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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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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 it’s 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....

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....

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....

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....

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....

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....

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....

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 coders—accurately 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....

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,....

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....

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