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GEMs Target to Source Exercise

Author: Foster, MeShawn

Source: CodeWrite | AHIMA newsletter article

Publication Date: October 2011



In order to use the General Equivalence Mappings (GEMs) effectively, it is imperative that both the forward and backward techniques are employed. GEM users will find that they are presented with a myriad of options when there is a “one-to-many” or “many-to-one” scen....

Translation Please: Mapping Translates Clinical Data between the Many Languages That Document It

Author: Foley, Margaret M.; Hall, Candace; Perron, Kathryn; D'Andrea, Rachael

Source: Journal of AHIMA

Publication Date: February 2007


Clinical mapping is essential because healthcare has no single medical terminology, making it difficult to understand and translate meanings across the different terminologies developed for different uses. Mapping allows the capture of data in the electronic health record (EHR) with the t....

Communication with a Side of Encouragement, Please: Effective Communication Strategies for a Smooth CDI Program implementation Transition

Author: Flood, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2012


Clinical documentation improvement (CDI) programs are spreading rapidly across the United States-and for good reason. They help facilities improve the level of documentation that goes into the patient medical record, leading to fewer errors and an overall improvement for continuity of care. Bu....

Injection and Infusion Coding Offers High Stakes: Outpatient Coders Must Play Their Cards Right

Author: Flewelling, Charles

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

Publication Date: June 2015



With the consistently rising value of highly skilled outpatient coders, numerous HIM departments are moving to a staffing model that employs coding professionals who are well versed in coding both inpatient and outpatient encounters. Coders in the profession today should possess a mastery....

Mobilizing to Do Adaptive Work

Author: Fletcher, Donna M.

Source: Journal of AHIMA

Publication Date: November 1999


Can our visionary leaders solve our problems? Sometimes. But more often, the reality is the power to solve problems lies with us. This is the fundamental assumption of the "adaptive work" concept presented in this article—along with some real-life examples of HIM adaptive work in action.....

Understanding How to Analyze Case Mix

Author: Fennick, Kathy

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction

Case mix analysis has been an ongoing challenge for hospital chief executive officers, chief financial officers, HIM directors, and case managers since the implementation of diagnostic related groups (DRGs) and the Medicare prospective payment system (PPS). Because no better....

Laying the Foundation for the NHII

Author: Featheringham, Meg

Source: Journal of AHIMA

Publication Date: May 2004


The news is spreading across the country about the need for a national healthcare information infrastructure (NHII). HIM professionals are crucial to getting the word out and moving this initiative forward. Gail Graham, RHIA, is at the forefront of the charge to implement an NHII. As director....

Advances in Burn Reconstruction Complicate Coding: Get Familiar with Terminology, Techniques for Accurate Coding

Author: Erhardt, Walter L.; Medal, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


Recent advances in the science of wound healing are making an impact on the treatment of burns. This is particularly evident not only in the way burn wounds are being managed initially, but also in how these wounds are being reconstructed. While these scientific advances make this field an exc....

Anatomy of a Physician Coder: Small, medium, and large physician practices all feature these multi-tasking, multi-responsibility coders

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2012


An analysis of the “physician coder” anatomy would reveal a cornucopia of responsibilities nestled under this one succinct title.

They are equal parts clinical documentation improvement specialist, office manager, patient counselor, physician process tracker, coder... the list goes....

Peeking Over the Fence: a Look at Canadian Coding and CDI Processes, and How They Differ From the US Due to Varied Financial Structures

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: February 2014

Even with different payment models, Canada and the US are both working to reform healthcare with pay-for-performance and quality measurement reforms. Though using a single payer system, Canada still struggles with many of the same US HIM concerns—coding accuracy, clinical documentation improvement, and proper reimbursement.

Don’t Deny the Denials: Experts Recommend Implementing a Strong Claims Denial Strategy to Offset ICD-10-based Coder Productivity Loss

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: June 2014



As organizations prepare for the implementation of ICD-10-CM/PCS next year, many are looking for creative strategies to mitigate anticipated decreases in coder productivity that will come with the switch. Some are ramping up education, others hiring additional staff members or implementin....

CPT Receives Update for 2014

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2014



On January 1, 2014, the American Medical Association’s Current Procedural Terminology (CPT) was updated with additions, revisions, and deletions. In total, 175 new codes were added, 107 codes were revised, and 47 codes were deleted. In addition, editorial changes and coding guideline addi....

Pain-free Wound Care Coding

Author: Endicott, Melanie

Source: Journal of AHIMA

Publication Date: January 2010


Wound care diagnoses and procedures can be challenging to code. In order for coders to code them correctly, clinicians must document diagnoses and procedures appropriately and thoroughly. Open communication between coders and clinicians can help facilitate better documentation.

Inpa....

New ICD-9-CM Diagnosis Codes for FY 2012

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2011


The new ICD-9-CM diagnosis codes go into effect October 1, 2011. This date marks the last regular annual update to the ICD-9-CM code set before the partial code freeze. On October 1, 2012, there will be only limited code updates to ICD-9-CM to capture new technology and new diseases. There wil....

Hypertension Coding Review

Author: Endicott, Melanie

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2011



Does coding hypertension elevate your blood pressure? There are several terms related to hypertension that may cause confusion among coders and require some clarification. This article will define terminology related to hypertension and review the coding guidelines associated with combina....

2012 CPT® Coding Changes

Author: Endicott, Melanie

Source: CodeWrite | AHIMA newsletter article

Publication Date: February 2012



January 1 marked a new year as well as several additions, deletions, and revisions to the CPT® code set. All six sections, the introduction, and Appendix A, underwent changes in 2012. Coding professionals should review Appendix B of the CPT codebook for a complete listing of all change....

Defining Difficult Modifiers

Author: Endicott, Melanie

Source: CodeWrite | AHIMA newsletter article

Publication Date: April 2011



The assignment of modifiers is often an area of frustration for outpatient coders. The purpose of this article is to help define some of those difficult modifiers and provide examples of appropriate modifier usage.


Modifiers are used to indicate any of the following situatio....

ICD-9-CM Refresher

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2014





Focus has been on training in ICD-10-CM/PCS for the past few years. With yet another delay, many organizations are slowing down their ICD-10 training and changing their focus back to ICD-9-CM.


The first quarter of 2014 was historic in “coder world” since t....

Coding Hip Fractures

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2010


Hip fractures are most commonly seen in elderly patients. They are a serious concern for this population because they can lead to a decreased quality of life, extended hospitalizations, or admission to nursing facilities.

Two of the most common causes for fractures are falls and ost....

Computer-Assisted Coding and Beyond

Author: Eminger, Heather

Source: AHIMA Convention

Publication Date: September 28, 2010


Introduction to CAC

Whether you're a facility reviewing the Computer-Assisted Coding (CAC) technologies because of coding challenges such as the ever evolving CMS requirements and backlogs, or preparing for ICD-10 CM. You will learn there is much more that Computer-Assisted Coding....

Data Abstraction Unplugged: Taking Trauma Registry to the Point of Care with Wireless Technology

Author: Eisenhower, Cynthia; McElwee, Karen; Wargo, Christina; Woodruff, Tracy

Source: Journal of AHIMA

Publication Date: July 2005


Central to Geisinger Medical Center’s success with concurrent abstraction is wireless technology that enables registrars to work at the point of care.
Registry abstraction can have trouble keeping up with technology. Often located away from IT-intensive clinical departments and oper....

Physician Office Billing Compliance Program

Author: Eisenhauer, Sue

Source: Journal of AHIMA

Publication Date: October 1997


Physician offices try to adhere to the coding and billing guidelines as defined by Medicare. However, claims to commercial insurance carriers frequently are not handled as precisely. The passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has brought to our atte....

Use Data Mining Findings as a Tool to Support CDI Education

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

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

Publication Date: July 2014



Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

Forgotten Denial: Automated

Author: Easterling, Sharon

Source: CodeWrite | AHIMA newsletter article

Publication Date: September 2013



With the never-ending volume of complex medical necessity denials and inpatient coding denials, automated denials get lost in the shuffle. We cannot forget the importance of these denials, which require intense energy, research, and effort, often only to yield a line item charge total of $....

Busy Year for the RACs

Author: Easterling, Sharon

Source: Journal of AHIMA

Publication Date: March 2012



Learning from last year's denials and preparing for what's ahead will help providers avoid being stung in 2012.


When the Recovery Audit Contractor (RAC) permanent program began in 2009, providers were hopeful that the process for identifying underpayments and overpayments w....

Checks, Balances, and Ethics: Implementing Financial Controls for Associations

Author: Dunn, Rose T; Klaver, Jill Callahan; Rinehart-Thompson, Laurie A.

Source: Journal of AHIMA - website

Publication Date: November 2014


Health information management (HIM) professionals are recognized for their compliance-focused activities. Coding professionals, for example, assign codes based on the available documentation and the rules that define proper code application. When hospital coders are asked to resequence a condit....

When Health Information and Fiscal Management Meet

Author: Dunn, Rose T

Source: Journal of AHIMA

Publication Date: January 2001




HIM professionals have skills that can allow them to contribute to the bottom line in many ways. The author describes areas where HIM expertise can make a difference in evaluating an organization's fiscal performance through analysis of services driven by health information.
HI....

ABNs--Always Been Neglected

Author: Dunn, Rose T

Source: AHIMA community resource

Publication Date: November 14, 2003


For something that has been around for nearly 2 decades and supported by regulation since 1965, Advance Beneficiary Notices (ABNs) continue to cause headaches today. The use of written notices has been available since the enactment of PL 92-603 in 1972. The specific format called an Advance B....

Putting Productivity Plans to Work

Author: Dunn, Rose T

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2001




This is the last in a series of three "Coding Notes" articles addressing productivity measurement and incentive plans for coding professionals. The April Journal of AHIMA (vol. 72, no. 4) article discussed the general principles of developing facility-specific productivity m....

Communicating with Physicians: Something to Talk About

Author: Dunaway, M. Tray

Source: Journal of AHIMA

Publication Date: September 2002


Ask a physician: "Doctor, are your detailed history and physicals comprehensive?" Now ask: "Doctor, are your comprehensive history and physicals detailed?" Chances are, you'll get two affirmative replies. To a physician, detailed workups are comprehensive, and comprehensive workups are detaile....

The ICD-10 2011 To-Do List

Author: Dowling, Alan F.; Wisdom, Theresa A

Source: Journal of AHIMA

Publication Date: September 2010



As the ICD-10 conversion deadline approaches, its implementation is likely to become a healthcare facility's most significant objective. It presents HIM professionals with an opportunity to demonstrate their expertise and assume a leadership role within their institutions as they lead this....

On the Line: Professional Practice Solutions

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: November 2001


Q: Where can I find the updated data elements and data definitions for the Uniform Hospital Discharge Data Set (UHDDS)?

Q: Where can I find an easy-to-use glossary for terms in the HIPAA regulations?

Michelle Dougherty (michelle.dougherty@ahima.org) is an HIM practice manager....

Validating MDS and OASIS Data with DAVE

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: March 2004


In January 2004 the Center for Medicare and Medicaid Services (CMS) launched a new initiative to improve the accuracy and reliability of Minimum Data Set (MDS) data in long-term care. The Data Assessment and Verification program (DAVE) is a collaborative effort between multiple CMS program ar....

Post-acute PPS: Changing the Way We Code

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: June 1999


HIM professionals in post-acute care are reinventing their roles to accommodate the new coding demands of a prospective payment system. Here are some of the developments that are creating new interest in coding issues for post-acute settings.
Three major forces -- the prospective payment....

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