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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....

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....

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?....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Teach Your Attorney Healthcare Contracting

Author: Le, Huan N.

Source: Journal of AHIMA

Publication Date: February 2003


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

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....

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....

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....

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....

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 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. Here’s 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....

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....

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....

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....

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....

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....

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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