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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. Here’s what they fou....

Improving Coding for Right Heart Catheterization

Author: Kerr, Anneliese; Yoder, Lois M.; Michelman, Mark S.

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

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

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

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

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.

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.

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

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.

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.

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

Author: Institute of Medicine. Board on Health Care Services. Committee on the Consequences of Uninsurance

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 doesn’t 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.

What’s 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

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

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

Publication Date: June 2002

In the July/August 2001 Journal of AHIMA, “SNOMED Takes the Next Step” describes the terminology’s 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

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.

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

Publication Date: September 2013

Help! I am Encoder-Dependent!

Author: Horn, Kelli

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 coders—accurately reporting the services provided by these prof....

Next Generation of E/M Guidelines

Author: Hill, Emily

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

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