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Clinical Documentation Improvement in the Outpatient Setting

Author: Arrowood, Danita; Johnson, Laurie M.; Wieczorek, Michelle M.

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

Publication Date: July 2015



Clinical documentation improvement (CDI) programs have proven their worth with over a decade of success and continued role expansion in the inpatient setting. As the healthcare industry prepares for new initiatives such as value-based purchasing, electronic health records (EHRs), and ICD-1....

Codes for Chronic Kidney Disease: Help in Distinguishing between Renal Failure and Renal Insufficiency

Author: Gold, Robert S.; Bowman, Sue E

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

Publication Date: January 2006


Coders assign codes to disease processes for many reasons, including capturing diseases treated at facilities, accurate representation of illness severity, and specificity of causes of symptoms and justification for treatment. To this end, we have been perplexed by terminology used by physicia....

Coding Complex Bariatric Surgery

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2005


Bariatric, or weight-loss, surgery is a rapidly evolving specialty. From jejunocolic and jejuno-ileal bypass procedures, through the days of minimally invasive procedures such as gastric balloons and endoscopic-banded gastroplasty, to today’s procedures that involve both gastroplasty and....

Coding Debridement Procedures

Author: McCullough, Dan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2008


Coding debridement procedures can be difficult-even for the most experienced coding professional. Recent studies have documented inappropriate coding of debridement procedures that have resulted in millions of dollars in overpayments.

This article offers guidance on the app....

Coding Dementia

Author: Laakso, Roz

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2004


Dementia is defined as “a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living.”1 Alzheimer’s disease is an age-related, irreversible brain disorder that occurs gradually and results in me....

Coding Diabetes Mellitus in ICD-10-CM: Improved Coding for Diabetes Mellitus Complements Present Medical Science

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2012


Results of a recent coding and clinical documentation pilot study indicate that the ICD-10-CM coding classification changes made for diabetes mellitus have significantly improved coding for this disease. The results of the study noted that although a few ICD-10-CM "unspecified" diabetes codes....

Coding Ethically

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2005


With the many reimbursement issues and regulatory requirements surrounding coding, it is sometimes necessary for coders to refamiliarize themselves with what it means to code ethically. AHIMA’s Coding Policy and Strategy Committee developed the Standards of Ethical Coding, which were app....

Coding for APCs: Case Studies

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2000


When APC implementation begins on August 1, HIM professionals can expect increased complexity when coding outpatient encounters. Examining case studies in selected areas subject to APC payment may help coding professionals better understand the APC reporting process. Although coding guidelines....

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....

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Measurement and Monitoring, Extracorporeal Assistance and Performance, and Extracorporeal Therapies

Author: Barta, Ann

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

Publication Date: May 2014



Editor’s note: This is the second in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.


In this article, the Journal of AHIMA continues its three part Coding Notes series focusing on the nine Medical and Surgical-related secti....

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Osteopathic, Other Procedures, and Chiropractic

Author: Barta, Ann

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

Publication Date: June 2014


Editor’s note: This is the third in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.

IN THIS ARTICLE, the Journal of AHIMA continues its three-part Coding Notes series focusing on the nine Medical and Surgical-related sections of ICD-10-PC....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: September 2014



Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: July 2014



Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....

Coding in Critical Access Hospitals

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2009


National health policy has been increasingly responsive to the healthcare needs of rural residents and providers. Rural America has a large percentage of the nation’s Medicare population, and this percentage continues to grow as residents born in the Baby Boomer generation begin to retir....

Coding Neoplasms in ICD-10-CM

Author: Bielby, Judy A

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2011


ICD-10-CM codes provide greater detail than ICD-9-CM codes for reporting neoplasms. In many instances, ICD-10-CM neoplasm codes can provide information on whether a neoplasm occurred in a right-sided or left-sided body part. ICD-10-CM also provides codes for reporting neoplasm sites with great....

Coding on the Home Front

Author: Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2002


Recently, a group of coders participated in a survey about their day-to-day experiences as remote, or at-home coders. The survey asked a series of questions related to the positives and negatives of coding at home versus coding in the more traditional office setting. Below is a summary of the....

Coding Open Fractures in ICD-10-CM

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2012


Fractures are a common medical malady, and coders encounter them often. But the differences between coding fractures in ICD-9-CM and ICD-10-CM are vast.

Upon implementation of ICD-10-CM the code system currently in place for fractures within ICD-9-CM will cease to exist, and a new,....

Coding Pregnancy

Author: Bronnert, June

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

Publication Date: October 2006


While science and research have shed light on the various stages of fetal development, the process is still fascinating. This article details each month of a fetus’s development and reviews common delivery complications and where related information may be documented in the record.
....

Coding Preventive Care Services

Author: Wilkinson, Dianne

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2008


According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....

Coding Radiology Services

Author: Walk, Gerri

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2009


Because coding and radiology departments often share accountability for the quality of outpatient radiology coding, it is important that coding professionals share coding issues and charge capture expectations with radiology staff. This article outlines methods to improve the quality of coded....

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