1874 results.
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Comments of the American Health Information Management Association (AHIMA) Pursuant to the Town Hall Meeting at HIMSS
Author: Kloss, Linda L
Source: AHIMA testimony and comments
Publication Date: March 08, 2004
March 8, 2004
Jonathan G. Javitt, MD
Chairman, Health Care Delivery and Information Technology Subcommittee
President's Information Technology Advisory Committee
Office of Science and Technology Policy
Executive Office of the President
Re: Comments of the American....
AHIMA Letter to the Secretary of HHS on the Adoption of ICD-10
Author: Kloss, Linda L
Source: AHIMA testimony and comments
Publication Date: July 24, 2003
July 24, 2003
The Honorable Tommy Thompson
Secretary
Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201
Dear Secretary Thompson:
I commend your leadership in making SNOMED-CT available through the National L....
Clinical Coding: Part of the HIM Mosaic
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: July 2003
Many in healthcare today understand coding only in the context of billing, not recognizing that the very same coded data are used for important healthcare operations, policy, epidemiology, and many other uses. For 75 years, AHIMA has been the professional forum to advance the quality of health....
Data Quality Management: Every Health Information Manager's Business
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: June 1998
This issue of the Journal of AHIMA does more than feature articles of timely importance to HIM practice. It actually contributes to the advancement of the field by presenting a model for an important dimension of HIM practice: data quality management. The practice brief in this issue (....
Wider World of Coding
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: July 2009
Coding reminds me of the parable of three blind men describing an elephant. Each one touches just one part of the elephant.
The blind man who examined the elephant’s tail likened it to a straw fan swinging back and forth; the man who explored the legs described the elephant as....
CPT Changes for 2000
Author: Kirschner, Celeste G.; Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2000
The American Medical Association's CPT 2000 Coding Symposium was held recently in Chicago to discuss the more than 300 revisions in the 2000 Current Procedural Terminology (CPT). Here is a brief summary of the changes.
A complete listing of the code and guideline changes can be foun....
Preparing For ICD-10 Documentation Needs: Areas to Focus On Now
Author: Kirkpatrick, Gayl W.
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
As with any change, to accomplish a smooth transition from the old environment, it is necessary to plan well in advance of the actual implementation date. Converting from ICD-9-CM to ICD-10-CM and ICD-10-PCS will require careful assessment of impact and thorough planning to p....
E/M Coding Problems Plague Physicians, Coders
Author: King, Mitchell S.; Lipsky, Martin S; Sharp, Lisa
Source: Journal of AHIMA
Publication Date: July 2002
As the government turns its high beams on fraudulent billing, physician E/M coding is raising questions. With several studies spotlighting the difficulty physicians have in applying CPT E/M codes, the authors wanted to know if credentialed coders had the same problem. Heres what they fou....
Improving Coding for Right Heart Catheterization
Author: Kerr, Anneliese; Yoder, Lois M.; Michelman, Mark S.
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2000
If your facility is having trouble coding heart catheterizations correctly, education may be the missing piece. An atypical number of right or bilateral heart catheterizations can indicate a need for coder education, physician education, or both. The state of Florida identified an opp....
SARS Tops Healthcare Concerns
Author: Kennedy, James S.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2003
HIM professionals serve a vital public health role as they capture and report illnesses, including the newly discovered Severe Acute Respiratory Syndrome (SARS). Accurate reporting of SARS and its comorbid or complicating conditions facilitates optimal disease tracking, use of resources, and p....
Pathophysiology of Hypovolemia and Dehydration
Author: Kennedy, James S.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2006
This year ICD-9-CM expanded code 276.5, Volume depletion, and created the more specific codes 276.51, Dehydration, and 276.52, Hypovolemia, at the request of the American Academy of Pediatrics.1 As treatments for these conditions differ and accurate coding must reflect illness severity and mort....
Documentation Issues
Author: Kennedy, James S.
Source: AHIMA community resource
Publication Date: March 02, 2003
Issues to Consider If you write: Consider this: Acute Coronary Syndrome: This is a great admitting diagnosis, however it is so broad that it doesn't tell us the exact pathophysiology of what we found after study, diagnosis, and treatment of our patient. Does the patient have a coronary thromb....
Post-acute Prospective Payment: What You Should Know
Author: Keillor, Ann; Nutten, Sandra
Source: Journal of AHIMA
Publication Date: June 1999
Post-acute prospective payment is one of the latest reimbursement changes to affect healthcare. How does it work, and how will it affect HIM professionals? The authors offer an overview of the new system.
Volumes have been written about the spiraling healthcare expenditure crisis and the....
CY 2011 Changes to the Hospital OPPS
Author: Karban, Karen M
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2011
The final rule for the calendar year 2011 Hospital Outpatient Prospective Payment System (OPPS) was released November 24, 2010. Changes in the rule went into effect with January 1, 2011, outpatient hospital-based services.
The changes to OPPS continue to reflect packaging adjustments....
Coding Bunionectomy
Author: Kapoor, Alka
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2014
Bunionectomy is a surgical procedure to excise a bunion. After reading this article you should be able to understand the concepts of assigning the correct CPT code for bunionectomy.
The online Encyclopedia of Surgery defines a bunion as "an enlargement of the joint at....
Vocabularies: Critical Software Infrastructure for Interoperability and Adoption
Author: Kanter, Andrew S.
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Using Internal and External Resources to Negotiate Contracts
Author: Kane, Cheri
Source: Brief Encounter
Publication Date: October 02, 2000
Managed care is here to stay and it is incumbent upon the health plan and the providers to develop positive long-term relationships. These agreements are only limited by the creativity of the provider and the health plan. Financial arrangements may take a variety of forms, from fee for servic....
Data Content for EHR Documentation
Author: Kallem, Crystal; Burrington-Brown, Jill; Dinh, Angela K.
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2007
This practice brief has been retired. It is made available for historical purposes only.
Rare and Unlikely ICD-10 Codes are Needed
Author: Journal of AHIMA Staff
Source: Journal of AHIMA
Publication Date: October 2015
This summer, if you listened very closely, you could almost hear a vast chorus of coders saying “I told you so,” after a freak accident alarmed local boaters in Southern California. On June 21, an over-excited dolphin accidentally jumped into a California family’s speed boat and broke both ankl....
2008 CPT Coding Update
Author: Jorwic, Therese M
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2008
The new CPT codes took effect January 1, 2008. Changes include 244 additions, 314 revisions, and 50 deletions. A comprehensive list of changes can be found in appendix B of the CPT book. Highlights of the changes by section are outlined here.
Evaluation and Management
A revised....
E/M Options in the Outpatient Arena
Author: Jones, Lolita M.
Source: Journal of AHIMA
Publication Date: July 2001
Under the Medicare ambulatory payment classification (APC) system, hospitals must establish criteria for mapping the medical care rendered in the emergency department and hospital-based outpatient settings to appropriate CPT medical visit codes. Do you know how to establish a sound rationale f....
Coders Can Benefit from Bare Bones Podiatry Lesson
Author: Jones, Lolita M.
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2003
Podiatry is the specialty that manages diseases and problems of the feet. Many coding specialists find it difficult to assign CPT codes to podiatry cases. Because so many podiatry procedures are currently performed in the outpatient setting, it is common for coding specialists to be faced with....
Model for International Comparative Studies Using Routine Hospital Morbidity Data
Author: Jones, Lauren M.; Reid, Beth A.; Aisbett, Chris W.
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Abstract
The problem addressed in this paper is the difficulty of assessing across nations the impact of different policies on health outcomes without a reliable way of comparing routine hospital morbidity data. This paper presents the findings of a study that evaluated the accessibility and....
Managing and Mapping Coded ICD-9-CM Data to ICD-10-CM/PCS
Author: Johnston, Gloria
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2013
Although the process of dual coding—assigning both ICD-9-CM and ICD-10-CM/PCS codes at the time of coding—is one way to compare equivalence of the codes, it is too resource-intensive to be practical for every instance where both codes are needed. ICD data mapping can supplement....
Reengineering Medical Records: The Dubois Regional Medical Center's Experience
Author: Johnson, Thomas H.; Pesek, James G.
Source: Journal of AHIMA
Publication Date: March 1998
Introduction
Many health services organizations were pushed in the direction of CQI/TQM by the Joint Commission on Accreditation of Healthcare Organizations' Agenda for Change, which recognized the critical need for quality improvement efforts.1 Reengineering and work redesign have....
Strategies for Reducing Medical Errors: HIM's Role
Author: Johnson, Sandra K; Rozovsky, Fay A.
Source: Journal of AHIMA
Publication Date: July 2000
Medical errors are a problem of national concern. How can HIM professionals improve documentation and prevent errors? This article offers some risk management strategies.
Medical errors have been a hot topic since the release of last year's Institute of Medicine rep....
FY 2007 IPPS Overview: Comprehensive Changes in Effect for Inpatient Prospective Payment System
Author: Johnson, Laurie M.; Garrett, Gail S.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: November 2006
The Inpatient Prospective Payment System (IPPS) final rule for fiscal year 2007 will prove challenging for inpatient providers. The rule (published in the August 18 Federal Register and available at www.access.gpo.gov/su_docs/fedreg/a060818c.html) includes some of the most comprehensive changes....
PHIMA's ICD-10 Task Force: A Little Less Conversation, A Little More Action?
Author: Johnson, Laurie M.
Source: CodeWrite | AHIMA newsletter article
Publication Date: July 2011
Pennsylvania Health Information Management Association’s (PHIMA) International Classification of Diseases, Tenth Revision (ICD-10) initiative began in November 2010 with the appointment of a chair of the ICD-10 Task Force. PHIMA president Chris Parfitt, RHIT, appointed Laurie Johnson, MS,....
Hospital Acquired Conditions Changing for FY2013
Author: Johnson, Laurie M.
Source: CodeWrite | AHIMA newsletter article
Publication Date: November 2012
In a year with very few ICD-9-CM changes, there are additions to the Hospital Acquired Conditions (HACs) for FY2013. The Inpatient Prospective Payment System (IPPS) final rule for fiscal year 2013 was published on August 31. The section on HACs included the changes that were alluded to in....
Clarifying the Infusion and Injection Quandary
Author: Johnson, Laurie M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2007
Coding infusions and injections has been a source of confusion and frustration since the Centers for Medicare and Medicaid Services (CMS) introduced C codes in 2006. However, in calendar year 2007, CMS made an about face and eliminated the C codes, reverting back to the published 2007 CPT....
ICD-10: Managing Data Quality through Change
Author: Johnson, Kerry
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
As HIM professionals, one of our major concerns is data quality. We are charged with the responsibility of ensuring that the quality of coded data in our facilities and data in healthcare in general is of the highest quality in order to accurately reflect our organization&rsq....
Implementation of ICD-10: Experiences and Lessons Learned from a Canadian Hospital
Author: Johnson, Kerry
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
When individual Canadian hospitals first started the journey towards The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) and The Canadian Classification of Health Interventions (CCI) (from now on referred t....
RAC Ready: How to Prepare for the Recovery Audit Contractor Program
Author: Johnson, Kathy M; Bloom, Allison; Morris, Denise; Madamba, Roderick
Source: Journal of AHIMA
Publication Date: February 2009
The Centers for Medicare and Medicaid Services is expected to announce the official start date of the Recovery Audit Contractor program this month, but it is already time for providers to be preparing for a potential audit. Managing a RAC audit effectively and efficiently requires preparing de....
Reflections on Coding Compliance Program Effectiveness
Author: Johnson, Kathy M
Source: AHIMA Convention
Publication Date: October 02, 2011
Efficiency is about doing things right while effectiveness is about doing the right things. Effectiveness assesses whether the actual outcomes reflect the desired outcomes. Effectiveness begins upfront in the planning process - there is a need to clearly articulate the intent, desired outcomes....
Crystal Ball for Coding
Author: Johns, Merida L.
Source: Journal of AHIMA
Publication Date: January 2000
What will the future of coding look like? A special AHIMA task force has several ideas. What will really happen depends on how coders choose to respond. Here's an overview of the task force's findings, plus suggestions on how readers can make the most of possible career opportunities.
It....
How Does the System Know It’s Right? Automated Confidence Assessment
Author: Jiang, Yuankai; Nossal, Michael; Resnik, Philip
Source: AHIMA Computer-Assisted Coding Meeting
Publication Date: September 06, 2006
Wilensky: Major Changes Ahead for Healthcare, But HIM Future is Bright
Author: Jeffries, Jane; Zender, Anne
Source: Journal of AHIMA
Publication Date: January 2003
After a decade of stable spending, healthcare expenditures are on the rise, according to Gail Wilensky, PhD. If the industry doesnt reexamine its course, we can expect healthcare spending to leap to 17 or 18 percent of the gross domestic product, an increase of up to 6 percent.
Writing a Coding Success Story: Best Practices and Beyond
Author: Jeffries, Jane
Source: Journal of AHIMA
Publication Date: July 2001
What are the cornerstones of a thriving coding department? How can you ensure your coding team is built on a foundation of education, compliance, and satisfaction? We spoke with several coding managers to collect solutions and guidance for common coding challenges.
Whats the s....
HFMA Tackles Hospital Billing Chaos
Author: Jeffries, Jane
Source: Journal of AHIMA
Publication Date: January 2001
Hospital bills are lengthy, often incorrect, and potentially confusing-to no one's surprise. A hospital bill is the result of a long process with numerous participants, beginning at pre-intake and ending with final collections.
Richard L. Clarke, FHFMA, president and CEO o....
Joining Forces on ICD-10-CM/PCS: Collaboratives Form to Help Handle Coding Transition
Author: Jahn, Mark
Source: Journal of AHIMA
Publication Date: June 2013
As providers and payers grapple with the complexities of ICD-10-CM/PCS (ICD-10), many are formally collaborating with one another to learn best practices and accelerate ICD-10 implementation.
Across the country, many different types and sizes of ICD-10 collaboratives have fo....
Natural Language Processing Technology and Terminologies: Mining Free Text
Author: Jagannathan, V.; Heinze, Daniel T.; Naeymi-Rad, Frank; Flanagan, James R.; Bowie, Jack; Kivatinetz, Raul
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
The dictation and transcription process is one of the most widely used ways of documenting clinical content. This session brings leading vendors with NLP and terminology solutions to discuss their approach and technologies in support of data mining of free text. The applications t....
Insuring America's Health: Principles and Recommendations
Author: Institute of Medicine. Board on Health Care Services. Committee on the Consequences of Uninsurance
Source: External web site
Publication Date: January 14, 2004
Ten Down Under: Implementing ICD-10 in Australia
Author: Innes, Kerry; Peasley, Karen; Roberts, Rosemary
Source: Journal of AHIMA
Publication Date: January 2000
Coders in Australia have already made the change to coding an Australian modification of ICD-10. What was the process of conversion like, and what lessons can we learn from it? Here's a step-by-step account of the change process.
While no definite date for making the change....
SNOMED CT to ICD-9-CM Mapping Overview
Author: Imel, Margo; Wilson, Patricia S
Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting
Publication Date: October 15, 2005
Essentials for Mapping from a Clinical Terminology
Author: Imel, Margo; Giannangelo, Kathy; Levy, Brian
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
This paper explains the principles of mapping from a clinical terminology, such as SNOMED Clinical Terms (SNOMED CT®), to other classifications and terminologies. It discusses the benefits and challenges in designing a map and the rationale behind developing a map to support different cli....
Mapping from a Clinical Terminology to a Classification
Author: Imel, Margo; Campbell, James R.
Source: AHIMA Convention
Publication Date: October 21, 2003
The paper discusses mapping and the relationships of SNOMED CT® to a statistical and administrative classification system such as ICD-9-CM. It explores the purpose and differences encountered in creating a mapping and provides a brief overview of SNOMED® and its evolution. The Terminology- SN....
SNOMED RT: Using a Controlled Terminology in Computer-based Patient Records
Author: Imel, Margo
Source: AHIMA Convention
Publication Date: October 10, 2001
Abstract
The poster presentation will provide a brief overview of SNOMED definition, evolution to SNOMED® RT, and the SNOMED RT to ICD-9-CM mapping table.
The key content areas are as follows.
SNOMED is the Systemized Nomenclature of Medicine. It is a co....
Closer Look: the SNOMED Clinical Terms to ICD-9-CM Mapping
Author: Imel, Margo
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2002
In the July/August 2001 Journal of AHIMA, SNOMED Takes the Next Step describes the terminologys structure, use in electronic patient records, the evolutions from SNOMED® RT and an overview of the mappings of SNOMED® CT. This article is an update on SNOMED, with a clo....
SNOMED Overview
Author: Imel, Margo
Source: AHIMA Convention
Publication Date: September 23, 2002
Implementing CORE Measures -- A Measurement System Perspective
Author: Hyde, Lynda
Source: AHIMA Convention
Publication Date: October 10, 2001
Introduction
In 1987, the Joint Commission on Accreditation of Healthcare Organizations introduced the Agenda for Change. This program was designed to streamline and update the accreditation process, and introduced for the first time the creation of a national performance mea....
Fracture Treatment Poses Coding Challenge: Multiple Treatment Options Require Special Attention
Author: Hutchinson, Mark R.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2003
There are 206 bones in the human body and each is susceptible to fracture. The choices in fracture management are complex and based on a number of issues including fracture type, fracture pattern, specific bone, age of fracture, age of patient, associated injuries, and physician preference. Co....
UK's Agenda for Managing Health Information: First Steps to Improving Data Quality
Author: Huston, Janis L.; Brox, Georg A.
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction to the Information for Health NHS Strategy Document
The National Health Service (NHS) of the United Kingdom (UK) published its Information for Health agenda in 1998 to address such issues as information management, information technology (IT), security, and data quality. In t....
ICD-10 Coding Training in England: Greater Access to Education Should Aid US Coders with Transition
Author: Huston, Janis L.
Source: Journal of AHIMA
Publication Date: September 2009
A lack of comprehensive training on ICD-10 and other code sets has contributed to data quality issues in England. US coders, looking ahead to their own transition to the code set, should be encouraged by their access to a strong coding infrastructure.
As professional coders in the U....
New Procedures for Joint Resurfacing of the Knee
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2005
For 2005, CPT added a number of codes to reflect the continuing evolution of reconstructive knee procedures, especially those that address resurfacing of the articular surface of the joint following loss of normal chondral tissue. The fact that chondral tissue is avascular and has limited rege....
Coding for Vascular Access Devices: New CPT Subsection Sheds Light on Procedures, Devices
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2004
The coding of vascular access procedures has been problematic for some time. New codes were added to CPT as new techniques developed, but the organization of the subsection was vague and the coding of some types of devices unclear. With CPT 2004, an entire new subsection, Central Venous Acces....
Coding Complex Bariatric Surgery
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2005
Bariatric, or weight-loss, surgery is a rapidly evolving specialty. From jejunocolic and jejuno-ileal bypass procedures, through the days of minimally invasive procedures such as gastric balloons and endoscopic-banded gastroplasty, to today’s procedures that involve both gastroplasty and....
Characteristics and Challenges of Long-term Acute Care Hospitals
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2006
Governed by somewhat different rules than other acute care providers, long-term acute care (LTAC) hospitals represent a special segment of the provider market. This article reviews the definition of a LTAC hospital and discusses some of the special challenges facing HIM practitioners and codin....
Long-term Care Hospital PPS Creates Opportunities for Coders: Proposed Rule Addresses Related Coding Issues
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2003
A prospective payment system has been in effect for Medicare reimbursement for various healthcare providers for almost 20 years. Most recently, long-term acute care hospital (LTCH) facilities have been added to the prospectively reimbursed providers. This is a significant change from the cost-....
Keeping up to Date: 2005 CPT Surgery Changes
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2005
CPT changes for 2005 affect all portions of the manual, although there are very few changes in the pathology and laboratory section. This article will focus on the changes for the surgery section. The January and February 2005 issues of CodeWrite (available through the Coding Community of Prac....
2006 CPT Coding Update
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2006
A number of changes to CPT codes take effect January 1, 2006. These changes affect category I, II, and III codes, with a total of 277 additions, 110 deletions, and 71 code revisions.
Evaluation and Management
Within the evaluation and management (E/M) section, the codes for fol....
Coding Peripheral Angioplasties
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2006
Like other interventional procedures, peripheral angioplasties involve complex combination coding. Surgical and radiological supervision and interpretation codes must be assigned for each procedure. In some instances multiples of both code types are assigned. This article discusses the various....
Changes Abundant for CPT 2004
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2004
Changes for CPT 2004 affect all chapters, and its important to stay up to speed. This article presents a summary of CPT changes for 2004. Because a number of the procedures may be unfamiliar to some coding professionals, AHIMA has provided online links to descriptive articles on these s....
Understanding Diabetes Mellitus
Author: Huff, Garry L.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2003
Diabetes mellitus represents a group of disorders that are characterized by hyperglycemia. The clinical and ICD-9-CM classification of diabetes mellitus have evolved as understanding of insulin physiology has expanded. This article will explain diabetes mellitus and its ICD-9-CM classification....
Endoscopic Surgery Brings Relief to Sinus Patients
Author: Huff-Allen, Angela; Wills-Dubose, Sarah
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2004
Millions of people are afflicted with chronic sinusitis annually. Most patients can be effectively treated with antibiotics, but for those who cannot, surgery is often recommended.
Endoscopic sinus surgery (ESS) is one of the fastest growing procedures performed in the field of otolaryng....
CPT 2013 Changes In Nerve Conduction Studies
Author: Huey, Kim
Source: CodeWrite | AHIMA newsletter article
Publication Date: April 2013
In recent years, many changes to the Current Procedural Terminology (CPT) have made coding of certain procedures less complicated. This is true this year for the coding of nerve conduction studies. The codes have been restructured to reflect the number of studies performed as the unit of s....
Transitional Care Management Codes
Author: Huey, Kim
Source: CodeWrite | AHIMA newsletter article
Publication Date: November 2013
Transitional care management codes 99495 and 99496 were introduced by the American Medical Association (AMA) in CPT 2013 to capture the work involved in managing a patient after discharge from a facility setting to a community-based setting. These codes are part of an initiative between t....
Introduction to Evaluation and Management Services
Author: Huey, Kim
Source: CodeWrite | AHIMA newsletter article
Publication Date: October 2014
Evaluation and management (E/M) are cognitive services in which a physician or other qualified healthcare professional diagnoses and treats illness or injury. Almost all specialties will perform evaluation and management services. Even physicians who generate the bulk of their revenue in....
Assigning Advance Care Planning Codes
Author: Huey, Kim
Source: CodeWrite
Publication Date: May 2016
Physicians have a new opportunity to bill and be paid separately for a counseling service they may already be performing. Advance Care Planning codes 99497-99498 were introduced in Current Procedural Terminology (CPT®) in 2015 but were not paid by Medicare until January 1, 2016. CPT code 9....
Mitigating Coding Risks in the EHR: Physician Coders More Valuable With EHR Implementation
Author: Huey, Kim
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2013
Though it may seem contrary to popular opinion, electronic health record (EHR) products will make providers' coders more necessary and valuable than ever. Physicians who trust only EHR and computer-assisted coding software to choose the codes they bill, without any training or oversight, a....
Improve Your Organization's Financial Health: Tools and Strategies to Manage
Author: Huber, Nancy; Stolze, Maria; Youmans, Karen; Wharton, Trish
Source: AHIMA Convention
Publication Date: October 15, 2004
I. Introduction
What comprises the revenue cycle? Simply put, revenue is regular income, and the cycle is the regularly repeating set of events that produces it. In a healthcare facility, many administrative and clinical functions from patient access to collections comprise the revenue c....
HIM and PEPP: an Opportunity to Promote Compliance
Author: Hrehor, Kimberly; Osterberg, Carol; Shearry, Joyce
Source: AHIMA Convention
Publication Date: September 23, 2002
Trends Related to DRG Coding Errors
Author: Hrehor, Kimberly
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
The HIM profession has been involved in many aspects of hospital operation. More recently, HIM professionals have become more involved in compliance matters surrounding reimbursement issues related to complete documentation in the medical record and accurate coding of....
Codes to Watch: Identifying the DRGs Most Prone to Payment Error
Author: Hrehor, Kimberly
Source: Journal of AHIMA
Publication Date: July 2005
Monitoring error-prone DRGs is one good way to ensure coding accuracy. Data from the HPMP helps identify codes that bear watching.
Monitoring codes prone to payment error is an important part of an organization’s ongoing efforts to verify coding accuracy. Data from the Hospital Pay....
Resolving Confidentiality Barriers in Research Data Collection
Author: Houser, Shannon H.; Engle, Molly; Schumacher, Joseph E; Caldwell, Ellen; Kohler, Connie L; Phelan, Sharon T; Raczynski, James M; Reynolds, Kim D
Source: Journal of AHIMA
Publication Date: March 2000
How can HIM professionals ensure data collection consistency without access to earlier records? When protecting patient anonymity posed a challenge in a research study, HIM professionals took a team approach to abstracting records that maintained quality without compromising confidentiality.
Improving Coding and Documentation Quality Through Real-Time Collaboration: Nurses and Coding Professionals Team Up to Tackle Documentation Issues
Author: Horn, Kelli; Younger, Adrienne; Snow, Trevor
Source: Journal of AHIMA
Publication Date: August 2016
While working through the recent implementation of ICD-10, leaders at Ardent Health Services began to focus on the re-bill process and what it would look like in the months following use of the new code set. Re-billing means submitting a corrected bill to the payer after it has been rejec....
How to Gain Inpatient Coding Experience in Preparation for the CCS Exam
Author: Horn, Kelli
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2013
Those who take the Certified Coding Specialist (CCS) exam are strongly encouraged to have at least three years of inpatient and outpatient coding experience, with a variety of patient types. Sometimes a candidate believes he or she can pass the test without this comprehensive experience....
Five Steps to Take If You Do Not Pass the CCS Examination
Author: Horn, Kelli
Source: CodeWrite | AHIMA newsletter article
Publication Date: January 2014
While some individuals pass the Certified Coding Specialist (CCS) examination the first time, many do not. The annual pass rate has remained below 50 percent for at least the last three years. According to AHIMA, the pass rate for first-time test-takers was 48.5 percent in 2010, 47.8 perc....
Which Should You Take: the CCA or CCS Exam?
Author: Horn, Kelli
Source: CodeWrite | AHIMA newsletter article
Publication Date: November 2013
As a CCS exam course review instructor and in my efforts to help students and coders obtain a coding credential, I am often asked which credential would be the most beneficial, and whether an individual is better prepared to pass the Certified Coding Associate (CCA) or the Certified Codin....
Gestational Diabetes: CDI ICD-9/ICD-10 Comparison
Author: Horn, Kelli
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2013
Help! I am Encoder-Dependent!
Author: Horn, Kelli
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2014
Many coders in the workforce preparing to take their CCS examination acknowledge that they are dependent on encoders. While this is beneficial in performing daily job duties, it can be a hindrance to successfully passing the examination. The four-hour examination requires that exam-takers....
Top Ten Challenges of Passing the CCS Examination (And How to Overcome Them)
Author: Horn, Kelli
Source: Journal of AHIMA
Publication Date: January 2015
Hundreds of coders and students desire to take the next step in their career by obtaining the Certified Coding Specialist (CCS) credential. This examination represents high-level achievement and proficiency in inpatient and outpatient coding and associated concepts. Benefits of certificat....
Data Capture for Performance Measures: What Coders Need to Know
Author: Hoag, Patience J.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2007
These days, cost control, efficiency of care, and quality outcomes are hot topics in every healthcare setting. One way to achieve quality outcomes and cost-efficient healthcare is through performance measures. This article provides a brief overview of HEDIS® and other performance measures....
Revenue Integrity and Coding Compliance: the Sharp Experience
Author: Hirschl, Nancy; Belton, Paul
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
Traditionally, compliance programs have focused on the seven required elements from auditing and monitoring to hotline investigations. Most of these elements have become routine and solidified into every compliance program. In truth, seasoned compliance officers often....
Trend Watch: Coding for Nonphysician Services
Author: Hill, Emily
Source: Journal of AHIMA
Publication Date: January 2000
From physician assistants to nurse practitioners, the number of healthcare professionals offering patient care services has increased dramatically in recent years. With this increase comes a challenge to codersaccurately reporting the services provided by these prof....
Next Generation of E/M Guidelines
Author: Hill, Emily
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2000
Few non-clinical issues have inspired as much discussion, revision, and anxiety as the evaluation and management (E/M) services and their accompanying documentation guidelines. E/M services have produced a cottage industry focused on ensuring that medical records contain necessary docu....
Dialysis Settings Offer Diverse Opportunities
Author: Heustis, Kathryn D.
Source: Journal of AHIMA
Publication Date: July 2000
Opportunities for HIM professionals are continually expanding into new and challenging care settings. Renal dialysis facilities are one of the more unusual settings offering HIM professionals a new role.
Renal Dialysis Basics
Medicare coverage for indiv....
Pick One: Comparing the Medicare and Medicaid EHR Incentive Programs
Author: Heubusch, Kevin
Source: Journal of AHIMA
Publication Date: September 2011
Approximately 77,000 healthcare providers had registered for the meaningful use EHR incentive programs through July, program officials told the Health IT Policy Committee at its August 3 meeting. That is a significant number, but it leaves plenty of eligible providers and hospitals still to re....
Coding’s Biggest Challenges Today
Author: Heubusch, Kevin
Source: Journal of AHIMA
Publication Date: July 2008
Coding departments are hectic places in 2008, busy adapting to new requirements. To meet the challenges, they are seeking the right staffing, education, and coordination.
How many challenges does coding face today? Open positions, revenue cycle, MS-DRGs, POA, RACs,....
Cervical Dysplasia and CIN: What's the Difference?
Author: Herr, Victoria A.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2005
In fiscal year 2005, new ICD-9-CM codes were created for reporting cervical dysplasias and abnormal Pap smears. From a clinical perspective, the new codes and instructional notes align ICD-9-CM with current terminology used in diagnosing and reporting cellular abnormalities of the cervix. From....
Healthcare Trends: the Big Picture. Megatrends You Need To Know About
Author: Herrick, Michael; Patterson, Andrew
Source: Journal of AHIMA
Publication Date: May 2000
All of these factors make it difficult to get a handle on "the big picture" of healthcare. Take into consideration most HIM professionals' ever-increasing workload, proliferating forms of media competing for their attention, and the normal concerns of everyday life, and keeping the big picture....
ABCs of Medicare Advantage
Author: Hernandez, Jeannette
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2008
Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.
By June 2....
Another Look at LOINC
Author: Herbst, Maida Reavis
Source: Journal of AHIMA
Publication Date: January 2002
We have all heard Logical Observation and Identifier Codes (LOINC) mentioned in the same breath with standards or medical vocabularies, but what are they exactly?
What Is LOINC?
LOINC is a niche vocabulary useful in reporting laboratory and clinical observations. The....
Nursing Data, Classification Systems, and Quality Indicators: What Every HIM Professional Needs to Know
Author: Henry, Suzanne Bakken; Warren, Judith J.; Zielstorff, Rita D.
Source: Journal of AHIMA
Publication Date: May 1998
by Suzanne Bakken Henry, RN, DNSc, FAAN, Judith J. Warren, RN, PhD, FAAN, and Rita D. Zielstorff, RN, MS, FAAN
The nursing profession has developed a number of classification systems. What can HIM professionals learn from the processes and results? This article presents an overview of the....
Changing the Face of Coding-Experiences from the Home
Author: Hemphill, Tasha; Shackleford, Cheryl
Source: AHIMA Convention
Publication Date: October 10, 2001
Introduction
Home coding has been identified as one of the leading trends for health information management (HIM) in 2001. Similar to home-based transcription, coding from home has opened doors and reinvented coding careers for hundreds of clinical coders throughout the Unite....
Computer Assisted Auditing for High-Volume Medical Coding
Author: Heinze, Daniel T.; Feller, Peter; McCorkle, Jerry; Morsch, Mark
Source: AHIMA Computer-Assisted Coding Meeting
Publication Date: September 06, 2006
Observation Status or Inpatient Admission - Guidance for Physicians
Author: Health Care Excel
Source: External - used with permission
Publication Date: July 07, 2003
"Observation Status or Inpatient Admission - Guidance for Physicians" has been modified so that physicians can download all, or portions, through HCE’s website.
Observation
The quality of care should be the same whether the Medicare patient is placed in observation or admitted as an....
Gastrointestinal (GI) Bleeding [Documentation Suggestions]
Author: Health Care Excel
Source: External - used with permission
Publication Date: July 07, 2003
Describe clinical signs and symptoms (e.g., dizziness, orthostatic hypotension, fatigue, pallor, etc.).
Document work-up (e.g., colonoscopy, CBC, esophagogastroscopy, etc.).
Note source of bleed, if known (e.g., erosive gastritis, angiodysplasia, stomach ulcer, diverticular disease, colo....
Congestive Heart Failure (CHF) [Documentation Suggestions]
Author: Health Care Excel
Source: External - used with permission
Publication Date: July 07, 2003
Describe clinical signs and symptoms (e.g., exertional dyspnea, orthopnea, peripheral edema, pulmonary rales or crackles, or jugular vein distention, etc.).
Document work-up (e.g., chest x-ray, EKG, Swan-Ganz, echocardiogram, etc.).
Document treatment (e.g., diuretics, ACE inhibitors....
Intestinal Obstruction [Documentation Suggestions]
Author: Health Care Excel
Source: External - used with permission
Publication Date: July 07, 2003
Describe clinical signs and symptoms (e.g., abdominal distention, hyperactive bowel sounds, vomiting, etc.).
Document work-up (e.g., abdominal x-ray, barium enema, etc.).
Describe treatment (e.g., nasogastric suction, NPO, surgery, etc.).
Describe etiology, if known (e.g., hernia, fe....
Renal Failure [Documentation Suggestions]
Author: Health Care Excel
Source: External - used with permission
Publication Date: July 07, 2003
Describe clinical signs and symptoms (e.g., skin darkening, itching, muscle cramps, progressive rise in BUN, elevated urine protein, etc.).
Document work-up (e.g., kidney CT scan, kidney venogram or arteriogram, etc.).
Document treatment (e.g., IV erythropoietin, dialysis, etc.).
No....
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