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Pneumonia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).
Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).
Describe preadmission treatment tha....

Septicemia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., hypoxemia, tachycardia, leukopenia, bradypnea, leukocytosis, etc.).
Identify causative organism, if known (e.g., pneumococcal, E. coli, aerobacter aerogenes, etc.).
List infection source, if known (e.g., UTI, pneumonia, postoperative wound, etc.....

Developing the Coder's Role in Revenue Cycle Management

Author: Hattan, Dorothy

Source: AHIMA Convention

Publication Date: October 21, 2005


In 1995, AMC combined the hospital and clinic to become a hospital-based provider facility in addition to becoming an affiliate of the Mayo Health System. This required a complete retooling of the financial system, and the CFO had the foresight to realize that this was going to require many st....

Impact of Creating a Pay for Quality Improvement (P4QI) Incentive Program on Healthcare Disparity: Leveraging HIT in Rural Hospitals and Small Physician Offices [Commentary]

Author: Hart-Hester, Susan; Jones, Warren A.; Watzlaf, Valerie J.M.; Fenton, Susan H.; Nielsen, Carol; Madison, Mary; Arthur, Chris; Marbury, David; Rudman, LeeAnn; Patterson, Randi; Reynolds, Rebecca; Rudman, William J.

Source: Perspectives in Health Information Management

Publication Date: September 2008

Introduction

Reducing health disparities and improving healthcare quality for all Americans has become a national priority. 1–4 Approximately 16 percent (or $4 trillion) of America's gross domestic product is spent on healthcare. 5–7 Despite spending twice as much on healthcare as other i....

HIM & Ethical Decision Making: Complex Challenges

Author: Harman, Laurinda B.

Source: AHIMA Convention

Publication Date: October 10, 2001




The successful health information management (HIM) professional (RHIT and RHIA) must be simultaneously passionate about two things: (1) information management expertise and (2) ethical principles and professional values. Technical expertise without ethical principles and professional....

Covering the Bases of Coding Compliance

Author: Hapner, Peggy

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2001




As HIM professionals already know, data quality-one of the basic tenets of compliance-depends on comprehensive documentation and accurate code assignments. Because coding plays a major role in payment, reporting data accurately, managing data flow and data collection, and training st....

Observation Services

Author: Hapner, Peggy

Source: AHIMA Convention

Publication Date: September 25, 2010



Observation is a necessary, though cumbersome, service provided in hospitals today. Many facilities would like to see observation eliminated because it is a logistical nightmare, particularly when it comes to charges and reimbursement.

The most stringent rules about observation....

Outpatient Wound Care – Keys to Getting Paid

Author: Hapner, Peggy

Source: AHIMA Convention

Publication Date: October 02, 2011


Ever since the Ambulatory Payment Classification (APC) system was launched, hospitals have struggled to receive the full appropriate reimbursement for outpatient wound care. Why? In many cases, the facility lacks adequate documentation to support coding and billing. And increasingly, medical n....

CAD vs. Angina

Author: Hansen, Abby

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2013



Unstable angina pectoris is a type of chest pain that happens suddenly and becomes worse over time. It can often be felt in the shoulders, arms, and neck. It is caused by poor blood flow through the blood vessels of the heart muscle and can evolve into a myocardial infarction. Coronary at....

Constructing a Coding Compliance Plan

Author: Hanna, Joette

Source: Journal of AHIMA

Publication Date: July 2002


The government has turned its attention to coding compliance. Do you have an effective program in place? Use the steps in this article to build a coding compliance program that protects your organization.


Coding compliance has become an integral part of every HIM department....

Choosing Consultants Without Compromising Compliance

Author: Hammen, Cheryl

Source: Journal of AHIMA

Publication Date: October 2001




Auditing coding and DRG accuracy has become an important component in the daily operation of the HIM department. Many providers are choosing to contract with external coding consultants to perform this task. This can be an appropriate solution as long as the vendor meets the necessary....

Documentation Errors Result in Medicare Overpayment

Author: Hammen, Cheryl

Source: Journal of AHIMA

Publication Date: July 2000



The objective of the Office of the Inspector General's (OIG) fiscal year 1999 audit was to determine whether medical fee-for-service claims complied with Medicare rules and regulations. The OIG examined claims for accurate documentation and coding, medical necessity, and to ensure that c....

Developing Technical Applications for Coding Compliance

Author: Hammen, Cheryl

Source: AHIMA Convention

Publication Date: October 10, 2001


Introduction

Although high-risk DRG pairs have been audited to ensure compliance in hospitals over the past several years, there are still opportunities available for streamlining this time-consuming process. Monthly data review regarding the frequency of the high-risk pairs is only a....

Perfect Time for Documentation Improvement

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: July 2006




When new IT systems come online, the time couldn’t be better to assess and improve clinical documentation.

Electronic health record system implementations offer a perfect opportunity to assess and improve an organization’s clinical documentation. The renewed attention is ne....

Here Comes Rehab PPS!

Author: Grzybowski, Darice; Draper, Skeeter

Source: Journal of AHIMA

Publication Date: January 2002


Just when you thought it was safe to come up for air.


After Medicare’s introduction of the Outpatient Prospective Payment System (PPS, which brought us APCs), the Home Health PPS (with its HHRGs), and Skilled Nursing Facility PPS (with RUGS), another new reimbursement syst....

Teaching Physician Guidelines

Author: Graff, Jean Stevens

Source: Brief Encounter

Publication Date: September 02, 2001


Working in an orthopedic clinic, I understand the great need for my newly created position. I am employed at a teaching hospital as a medical record auditor charged with the task of educating physicians on the art of coding and documentation. My job is to ensure compliance with the Medicare ma....

Coding Mastectomy Procedures

Author: Goswami, Chaitali

Source: CodeWrite | AHIMA newsletter article

Publication Date: September 2014



OBJECTIVE

The purpose of this article is to enable you to understand and correctly implement the coding principles, concepts, and guidelines associated with various mastectomy procedure codes.


SURGICAL INFORMATION

Mastectomy is the surgical procedure in....

Seizing the Moment to Improve the Quality of Health Information Management

Author: Goshen, Naomi; Nachmani, Frances ; Sasson, Nadine ; Itzchak, Tzipi ; Sayfan, J; Kopelman, D; Kolton, L; Vigder, L; Almog, D; Tiosano, T

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Introduction

The need for accurate and complete records pertaining to operative procedures and diagnoses in surgery wards is almost self-evident. It is so because human life issues are at stake and erroneous and incomplete documentation may harm follow-up treatment as well as research da....

AHIMA Comments on CMS' Proposed Hospital Outpatient Prospective and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program, published in the July 19, 2013 Federal Register

Author: Gordon, Lynne Thomas

Source: AHIMA testimony and comments

Publication Date: September 06, 2013

Comments on the proposed Hospital Outpatient Prospective and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program, focusing on sections of the proposed rules that are of specific relevance and interest to AHIMA members.

Codes for Chronic Kidney Disease: Help in Distinguishing between Renal Failure and Renal Insufficiency

Author: Gold, Robert S.; Bowman, Sue E

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: January 2006


Coders assign codes to disease processes for many reasons, including capturing diseases treated at facilities, accurate representation of illness severity, and specificity of causes of symptoms and justification for treatment. To this end, we have been perplexed by terminology used by physicia....

Implementing and Managing a Virtual Coding Department

Author: Glass, Sarah

Source: AHIMA Convention

Publication Date: October 31, 2006

Implementing and Managing a Virtual Coding Department
Sarah Glass, MA, RHIA, CCS
Introduction

The electronic health record (EHR) provides facilities with an opportunity to offer teleworking as a recruitment and retention tool for the coding staff in the HIM department. This pape....

Audit of Automated Code Assignment in Israeli Hospital's Computerized Medical Information Systems

Author: Gill, Rhonda; Hecht, Rivka

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Introduction
How accurate and complete is the coded diagnostic (and procedure) data collected on patients who are discharged from Israeli government-owned general hospitals that have implemented automated code assignment? Can the individual facilities and the Israel Ministry of Health rely on....

ICF: Representing the Patient beyond a Medical Classification of Diagnoses

Author: Giannangelo, Kathy; Bowman, Sue E; Dougherty, Michelle; Fenton, Susan H.

Source: Perspectives in Health Information Management

Publication Date: November 2005


The World Health Organization (WHO) family contains two core, or reference, classifications: the International Classification of Diseases (ICD) and ICF. A third classification, the International Classification of Health Interventions (ICHI), is under development. The core WHO classifications c....

Countdown to HIPAA Claims Attachments

Author: Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: October 2005


With the clock ticking down to the HIPAA national provider identifier compliance deadline, HIM professionals should start thinking about the next HIPAA standard on the horizon, claims attachments. While not one of the original eight administrative transactions approved for use in the healthcar....

Changes Ahead in Data Standards

Author: Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: June 2011


HIM professionals are most familiar with the data standards mandated through HIPAA. However, the data standard adoption process is also now part of the requirements for EHR technology in the meaningful use program.

Understanding the data standards adoption process under HIPAA and th....

Reporting Codes Accurately

Author: Giannangelo, Kathy

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2005


Coding professionals routinely review records and, when appropriate, query physicians to clarify a condition. Once the specifics are known, ICD-9-CM is used to determine the appropriate codes to record a patient’s diagnosis and report the healthcare claim. Coding professionals know that....

Overview of Trauma Registries in the United States

Author: Garthe, Elizabeth

Source: Journal of AHIMA

Publication Date: July 1997

Overview of Trauma Registries

How many trauma registries are there in the US? This is a tough question to answer. According to a survey conducted by members of the Emergency Nurses' Association (ENA), the number of clients reported by trauma registry software companies exceed 1850 organi....

Present on Admission: Where We Are Now

Author: Garrett, Gail S.

Source: Journal of AHIMA

Publication Date: July 2009


Hospitals have nearly two years of POA reporting under their belts. With time, effort, and updates, assigning POA indicators is becoming routine business for coding professionals.

For the past several years, HIM professionals have served as a conduit for a rapidly evolving pay-for-pe....

Three-Day Window Updates

Author: Garrett, Gail S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011


The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 was signed into law on June 25, 2010. One of its provisions revised the three-day payment policy, or the so-called "three-day DRG window."

This article highlights the changes to the three-da....

Hospital Authority Clinical Vocabulary Table: the Past, the Present, and the Future

Author: Fung, V.; Cheung, N T; Szeto, K; Ngai, L; Lau, M; Kong, J HB

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Abstract

The use of standard clinical vocabulary to support the development of clinical information systems is well established. The ICD-9-CM was adopted locally to form the basis of the Hospital Authority Master Disease Code Table (HAMDCT) and incorporated for use into the Clinical Mana....

External Cause Codes in ICD-10-CM

Author: Fuller, Jan C.

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2014



The increased specificity in ICD-10-CM is reflected in a substantial increase in external cause codes. The traditional “E code” has been replaced with V, W, X and Y codes. While the purpose of the codes remains the same, the ICD-10-CM codes provide a level of detail not possible in ICD-9-....

Problem List Coding in e-HIM

Author: Fraser, Greg

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2005


In 1968 Larry Weed, MD, introduced the idea that a complete and accurate problem list is an essential component of the medical record.1 The problem-oriented medical record (POMR), in which all data contained in the medical record can be linked to a list of problems, has been almost universally....

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