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Preventive Services Modifier: Just the Facts

Author: AHIMA Staff

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2011


The American Medical Association introduced a new CPT® modifier earlier this year. The use of modifier 33 is effective January 1. However, this new modifier is not found in the 2011 CPT® codebook, which has caused some confusion. This table provides some facts and resources about this new modif....

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....

Preparing the Physician Office for HIPAA

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2001




Change has been a constant factor in coding and reimbursement with the intensified focus on billing, compliance, and cost control. Out of necessity, coding professionals in physician settings have learned to be organized, adaptable, and armed with the latest information. The mandates....

Preparing for the ICD-10 Journey

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: March 2004



After years of doubt as to whether ICD-10 was ever going to be implemented in the United States, the journey toward replacement of ICD-9-CM has finally gotten under way. The historic decision of the National Committee on Vital and Health Statistics (NCVHS) to send a letter to the Secretar....

Preparing for the CAC Transition

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2011


One of the biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the "use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare p....

Preparing for ICD-10- CM/PCS Implementation: Impact on Productivity and Quality

Author: Stanfill, Mary H; Hsieh, Kang Lin; Beal, Kathleen; Fenton, Susan H.

Source: Perspectives in Health Information Management

Publication Date: July 2014


Abstract


Coding productivity is expected to drop significantly during the lead-up to and in the initial stages of ICD-10-CM/PCS implementation, now expected to be delayed until October 1, 2015. This study examined the differences in coding productivity between ICD-9-CM and ICD-10-....

Preparing for ICD-10-CM in Physician Practices

Author: Kuehn, Lynn

Source: Journal of AHIMA

Publication Date: August 2009




What will change under ICD-10-CM, and what must be done to prepare? This is the year for physician practices to get their ducks in a row: become informed, assess their IT and training needs, and make a plan that leads to the October 1, 2013, deadline.



On September....

Preparing for ICD-10-CM: A Clinician's Perspective

Author: Rose, Eric

Source: Journal of AHIMA

Publication Date: July 2009


America’s physician practices are facing the biggest change in healthcare coding in decades: the replacement of ICD-9-CM by ICD-10-CM. This article discusses ICD-10-CM from a clinical perspective and reviews how electronic health record (EHR) systems will need to adapt to the transition.....

Preparing for Automated Coding

Author: Cummins, Ruth

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

On an ongoing basis, the coding staff and HIM management teams in healthcare facilities anticipate and prepare for changes in codes, coding guidelines, payment systems, and coding regulations. Additionally, the proposed upgrade of the coding classification system to ICD-10 is....

Practice Toolkit: Medicare Billing in Long-term Care

Author: Sims, Michelle

Source: Journal of AHIMA

Publication Date: June 2005


In order to accurately bill for long-term care, an organization must achieve consistency between the minimum data set (MDS) and the UB-92. The first step is to ensure compliance with the completion of the MDS. It is helpful to have a system that identifies the assessment reference date span an....

PPS + New Technology = Growing Pains

Author: Blumenthal, Jane E

Source: Journal of AHIMA

Publication Date: September 1999


It's been a little more than a year since the prospective payment system (PPS) came into play in skilled nursing facilities. The post-acute PPS, initiated by the federal government under the 1997 Balanced Budget Act, was set in place to reduce the federal government's healthcare expend....

Post ICD-10 Implementation: Where Are We Now?

Author: Maccariella-Hafey, Patricia C

Source: CodeWrite

Publication Date: November 2015



We heard deep sighs of relief as October 1, 2015, came and went and ICD-10 was finally implemented in the United States. This has been a long time coming for coding and documentation improvement professionals in the HIM world. At the time of this article's writing, we are two weeks into im....

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....

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....

Pitfalls in Endovascular Coding

Author: Zielske, David R.

Source: AHIMA Convention

Publication Date: October 15, 2004

Overview

Endovascular refers to those procedures that involve percutaneous access to the vascular system. Diagnostic angiography and interventional procedures, such as angioplasty, stent placement, embolization, and dialysis access maintenance, are some of the procedures performed. These....

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....

Physician Coding Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: September 2015

This provider practice coding toolkit provides multiple tools and resources to help providers successfully navigate through the many changes in today’s healthcare environment.

Performance Improvement for Documentation

Author: Labak, Carol

Source: Journal of AHIMA

Publication Date: October 1998


We've all seen it before: that look of bewilderment on a physician's face when a discussion about documentation arises. While this is not the first incidence of this discussion between the physician and the health information manager, neither is it the first time the HIM professional ....

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....

PEPP: Collaborating to Improve Quality

Author: Poole, Laurie

Source: Journal of AHIMA

Publication Date: April 2001




By collecting and analyzing information about Medicare payment errors, PEPP initiatives are making a contribution to healthcare quality efforts nationwide. Here's how one organization takes a collaborative approach to improving quality.
State Payment Error Prevention Programs (....

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.

Payout: Reviewing Meaningful Use Payments

Author: Viola, Allison F.; Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2010


CMS will pay meaningful use bonuses through three programs: Medicare Fee for Service (FFS), Medicare Advantage (MA), and Medicaid programs.
FFS Payments to Providers

For eligible professionals (EPs), understanding the payment system is especially important, because they must ch....

Payers Guide Articles

Author: AHIMA

Source: AHIMA bibliography

Publication Date: 2001


The Quest for Quality and Comparability in the National Healthcare Database: Announcing A Payer’s Guide to Health Care Data Quality and Integrity
by AHIMA’s Coding Policy and Strategy Committee

Summary of ICD-9-CM Coordination and Maintenance Committee Meeting
by Sue Prop....

Partnering with Revenue Cycle for Success

Author: Biesboer, Pat; Pace, Mary Anne

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

For any business to be successful, revenue must flow quickly and efficiently into the organization. In healthcare, the revenue cycle is complicated, and success can be elusive, but there are plenty of success stories to know that good marks are achievable. Challenges have be....

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....

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....

Overview of the ESRD PPS

Author: Nelson, Tanai S

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010


In August the Centers for Medicare and Medicaid Services established a new prospective payment system (PPS) for end-stage renal disease (ESRD) facilities. The ESRD PPS will provide a single payment to ESRD facilities for renal dialysis services and other items and services related to home dial....

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....

Optimizing Data Representation Through the Use of SNOMED CT

Author: Bronnert, June; Daube, Julie L; Jopp, Gretchen; Peterson, Kathleen; Rihanek, Theresa; Scichilone, Rita A; Tucker, Vanna

Source: Journal of AHIMA

Publication Date: March 2014

Electronic health records (EHR) have changed the landscape for data representation. For many years health information management (HIM) professionals have relied on classifications for data representation and the support of clinical documentation. SNOMED CT is a data standard frequently used in electronic systems and has been included in the requirements for the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR Incentive Program. SNOMED CT is maintained and distributed by the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED CT is recognized throughout the world, and the terminology is available at no cost. The National Library of Medicine (NLM) serves as the US release center and the IHTSDO member country representative.

Opportunities for HIM in Revenue Cycle Management

Author: Campbell, Thea

Source: Journal of AHIMA

Publication Date: November 2003


The pressure on all healthcare organizations for improved financial performance continued to grow in 2003. Many healthcare organizations experienced a financial loss in the first quarter of 2003, and disproportionate reimbursement-to-expenditure ratios in healthcare are straining all organizat....

Opening Pandora's Box: Pure Coding vs. Charge Master Driven Coding--a Case Study at Duke University Health System

Author: Stone, Fabian; Egan, Jeanne M.; LeBoutillier, Richard; Blackwelder, Dean

Source: AHIMA Convention

Publication Date: October 31, 2006

Opening Pandora’s Box: Pure Coding vs. Charge Master Driven Coding
A Case Study at Duke University Health System
Fabian Stone, MBA, MHA, Duke University Hospital
Jeanne Egan, MBA, RHIA, CHP, CCA, BearingPoint
Richard LeBoutillier, MPA, CPHQ, BearingPoint
Dean Blackwel....

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....

On the Line: Professional Practice Solutions

Author: Smith, Cheryl M.

Source: Journal of AHIMA

Publication Date: February 2001




Q: Where can I find information on the interpretation of Joint Commission on Accreditation of Healthcare Organization standards?

Q: How does the Health Insurance Portability and Accountability Act of 1996 (HIPAA) define health information in the final rule for healthcare elec....

Off-Site Coding Success Story

Author: Kramer, Lynette; Meeks, Richard

Source: Journal of AHIMA

Publication Date: January 2000


If you asked HIM professionals about key success factors that substantially impact timely and accurate coding, three of the most common answers might be:
availability of the record immediately after the patient visit
availability of the complete record....

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