Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2001

The 2002 diagnosis related group (DRG) updates went into effect October 1, 2001. With the implementation of these changes to the hospital inpatient DRGs portion of the prospective payment system (PPS), there will be 499 DRGs in 25 Major Diagnostic Categories (MDCs).


Changes t....

Author: Willard, Dianne; Worthington, Debbie; Ashley, Patti

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2004

ICD-9-CM coding and DRG changes for fiscal year 2005 include 150 new diagnosis codes, 21 new V codes, 54 new procedure codes, 25 invalid diagnosis codes, and 3 new DRGs. The changes were released in the August 11 Federal Register and went into effect October 1, 2004, for discharges occurring o....

Author: Hull, Susan

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

Publication Date: January 2006

A number of changes to CPT codes take effect January 1, 2006. These changes affect category I, II, and III codes, with a total of 277 additions, 110 deletions, and 71 code revisions.
Evaluation and Management

Within the evaluation and management (E/M) section, the codes for fol....

Author: Wiedemann, Lou Ann; Zeisset, Ann M.

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

Publication Date: February 2007

A number of changes to the current CPT codes took effect on January 1, 2007. These changes affect categories I, II, and III codes, with a total of 258 additions, 308 deletions, and 79 revisions. A summary of all additions, deletions, and revisions can be found in appendix B of the 2007 C....

Author: Jorwic, Therese M

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2008

The new CPT codes took effect January 1, 2008. Changes include 244 additions, 314 revisions, and 50 deletions. A comprehensive list of changes can be found in appendix B of the CPT book. Highlights of the changes by section are outlined here.
Evaluation and Management

A revised....

Author: Majerowicz, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2009

Changes to CPT codes for 2009 include 293 additions, 133 revisions, and 92 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2009 CPT code manual. The changes took effect January 1.

E/M Codes


Nu....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2010

Changes to CPT codes for 2010 include 219 additions, 141 revisions, and 63 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2010 CPT coding book. The changes took effect January 1.
Resequencing

The most n....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2014

This article highlights the 2014 ICD-10-CM/PCS updates as approved by the ICD-9-CM Coordination and Maintenance Committee, which includes representatives from the Centers for Medicare and Medicaid Services and the National Center for Health Statistics. As a result of the partial code set....

Author: Huey, Kim

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

Publication Date: March 2017

The 2017 update to the CPT code set brings fewer new codes than in previous years but more guideline changes and clarifications, as well as revisions in code description. One Appendix is deleted and a new one is created. There are a total of 149 new CPT codes, 498 revised codes, and 81 del....

Author: Bruce, Tina MHIM, MHI, RHIA, CCS, CDIP

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

Publication Date: November 2018

By Tina Bruce, MHIM, MHI, RHIA, CCS, CDIP


Healthcare practices, clinical documentation improvement specialists, auditors, and coding professionals are on the edge of their seats anxiously awaiting the annual release of coding updates by the....

Author: Franklin, Janet

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

Publication Date: October 2014

There are three age-defined models under commercial risk adjustment. These are the Adult Model (ages 21 and up), the Child Model (ages 2–21), and the Infant Model (ages 0–1). The model applicable to a patient is dependent on their age at the end of the benefit year. If a 20-year-old patie....

Author: Hernandez, Jeannette

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008

Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.

By June 2....

Author: Franklin, Janet

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

Publication Date: September 2014

Known as the “Three Rs,” three mechanisms were included with the implementation of the Affordable Care Act (ACA) to reduce incentives insurers may have for avoiding the enrollment of high-cost members. The “Three Rs” are risk corridors, reinsurance, and risk adjustment.

Author: Combs, Tammy

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2018

By Tammy Combs, RN, MSN, CDIP, CCS, CCDS


Have you ever wondered what it means to be an effective communicator? In his article “Why Communication Is Today’s Most Important Skill,” Greg Satell discusses Michael Faraday, who helped tr....

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....

Author: Schraffenberger, Lou Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2008

On October 1, 2007, hospitals began reporting secondary diagnoses that were present on admission (POA). The POA indicator can be reported as Y, present on admission; N, not present on admission; U, unknown; or W, clinically undetermined.

Beginning October 1 of this year, N and U indi....

Author: Schraffenberger, Lou Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2008

Last October hospitals began reporting secondary diagnoses that were present on admission (POA). These indicators are reported as Y, present on admission; N, not present on admission; U, unknown; or W, clinically undetermined. Beginning October 1 of this year, N and U indicators will affect Me....

Author: Youmans, Karen; Scichilone, Rita A; Dougherty, Michelle

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2001

In the October 2000 Journal of AHIMA, we outlined the new home health care prospective payment system (PPS).1 Coding professionals working with home health providers have learned new terms and additional guidelines for reporting. However, confusion remains concerning code assignments, because s....

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....

Author: Peters, Robert; Wiedemann, Lou Ann

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

Publication Date: May 2007

Evaluation and management (E/M) codes were added to the CPT codebook in 1992 to classify physician services. Use of these codes increased when they became integral to physician practice reimbursement. E/M codes became a tool for practices to trend individual physician profiles and reimbursemen....

Author: Bowman, Sue E

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

Publication Date: January 2007

Reporting option “U” should not be routinely assigned and should be used in very limited circumstances. Coding professionals should query the provider when the documentation is unclear.
Medical record documentation from any provider involved in the care and treatment of the patient may be u....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2009

Two new E code sections go into effect October 1—E000, External Cause Status, and E001–E030, Activity. The sections will facilitate prevention strategies developed by epidemiologists and injury prevention specialists and bring ICD-9-CM E codes more in line with ICD-10-CM external c....

Author: Bronnert, June

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

Publication Date: March 2006

To code or not to code can be one of the toughest questions a coder faces on a day-to-day basis. Assigning the appropriate secondary diagnoses can be a challenge. This article describes appropriate coding of secondary diagnoses by reviewing documentation of a history and physical.

Un....

Author: Land, Daniel

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

Publication Date: October 2016

The complex and sophisticated nature of ICD-10-CM/PCS has increased both the intellectual demands on coding professionals and the importance of an educational approach to the audit process. On October 1, 2016 regular updates to ICD-10 will begin, marked by the introduction of over 5,500 n....

Author: Kuehn, Lynn

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2012

The human spine is a complex unit that combines the structures of both the nervous and musculoskeletal systems. Understanding the anatomy, terms and definitions, and procedure concepts associated with spinal surgery can make for a considerably smoother coding process.
Anatomy of the Spine....

Author: Barta, Ann

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

Publication Date: October 2016

The implementation of ICD-10-PCS has enhanced the skills of coding professionals as it contains many unique features that provide an opportunity to accurately reflect the complexity of the procedures being performed. The assignment of ICD-9-CM procedure codes for spinal fusions often chal....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2012

As organizations begin to prepare for ICD-10 implementation, the question of coder productivity is usually close to the top of everyone's list. Addressing productivity in ICD-9-CM will provide a baseline of information crucial for the transition to ICD-10-CM/PCS.

The AHIMA e-HIM Cod....

Author: Richmond, Rosalind; Chapman, Claudia; Cook, Jane; Levy, Brian

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2005

The health information technology (HIT) field can provide HIM professionals with many career opportunities at software and content companies. HIT roles require highly developed content analysis skills, including abstracting, coding, documentation compliance, and utilization review. The availab....

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....

Author: Bowman, Sue E

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

Publication Date: October 2007

Although the US continues to wait for an implementation date for ICD-10-CM and ICD-10-PCS, HIM professionals should maintain a basic familiarity with these new coding systems. This article provides an overview of ICD-10-PCS.
The Structure of ICD-10-PCS

ICD-10-PCS....

Author: Harris, Shelly; Kelly, Jeannie

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

Publication Date: October 2015

As the Centers for Medicare and Medicaid Services’ (CMS’) Probe and Educate Initiative draws to a close and the 2016 Outpatient Prospective Payment System (OPPS) proposed rules are released for comment, questions remain for the healthcare industry regarding expectations for selecting pati....

Author: Leonard, Janis

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

Publication Date: May 2017

Prior to the implementation of ICD-10-CM/PCS, Albany Medical Center (Albany), based in Albany, NY, was struggling with attracting qualified coding candidates. Despite recruitment efforts including sign-on bonuses and incentive pay, Albany was unable to maintain staffing levels to meet the....

Author: Maimone, Carol

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

Publication Date: March 2015

The Centers for Medicare and Medicaid Services (CMS) released a final rule providing required adjustments to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year (CY) 2015 on October 31, 2014.....

Author: Clack, Crystal

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

Publication Date: March 2016

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) finalized changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) payment system for calendar year (CY) 2016. The OPPS payment rates and policies impact approximately 4,000....

Author: Stanfill, Mary H

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

Publication Date: April 2015

The call for HIM professionals to develop measures and metrics that guide HIM efforts is not entirely new. Linda Kloss, MA, RHIA, FAHIMA, president of Kloss Strategic Advisors and former chief executive officer at AHIMA, discussed the importance of these measures in a Journal of AHIMA art....

Author: Warner, Homer R. Jr.

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2000

As HIM vendors strive to perfect automated coding, one supporting technology has reached an exciting stage of development. Natural language processing (NLP) is a major challenge for the computer industry because of the complexity and variability of human speech. NLP differs from simple word s....

Author: Nelson, Tanai S; Benjamin, Christina

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2009

Correctly coding casts, splints, and strapping can be confusing. Much of the confusion is related to what type of materials are classified as casts, splints, or strapping; whether the CPT application codes or the HCPCS level II codes should be assigned; and whether the work performed is includ....

Author: Merriweather, Kay; Slater, Leslie; Bohley, Michele

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

Publication Date: July 2017

“If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming the center of healthcare in th....

Author: Endicott, Melanie; Gardner, Amy

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2009

The HIM field continues to expand and change, opening up more opportunities for HIM practitioners to move out of the HIM department and into other areas of the hospital. Recent initiatives, such as ICD-10-CM/PCS, MS-DRGs, Hospital-Acquired Conditions, and Present on Admission reporting, have b....

Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi

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

Publication Date: January 2015

Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of detail....

Author: Herr, Victoria A.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2005

In fiscal year 2005, new ICD-9-CM codes were created for reporting cervical dysplasias and abnormal Pap smears. From a clinical perspective, the new codes and instructional notes align ICD-9-CM with current terminology used in diagnosing and reporting cellular abnormalities of the cervix. From....

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2002

Have you ever had a physician ask if you can put the encounter form on her hand-held computer? Or maybe the physicians in your medical group have been offered free personal digital assistants (PDAs) if they use a certain application and they want you to find out if these devices can expedite c....

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004

Changes for CPT 2004 affect all chapters, and it’s important to stay up to speed. This article presents a summary of CPT changes for 2004. Because a number of the procedures may be unfamiliar to some coding professionals, AHIMA has provided online links to descriptive articles on these s....

Author: Hull, Susan

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

Publication Date: April 2006

Governed by somewhat different rules than other acute care providers, long-term acute care (LTAC) hospitals represent a special segment of the provider market. This article reviews the definition of a LTAC hospital and discusses some of the special challenges facing HIM practitioners and codin....

Author: Pilato, Jeff

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2013

While the transition to ICD-10-CM/PCS has the potential to put revenue at risk, adding staff to the revenue cycle is rarely an option in today’s cost-cutting environment. There are no extra hands to review charges, double-check bills, or safeguard claims. To mitigate risk, preventive....

Author: Wiley, Sean

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003

One of the leading causes of stroke and transient ischemic attack (TIA) is carotid artery disease (CAD). With technology changing at such a rapid rate, it is difficult for physicians to decide on the gold standard of care when it comes to visualizing carotid stenosis. This article will explain....

Author: AHIMA Coding Policy and Strategy Committee

Source: Journal of AHIMA - Coding Notes

Publication Date: February 1999

[Please note: the content in this article is out of date. It is being updated by AHIMA's Clinical Terminology and Classification Practice Council]


Clinical data set, vocabulary, terminology, and classification system. We frequently hear, see, and speak these terms, but what....

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2008

The patient status code reflects the level of care a patient was discharged or transferred to when leaving an acute care hospital as an inpatient or outpatient (i.e., emergency department or emergency room). A recent Centers for Medicare and Medicaid Services MLN Matters publication provides a....

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2000

Coding for professional services is complicated enough when coding professionals are charged with assisting the physician to select the best five-digit number for the services rendered. It becomes even more complex when circumstances of the case require the CPT code to be modified. Add....

Author: Johnson, Laurie M.

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

Publication Date: September 2007

Coding infusions and injections has been a source of confusion and frustration since the Centers for Medicare and Medicaid Services (CMS) introduced C codes in 2006. However, in calendar year 2007, CMS made an about face and eliminated the C codes, reverting back to the published 2007 CPT....