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Another Career Avenue for HIM: Coding Compliance

Author: Lemire, Diane

Source: Journal of AHIMA

Publication Date: June 2001

If you're armed with a background in coding and management, a position in coding compliance may be an exciting next step in your HIM career. When I applied for coding compliance manager positions, many positions had been open for a year because facilities could not find individuals w....

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....

Anthrax: What Every Coder Should Know

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2002

The inhalation anthrax identified by a Florida physician in October 2001, during the recent series of bioterrorist attacks, was the first case of reported inhalation anthrax in the United States in more than 25 years.1 With the threat of anthrax as a biological weapon, correct coding could be....

APCs: A Hospital-wide Effort

Author: Neilson, Seana

Source: AHIMA Convention

Publication Date: October 10, 2001

For many healthcare providers, thriving under the Medicare outpatient prospective payment system (i.e., APCs) appears to be a distant goal not to be realized anytime soon. In fact, for the next year or so, most healthcare providers subject to APCs will most likely be satisfied with me....

APC Validation Audits ... The Nitty Gritty Details

Author: Knowles, Lisa

Source: AHIMA Convention

Publication Date: October 10, 2001

Ambulatory payment classifications (APCs) have been implemented, and APC validation audits are the next issue to contend with. Similar to DRGs, we must design and conduct APC validation audits. Whether the audit is performed in-house or by an external consulting firm, it is essential....

Are Ethics Guiding Your Workplace?

Author: Yokubaitis, Pamela R.

Source: Journal of AHIMA

Publication Date: September 2003

Sanctions under the HIPAA regulations mean serious financial consequences for healthcare professionals who release protected health information to others without following proper disclosure protocols. But HIM professionals should not be motivated by fear of financial consequences alone. Ou....

A Relook at POA Indicators

Author: Martin, Ginny

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2015

Accurate assignment of the present on admission (POA) indicator has new significance with the inception of value-based purchasing (VBP). Coding and the supporting medical record documentation are being used to identify the hospital-acquired conditions and patient safety indicators on whic....

Assessing Coder Change Rates as an Evaluation Metric

Author: Stoner, Jean; Nossal, Michael; Resnik, Philip; Kapit, Andrew; Toren, Richard

Source: AHIMA Computer-Assisted Coding Meeting | Perspectives in Health Information Management

Publication Date: September 2006

In a typical model for computer-assisted coding, the system automatically identifies codes, which are then improved by a human review coder in order to more closely approach the codes that would be assigned to the note by an idealized "gold standard" coder. Assuming such a model, a natural method for evaluating system accuracy might be the coder change rate—specifically, the percentage of notes approved by a coder without modification in a day-to -day business setting. In this paper we look more carefully at change rates as a measure of coding accuracy.

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....

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

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....

Automated Coding: The Next Step?

Author: Beinborn, Julie

Source: Journal of AHIMA

Publication Date: July 1999

Automated coding technology may be key to the evolution of the coding and billing processes. How do these systems work, and how will they change the role of the coder? The author offers a preview.
Technology is changing many aspects of healthcare, and coding is no exception.


Avoiding a War of Words (and Numbers): the Uncertain Future of Terminologies and Classifications

Author: Roberts, Rosemary; Innes, Kerry; Walker, Sue; Scott, Peter

Source: Journal of AHIMA

Publication Date: October 2004

With major changes under way worldwide, the evolving roles and relationships of classifications and terminologies are uncertain. But the future lies in collaboration, not competition.
Classifications and clinical terminologies have coexisted for decades. Both use clinical language, but t....

Back to Basics: APC Payment Methodology

Author: Tomak, Tracey

Source: CodeWrite | AHIMA newsletter article

Publication Date: April 2017

In August of 2000, the Centers for Medicare and Medicaid Services (CMS) introduced the Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS). The objective of the APC payment system was to control costs and increase efficiencies for outpatient ser....

Benchmarking Project Harvests Ideas for Network

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: November 1998

It started as a simple benchmarking project. But when Patricia Rhodes, RRA, Carol Keller, MPA, and their team finished, the project had taken them across the country, opened up lines of communication with staff members at nine other facilities, and helped them improve their....

Benchmarking with National ICD-9-CM Coded Data

Author: Osborn, Carol E.

Source: Journal of AHIMA

Publication Date: March 1999

As HIM professionals, we want to be assured that we are providing the highest quality data for reimbursement and research purposes. We can review coded data internally, but this does not give us a clear picture of the total information that is being submitted to the Health Care Financing Admin....

Best Practices for Medical Necessity Validation

Author: Scichilone, Rita A

Source: Journal of AHIMA

Publication Date: February 2002

To protect the Medicare Trust Fund from being drained, government health plans must provide coverage restrictions for unnecessary health services in vulnerable patient populations. One restriction mechanism is the provision of edits that look for valid reason-for-visit codes for selected servi....

Best Practices: What Works

Author: Carrier, Danielle

Source: Journal of AHIMA

Publication Date: July 1999

Medical record accuracy, record completion time, physician satisfaction—all of these are indicators of how well an HIM department is performing. The findings of a UHC benchmarking study may point the way to best practices that can be shared and adapted.


Boosting Efficiency in Home Health Record Systems

Author: Abraham, Prinny

Source: Journal of AHIMA

Publication Date: April 2000

The growing pains of the past decade have led to medical record backlogs and record retrieval crises for many home healthcare agencies. These problems have pushed more than one agency director into enlisting the skills of an HIM professional to evaluate the medical record systems in pl....

Bridging the ICD-10 Divide through Advocacy: New National AHIMA Advocacy Initiative will Mirror THIMA ICD-10 Outreach Efforts

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: November 2012

AHIMA has long advocated for ICD-10, and these advocacy efforts have overcome some stout barriers to ensure the implementation of the modern, more detailed classification system. Even with this recent success and the reassurance that comes with the final ICD-10 implementation date set for....

Bridging the Translation Gap from ICD-9

Author: Butler, Rhonda R.

Source: Journal of AHIMA

Publication Date: March 2008

A recurring theme in the ongoing ICD-10 implementation debate has been the need for a crosswalk between the old and new code sets to help the industry make the transition. The lack of an “official” mapping between ICD-9-CM and ICD-10-CM/-PCS has long been seen as a major challe....

Brief History of ICD-10-PCS

Author: Mullin, Robert L.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 1999

The International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) was developed as a replacement for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) volume 3, Procedures. This version of ICD, in use since J....

Bringing Physician Practices into the HIM Fold: Guidance on Making a Smooth Transition and Ensuring the MD/Hospital/HIM Relationship Remains Mutually Beneficial

Author: Lee, Christine

Source: Journal of AHIMA

Publication Date: April 2016

According to the American Medical Association (AMA), physician practices continued a slow but steady transition toward hospital ownership in 2015. In their July 2015 study, the AMA reported a decrease in physician-owned practices alongside a continual increase in physicians working direct....

Building a Better CPT

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: November 2000

The Health Insurance Portability and Accountability Act (HIPAA) presents numerous challenges to HIM processes and systems. Not least among these areas is coding. Among the concerns is whether the CPT system will be sufficient to meet the demands of HIPAA. The American Med....

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....

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....

Can You Manage Managed Care?

Author: Willner, Sue

Source: Journal of AHIMA

Publication Date: July 2001

HIM professionals’ data management skills make them a hot property in many settings, but none more so than managed care. In this second installment of the Journal of AHIMA’s special series on managed care, the author describes the ways managed care organizations use data and how HIM....

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