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Role of Coding and Documentation in the Quality Payment Program

Author: DeVault, Kathryn; Easterling, Sharon; Huey, Kim

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

Publication Date: January 2017



In the current era of healthcare transformation, the continuing importance of documentation and coding cannot be overstated. With the multitude of acronyms being added to the healthcare vocabulary, one may wonder where documentation and coding fits in. It’s important to remember that....

Role-based Model for ICD-10 Implementation: Outpatient Coders

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Role-based Model for ICD-10 Implementation: Long Term Care

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Role-based Model for ICD-10 Implementation: Inpatient Coders

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Role-based Model for ICD-10 Implementation: Health Plans

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Role-based Model for ICD-10 Implementation: Data Managers

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Rheumatoid Arthritis

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: November 1998


Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints, the tissue around the joints, and other organs in the body. An autoimmune disease is one in which the body tissues are mistakenly attacked by the body's own immune system. Patients have antibodies in....

Revisiting Unrelated Surgical Procedures (MS-DRGs 981-989)

Author: Wilson, Donna D

Source: CodeWrite

Publication Date: February 2016



Make a fresh start in the new year by revamping coding compliance plans to include a second level review of all claims that group into MS-DRGs 981-989 (Operating Room Procedure/Unrelated to Principal Diagnosis). Historically, MS-DRGs 981-989 have been "low hanging fruit" for outside audito....

Review of E/M Guidelines

Author:

Source: Brief Encounter

Publication Date: July 02, 2001


The Evaluation and Management guidelines are found in the Medicare Carriers Manual in the following sections. You may download the entire manual from the Center for Medicare and Medicaid Services or CMS (formerly HCFA) Web site by going to http://www.hcfa.gov/, click on Medicare, select laws an....

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.

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....

Reporting and Sequencing of V Codes

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2013



A few months ago, the Centers for Medicare and Medicaid Services (CMS) published the Inpatient Prospective Payment System fiscal year 2014 proposed rule. One of the proposals concerns ICD-9-CM code V45.88 for Tissue Plasminogen Activator (tPA) administration within 24 hours prior to admi....

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....

Recovery Audit Program Changes

Author: Wilson, Donna D

Source: CodeWrite

Publication Date: February 2015



Editor's note: The Centers for Medicare and Medicaid Services (CMS) has delayed the commencement of work under the Recovery Audit contract for durable medical equipment (DME), home health (HH), and hospice reviews. For more information and further updates on this new development, please s....

Ready, Set, Automate: Preparing for Automation in Coding Workflows

Author: Peterson, Kathleen; Smith, Gail I.; Phibbs, Kozie V.; Eminger, Heather; Giustina, Elizabeth

Source: Journal of AHIMA

Publication Date: July 2010



Coding departments are in training for a triathlon. They are swimming in regulations, cycling through changes in source documents, and running at breakneck speed to ICD-10-CM/PCS implementation. Luckily, new workflow “gear” is emerging that can help them improve endurance and e....

Reading the Fine Print on ICD-10 Conversions: Even Highly Automated Conversions Require Review

Author: Butler, Rhonda R.; Mills, Ronald E; Averill, Richard F.

Source: Journal of AHIMA

Publication Date: June 2011


Automation is a major help in converting to the ICD-10 code set, but it is not a magical solution. In fact, skipping a human review of converted systems exposes an organization to legal and financial risk.

People who are secondary users of coded medical records-who see only the resul....

Re-abstraction Studies to Assess Data Quality for Use in the Development of a Grouping Methodology

Author: Mitchell, Sandra; Bartoli, Holly

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Purpose

The purpose of this paper is to provide an overview of the data quality re-abstraction studies that have been conducted in Canada. These studies provide a baseline of reliability for clinical administrative data submitted to the Discharge Abstract Database (DAD). Canada began a s....

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....

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....

RAC Primer for LTC Facilities

Author: Leonard, Mary Ann

Source: Journal of AHIMA

Publication Date: January 2010



Last year the Centers for Medicare and Medicaid Services (CMS) began rolling out the Recovery Audit Contractor (RAC) program to all 50 states and all providers, including long-term care facilities. HIM professionals working in LTC facilities need to understand the basics of the program in....

Quick Take on Clearinghouses

Author: McLaughlin, Mark

Source: Journal of AHIMA

Publication Date: January 2001




HIPAA's provisions have brought healthcare clearinghouses into the spotlight. What is a clearinghouse, and how is its role affected by the new regulations? This article answers these questions.

A clearinghouse is typically used to collect, validate, and distribute insurance c....

Quest for Quality and Comparability in the National Healthcare Database: Announcing A Payer’s Guide to Health Care Data Quality and Integrity

Author: AHIMA Coding Policy and Strategy Committee

Source: Journal of AHIMA - Coding Notes

Publication Date: September 1996


As the computer-based patient record slowly becomes a reality, the need has never been greater for a national cooperative effort to recognize and apply uniform terminology and coding guidelines for both the clinical community and fiscal intermediaries. AHIMA’s Coding Policy and Strategy Commit....

Quality Clinical Documentation—A Costly Challenge

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: September 2009


The debate continues over how to reform healthcare while controlling costs and spending. The options are complex and controversial, and after decades of failed cost and spending control efforts, it’s not surprising that there is skepticism.

Reforming one of the world’s mo....

Quality at the Core

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 2002


Is your hospital getting ready for the Joint Commission’s core measures project? Some hospitals are already transmitting the necessary data as part of the pilot project. Here’s how they are handling the challenges and deriving benefits.
If you’re an HIM director, you prob....

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....

PRO-West's Payment Error Prevention Program

Author: Baron, Anne

Source: AHIMA Convention

Publication Date: October 10, 2001




Background

Beginning in 1997, the Office of the Inspector General (OIG) started conducting annual audits of Medicare billing practices. These audit results estimated that Medicare had paid more than $23 billion in incorrect payments in 1996 and more than $20 billion in 1997.....

Providers Join Hands to Tell Medicare What They Think about OPPS/APC Policies: Making Progress in Changing Future Rules and Regulations

Author: Shah, Jugna

Source: AHIMA Convention

Publication Date: October 15, 2004


The Provider Roundtable is the name of the group that I formed to offer an opportunity for providers to come together and communicate to Medicare about their day-to-day operational challenges under the Outpatient Prospective Payment System (OPPS). My hope was that, by engaging providers to bra....

Provider’s Condensed Resource for Revenue Cycle, Coding Tools, and More

Author: Clack, Crystal; Freeman, Rae; Lewis, Laquette

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2017


A cyclone of regulatory requirements for providers has officially touched down in the United States. The Affordable Care Act (ACA), Medicare Access and CHIP Reauthorization Act (MACRA), patient-centered medical home (PCMH), and value-based purchasing (VBP) initiatives are contributing to dramat....

Progress on ICD-10: Survey Shows Advances with Two Years to Go

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2011


With the ICD-10-CM/PCS deadline less than two years away, results of a recent AHIMA survey show that more organizations are getting their transitions in motion. In total, 85 percent of respondents to the August 2011 survey said that their organizations had begun work on ICD-10 planning and imp....

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....

Problem-Centered Care Delivery: How Interface Terminology Makes Standardized Health Information Possible

Author: Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank; Rose, Eric; Aldin, Greg

Source: Journal of AHIMA

Publication Date: July 2012




Terminologies ensure that the 'languages of medicine' can be understood by both humans and machines.



Electronic health records (EHRs) are the industry standard for documenting patient care. Industry initiatives and government legislation have facilitated EHR i....

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