Patricia C
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2014
This is the first of a two-part series on the history component of the CPT Evaluation and Management code.
As discussed in the October 2014 CodeWrite article "Introduction to Evaluation and Management Services," evaluation and management (E/M) services are cognitive services....
Post ICD-10 Implementation: Where Are We Now?
Author: Maccariella-Hafey, Patricia C
Source: CodeWrite
Publication Date: November 2015
We heard deep sighs of relief as October 1, 2015, came and went and ICD-10 was finally implemented in the United States. This has been a long time coming for coding and documentation improvement professionals in the HIM world. At the time of this article's writing, we are two weeks into im....
Letter to Secretary Thompson from NCVHS concerning ICD-10
Author: Lumpkin, John
Source: Government (U.S.)
Publication Date: November 05, 2003
November 5, 2003
The Honorable Tommy G. Thompson
Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Thompson:
As part of its responsibilities under the Health Insurance Portabil....
Qualifications for a Terminology Analyst
Author: Loucks, Melanie; Wilson, Patricia S; Matney, Susan; Fenton, Susan H.
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Establishing a CDI Program: How One Organization Leveraged Nursing and Coding Skills to Improve Clinical Data
Author: Lopez, Barbara A
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2010
Establishing a clinical documentation improvement (CDI) program is an organization-wide, transformational process that affects a hospital’s culture, reaching across all disciplines and touching every colleague and the way they perform their jobs. Many factors can lead healthcare organizations....
The DRG Shift: A New Twist for ICD-10 Preparation
Author: Long, Peri L
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2012
Every generation has a few defining moments they can look back upon-big news events, clothing and fashion trends, hair styles, and maybe even a dance craze or two.
Today's healthcare industry is currently experiencing a defining moment of its own: preparations for the transition to the In....
Computer-Assisted Coding: a Work in Progress
Author: Longosky, Sean; Main, Renee; Wood, Shirley; Helbig, Susan
Source: AHIMA Convention
Publication Date: October 17, 2008
Background
The amount of coding required in the Veterans Health Administration (VHA) is hefty, with more than seven million inpatient discharges and 37million outpatient encounters. VHA employs approximately 1,400 professional coders who code in the traditional manner of reading documenta....
Principles for Emergency Department Coding Guidelines
Author: Lojewski, Tedi
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2008
Since the implementation of the Outpatient Prospective Payment System (OPPS), the Centers for Medicare and Medicaid Services (CMS) has required hospitals to report facility resources for emergency department (ED) visits using CPT evaluation and management (E/M) codes.
However, CMS re....
NPP Services Furnished 'Incident-to' a Physician's Service
Author: Lojewski, Tedi
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2015
Non-physician practitioners (NPP) are becoming commonplace in the physician office setting as a way to increase a physician practice’s accessibility, productivity, and patient satisfaction without compromising quality medical care. Under physician supervision, NPPs such as nurse practitio....
Diagnosis Coding in the Outpatient ED: Back to Basics
Author: Lojewski, Tedi
Source: CodeWrite | AHIMA newsletter article
Publication Date: June 2013
Objective: To provide a refresher on basic ICD-9-CM coding guidelines related to outpatient emergency department (ED) services. Many of the ICD-9-CM Official Guidelines for Coding and Reporting will remain the same from ICD-9-CM to ICD-10-CM, and a good understanding of these principles wi....
Value-Based Purchasing Programs and Coding Impact: a VBP Primer
Author: Lojewski, Tedi
Source: CodeWrite | AHIMA newsletter article
Publication Date: August 2015
According to the Centers for Medicare and Medicaid Services (CMS), value-based purchasing (VPB) has been "a long-standing effort to link Medicare's payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting....
New Readmission Patient Discharge Status Codes: Follow-Up
Author: Lojewski, Tedi
Source: CodeWrite | AHIMA newsletter article
Publication Date: February 2014
The National Uniform Billing Committee (NUBC) approved 15 new "readmission" patient discharge status codes (81–95) for use with inpatient discharges, effective October 1, 2013. Following up on the November 2013 CodeWrite article on this topic, this article looks at three common myths....
Hypertension Coding - Crisis Averted
Author: Lojewski, Tedi
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2016
Thanks to the recent publication of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017, the past controversy over the interpretation of the term "With" has been resolved.1 The revision of Section I.A.15, "With," now incorporates what was previously clarified in AHA Coding C....
Finding the New Normal with ICD-10-CM/PCS
Author: Linder, Karen M
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2016
Rochester Regional Health is an integrated health services organization serving the people of western New York and the Finger Lakes region. The system provides care from 150 locations, including five hospitals; more than 100 primary and specialty practices, rehabilitation centers, and ambu....
Veterans Health Administration Enterprise Terminology Project and Mapping Issues
Author: Lincoln, Michael J.
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Reviewing the Details of Coding Septicemia
Author: Limjoco, Cesar M.; Youmans, Karen
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2000
In March 1999, the Office of Inspector General (OIG) released an executive summary on "Medicare Payments for Septicemia." The Health Care Financing Administration (HCFA) contracted with two clinical data abstraction centers to validate a national random sample of claims from all Medicare inpat....
Dissecting the Principles of Inpatient Coding: Principal Diagnosis and other Diagnoses
Author: Limjoco, Cesar M.
Source: AHIMA Convention
Publication Date: October 15, 2004
Introduction
This didactic lecture will provide you with valuable insight into the documentation requirements for accurate inpatient coding and help you decrease time-consuming requests for clarifications and denial appeals. In addition, it ties accurate clinical coding to healthcare fis....
Demystifying Nonphysician Practitioner Billing
Author: Lich, Denisha
Source: Journal of AHIMA
Publication Date: February 2000
To address today's financial challenges, healthcare facilities are increasing their use of nonphysician practitioners, such as nurse practitioners, clinical nurse specialists, and physician assistants, to provide patient care. As a result, providers need to pay close attention to the employmen....
Incorporating Maps into Software
Author: Levy, Brian
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
ICD-10-CM Field Testing Project
Author: Leon-Chisen, Nelly; Bowman, Sue E
Source: U.S. National Committee for Vital and Health Statistics
Publication Date: September 23, 2003
Coding and Quality Reporting: Resolving the Discrepancies, Finding Opportunities
Author: Leon-Chisen, Nelly
Source: Journal of AHIMA
Publication Date: July 2007
National quality-of-care and public reporting initiatives are creating new challenges and new opportunities for coding professionals.
Quality medical coding has always been important. Coded data are used for many essential functions including reimbursement, benchmark....
RAC Primer for LTC Facilities
Author: Leonard, Mary Ann
Source: Journal of AHIMA
Publication Date: January 2010
Last year the Centers for Medicare and Medicaid Services (CMS) began rolling out the Recovery Audit Contractor (RAC) program to all 50 states and all providers, including long-term care facilities. HIM professionals working in LTC facilities need to understand the basics of the program in....
Coding Cardiovascular Catheterization: Accuracy Requires a Multidisciplinary Effort
Author: Lenahan, Monica
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2009
Cardiac catheterization procedures involve the insertion of a catheter into a chamber or vessel of the heart for investigational and interventional purposes. A small puncture is made most commonly in the femoral artery in the groin region. A guidewire is then inserted into the incision and thr....
Another Career Avenue for HIM: Coding Compliance
Author: Lemire, Diane
Source: Journal of AHIMA
Publication Date: June 2001
If you're armed with a background in coding and management, a position in coding compliance may be an exciting next step in your HIM career. When I applied for coding compliance manager positions, many positions had been open for a year because facilities could not find individuals w....
Coding in the World of Compliance: the OIG's Perspective
Author: Lemanski, Susan
Source: Journal of AHIMA
Publication Date: July 1999
As statistics from a recent survey attest,1 compliance programs are on the forefront of many providers' agendas. In the wake of compliance program guidances2 issued by the Office of Inspector General (OIG) of the Department of Health and Human Services, many healthcare providers have devoted a....
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. Its a good idea to hire an attorney for contract negotiations and drafting, but even then, you mi....
When Good Chargemasters Go Bad
Author: Leeds, Erica
Source: AHIMA Convention
Publication Date: October 10, 2001
Introduction: What Is a Chargemaster?
A chargemaster is a master list of services, supplies, and drugs used for patient care. A chargemaster used by outpatient facilities (emergency rooms, clinics, same-day surgery centers, and so on) will have the associated HCPCS codes and rev....
Nothing Lasts Forever: How Physicians Can Prepare for the End of the One-Year Amnesty from Post Payment Reviews Due to Unspecified Codes
Author: Lee, Christine
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: May 2016
Just as ocean tides shift with the earth's gravitational pull, physician practice administrators align staff and focus resources to address their organizations' most pressing concerns. This year, the tsunami grabbing administrators' attention is the conclusion of a one-year grace peri....
Bringing Physician Practices into the HIM Fold: Guidance on Making a Smooth Transition and Ensuring the MD/Hospital/HIM Relationship Remains Mutually Beneficial
Author: Lee, Christine
Source: Journal of AHIMA
Publication Date: April 2016
According to the American Medical Association (AMA), physician practices continued a slow but steady transition toward hospital ownership in 2015. In their July 2015 study, the AMA reported a decrease in physician-owned practices alongside a continual increase in physicians working direct....
DRG Changes for FY 2006
Author: Leary, Renee; D'Amato, Cheryl
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2005
The final Medicare DRG changes for fiscal year (FY) 2006, which were published in the August 12, 2005, Federal Register, include 16 new DRGs, the deletion of 10 existing DRGs, and numerous changes to DRG assignments of current diagnosis and procedure codes. These DRG changes, along with other....
Human Factor: Ergonomics and the Coding Function
Author: Layman, Elizabeth J.; Heaps, Thomas; Bell, Brenda
Source: Journal of AHIMA
Publication Date: August 1992
Towards Data Interoperability: Practical Issues in Terminology Implementation and Mapping
Author: Lau, Lee Min
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Conclusion
The lack of data interoperability is a key obstacle in the implementation and use of EHR to achieve its full benefits. Standard vocabularies provide the means for organizations to exchange, compare and aggregate data externally. The problems surrounding the use of standard voc....
Towards Data Interoperability
Author: Lau, Lee Min
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Long-term Care Cost Accounting: Simple is Often Better
Author: Larson, Allan B.
Source: Journal of AHIMA
Publication Date: January 2001
"Cost accounting" has always been an ominous term within long-term care circles-but it doesn't have to be. Many different approaches and uses for cost accounting exist, and in many cases the process is easily integrated into monthly financial reporting.
This articl....
Auditing ICD-10 Through the Lens of Education
Author: Land, Daniel
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: October 2016
The complex and sophisticated nature of ICD-10-CM/PCS has increased both the intellectual demands on coding professionals and the importance of an educational approach to the audit process. On October 1, 2016 regular updates to ICD-10 will begin, marked by the introduction of over 5,500 n....
Performance Improvement for Documentation
Author: Labak, Carol
Source: Journal of AHIMA
Publication Date: October 1998
We've all seen it before: that look of bewilderment on a physician's face when a discussion about documentation arises. While this is not the first incidence of this discussion between the physician and the health information manager, neither is it the first time the HIM professional ....
Coding Dementia
Author: Laakso, Roz
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2004
Dementia is defined as “a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living.”1 Alzheimer’s disease is an age-related, irreversible brain disorder that occurs gradually and results in me....
Solving LTC Coding Challenges
Author: Laakso, Roslyn C.; Gottschalk, Reesa; Uppena, Mary
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2002
After an acute illness or injury, patients are often transferred from the hospital to a skilled care bed or nursing facility for continued care. In rural areas, the local hospital and skilled nursing facility are often located within the same building and may even be the very same bed (many r....
Sepsis Under the ICD-10-CM Microscope
Author: Kulanko, Jill
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2015
Sepsis is arguably the most challenging condition to code correctly in ICD-9-CM. The condition itself is complex and the definitions regarding sepsis, SIRS, and severe sepsis have evolved over time, keeping coders on their toes. The guidelines are also difficult to understand. Complicatin....
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....
Back to the Basics of Spine Surgery: Anatomy, Terminology Knowledge Can Improve Coding
Author: Kuehn, Lynn
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2012
The human spine is a complex unit that combines the structures of both the nervous and musculoskeletal systems. Understanding the anatomy, terms and definitions, and procedure concepts associated with spinal surgery can make for a considerably smoother coding process.
Anatomy of the Spine....
Spinal Surgery in CPT/HCPCS Unraveled
Author: Kuehn, Lynn
Source: AHIMA Convention
Publication Date: October 02, 2011
Introduction
Spinal surgery can involve a combination of nervous system and musculoskeletal system procedures. Understanding the definitions, anatomy and procedure concepts of these systems provides a foundation for use by the coder in correctly assigning codes in multiple classification....
SNOMED: A Controlled Vocabulary for Computer-based Patient Records
Author: Kudla, Karen M.; Rallins, Marjorie C.
Source: Journal of AHIMA
Publication Date: May 1998
SNOMED is a detailed and specific coded vocabulary of names and descriptions used in healthcare -- explicitly designed for use in the computerized patient record. Here's an overview of this system and a look at its next generation.
Methods to collect data about human morbidity and morta....
SNOMED Takes the Next Step
Author: Kudla, Karen M.; Blakemore, Margo
Source: Journal of AHIMA
Publication Date: July 2001
Healthcare terminologies SNOMED and the Read Codes have been around for a long time. Now, a new terminology combining the two promises to take the industry one step closer to realizing the vision of an electronic patient record. Heres a sneak peek at SNOMED® CT.
As technology e....
HIPAA Electronic Data Interchange Transactions: The Impact on Healthcare Billing Processes with Special Emphasis on 837 Electronic Claims Transactions and 835 Electronic Remittance Transactions
Author: Kubas, Debbie; Buck, Shawna
Source: AHIMA Convention
Publication Date: October 21, 2005
Rules for HIPAA-compliant electronic transactions were finalized on October 16, 2000. The finalized HIPAA transaction standards required that claims filed electronically after October 16, 2002 (or after October 16, 2003, if you filed for an extension) had to be in the HIPAA-compliant electroni....
Add Another "C" to Your CDI Program: Why "CDCITM (Clinical Documentation and Coding Integrity) is a Best Practice Model
Author: Kruse, Marion G.; Newell, Shannon K
Source: AHIMA Convention
Publication Date: September 25, 2010
Introduction
Inpatient clinical documentation improvement (CDI) programs, once found only in a small number of hospitals, have evolved into an essential part of the revenue cycle and quality programs. Reduced reimbursement, expanded compliance initiatives, and increased public and payer....
Cost of Converting Small Physician Practices to ICD-10 Much Lower than Reported
Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.
Source: Journal of AHIMA - website
Publication Date: November 2014
The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....
Off-Site Coding Success Story
Author: Kramer, Lynette; Meeks, Richard
Source: Journal of AHIMA
Publication Date: January 2000
If you asked HIM professionals about key success factors that substantially impact timely and accurate coding, three of the most common answers might be:
availability of the record immediately after the patient visit
availability of the complete record....
How Deep Do You Dig into ICD-10-PCS Coding?
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2015
All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.
ICD-10-PCS Scope of Work
On October 1, 2015, hospital inpatient pr....
Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2014
Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.
This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....
Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2014
Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.
This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....
Internal Radiation Brings Hope to Prostate Cancer Patients: With Brachytherapy Treatment Come New HCPCS Codes
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2003
In 2003, the American Cancer Society estimates that 220, 900 men will be diagnosed with prostate cancer in the US, making it the second leading cause of cancer deaths in men.1 Today in the US, patients with prostate cancer have access to less invasive surgical cancer treatment plans. This arti....
ICD-10-CM Update 2012
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2012
This article highlights the 2012 ICD-10-CM update as approved by the ICD-9-CM Coordination and Maintenance Committee. The 2012 ICD-10-CM update includes the addition of new codes that already exist in ICD-9-CM, implemented in the FY 2012 ICD-9-CM update or recently incorporated into ICD-10 th....
ICD-9-CM Diagnostic Coding for Shiga Toxin-Producing Escherichia Coli
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2012
At the request of the American Academy of Pediatrics, the FY 2012 ICD-9-CM code update expanded subcategory 041.4, Escherichia coli, to create unique codes for Shiga toxin-producing Escherichia coli (STEC). This article describes STEC and its clinical features and summarizes the new STEC ICD-9....
Coding for External Causes of Morbidity in ICD-10-CM
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2011
The ICD-10-CM external causes of morbidity tabular list includes significant enhancements to the ICD-9-CM supplementary classification of external causes of injury and poisonings (E800–E999). The ICD-10-CM list features category restructuring, reorganization, and major code expansion.
From V Codes to Z Codes: Transitioning to ICD-10
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2004
V codes, described in the ICD-9-CM chapter “Supplementary Classification of Factors Influencing Health Status and Contact with Health Services,” are often misunderstood in reporting healthcare services. These codes are designed for occasions when circumstances other than a disease....
From V Codes to Z Codes: Transitioning to ICD-10 (Updated)
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2011
Editor's note: This column supercedes the February 2004 article "From V Codes to Z Codes: Transitioning to ICD-10."
V codes, described in the ICD-9-CM chapter "Supplementary Classification of Factors Influencing Health Status and Contact with Health Services," are designed for occasi....
Staying Alert on Sleep Medicine Coding
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2011
The field of sleep medicine is rapidly expanding, and its coding and reimbursement are attracting more attention from federal and state governments, public health organizations, scientists, payers, auditors, the transportation industry, and healthcare consumers. Emerging topics in the area of....
Coding in Critical Access Hospitals
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2009
National health policy has been increasingly responsive to the healthcare needs of rural residents and providers. Rural America has a large percentage of the nation’s Medicare population, and this percentage continues to grow as residents born in the Baby Boomer generation begin to retir....
SNOMED CT Integral Part of Quality EHR Documentation
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2012
The use of many distinct standardized clinical vocabulary terminologies and classifications is integral to the development of a nationwide health IT infrastructure that allows for electronic use and exchange of health information. SNOMED CT is one of the key clinical terminologies designated f....
Taking a Closer Look at Physician-based Coding
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2002
Since 1997, AHIMA has offered a Certified Coding Specialist--Physician-based credential (CCS-P) for HIM professionals who are employed in the physician setting. In recent interviews, an office manager, coding manager, coding coordinator, and two physician-based consultants shared their coding....
Resolving Coding Questions: Where to Find Answers to Coding Questions
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2010
WHEN CODING Questions arise, coding professionals should evaluate all possible resources, including querying physicians, networking with other coding professionals, and seeking official coding advice. These techniques help ensure consistent healthcare diagnostic and procedure coding.
Coding Diabetes Mellitus in ICD-10-CM: Improved Coding for Diabetes Mellitus Complements Present Medical Science
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2012
Results of a recent coding and clinical documentation pilot study indicate that the ICD-10-CM coding classification changes made for diabetes mellitus have significantly improved coding for this disease. The results of the study noted that although a few ICD-10-CM "unspecified" diabetes codes....
Too Many Coding Systems, Too Much to Do: Different Clinical Classification and Clinical Terminology Systems Uniquely Impact IT, Quality Management
Author: Kohn, Deborah
Source: Journal of AHIMA
Publication Date: May 2014
The notion of managing and being accountable for the health status of defined populations requires much more sophisticated clinical data collection methods and skills than most healthcare organizations have today. Numerous “coding systems” have been used for decades to successf....
APC Validation Audits ... The Nitty Gritty Details
Author: Knowles, Lisa
Source: AHIMA Convention
Publication Date: October 10, 2001
Ambulatory payment classifications (APCs) have been implemented, and APC validation audits are the next issue to contend with. Similar to DRGs, we must design and conduct APC validation audits. Whether the audit is performed in-house or by an external consulting firm, it is essential....
Skilled Knowledge Workers in Short Supply
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: July 2008
This is a demanding time for coders. MS-DRGs and present on admission requirements would have been challenging on their own; however, both came at virtually the same time, straining coders already stretched to meet their job requirements.
Recruitment and retention of coding staff is....
AHIMA's Response to HCFA on the Notice of Proposed Rule-Making on the Proposed Prospective Payment System for Hospital Outpatient Services
Author: Kloss, Linda L
Source: AHIMA testimony and comments
Publication Date: January 06, 1999
Text:
The American Health Information Management Association (AHIMA) is pleased to have the opportunity to submit comments on the proposed prospective payment system for hospital outpatient services.
Description of the Ambulatory Payment Classification (APC) Groups
W....
Coding at a Crossroads
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: July 2005
It has been nearly 25 years since ICD-9-CM codes became the basis for hospital inpatient payment. Over the years, code-based payment has extended to virtually all healthcare services, and CPT and HCPCS code sets have been added to the mix. We now use software tools to facilitate coding and hav....
Accuracy Imperative: New Stakes for Coded Data
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: July 2007
The requirements for coding accuracy have always been high, even before coding became the basis for reimbursement. HIM professionals have championed improvements to medical record documentation and classification systems essential to accurate coding, and the profession has also led the wa....
AHIMA's Statement Regarding Replacement of ICD-9-CM Procedural Coding System
Author: Kloss, Linda L
Source: AHIMA testimony and comments
Publication Date: May 17, 2001
Thursday, May 17, 2001
Good morning, I am Linda Kloss, chief executive officer of the American Health Information Management Association (AHIMA). On behalf of the Association, I thank you for this opportunity to provide input on replacing the ICD-9-CM procedural coding system with ICD-10-....
New Languages of Medicine: Inform and Influence Now
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: July 2004
Many healthcare decision makers do not understand the many ways coded data are used throughout healthcare and the urgency of moving forward with ICD-10. They also are unable to visualize how reference terminologies such as SNOMED CT are used in electronic health record systems and how these te....
AHIMA's Comments re: 42 CFR Parts 411 and 489: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities-Update
Author: Kloss, Linda L
Source: AHIMA testimony and comments
Publication Date: June 08, 2000
June 8, 2000
Health Care Financing Administration
Department of Health and Human Services
Room 443-G
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
Re: 42 CFR Parts 411 and 489: Medicare Program; Prospective
Payment Syste....
AHIMA Comments to PITAC's Recommendation Regarding ICD-10 and SNOMED-CT
Author: Kloss, Linda L
Source: AHIMA testimony and comments
Publication Date: April 21, 2004
April 21, 2004
Jonathan C. Javitt, MD, MPH
Co-chair PITAC Health Care Delivery and IT Subcommittee
President's Information Technology Advisory Committee
c/o National Coordination Office for Information Technology
Research and Development
4201 Wilson Bou....
ICD-10 Malaise: A Symptom of US Healthcare’s Ills
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: March 2008
Approximately 100 countries use some form of ICD-10 for clinical morbidity coding. That’s correct: 100 countries, and the US is not among them.
The World Health Organization released ICD-10 in 1990, and countries began implementing it in 1994. Most had fully implemented it by....
Time to Talk about Healthcare's Language: Accelerating the Dialogue on Standards for Terminologies and Classifications
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: February 2007
Structured terminologies and classifications form the necessary language for a nationwide health information network. However, the US lacks a national strategy for coordinated development, maintenance, and use of these essential tools.
It’s time to talk seriously abo....
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....
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