Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2013

Editor’s note: This is the third in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.

The implementation of ICD-10-PCS will challenge the skills of coders-it contains many unique features and provides an opportunity to truly reflect the complexity of....

Author: Scott, Karen S.

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2013

ICD-10-PCS will bring about many changes and challenges for coding professionals. It is important for those involved in coding to start preparing today for the many unique features of the coding system. One of the keys to understanding ICD-10-PCS is the many new definitions and description....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2014

With this article the Journal of AHIMA concludes its 10-part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This installment focuses on three root operations in the Medical and Surgical Section that define other objectives:

• Fusion
• Alteration
• Creation

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2014

Editor’s note: This is the eighth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.


In this article, the Journal of AHIMA continues the 10-part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This article will describe three....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2013

Editor’s note: This article is the sixth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.


With the upcoming implementation of ICD-10-PCS, there are new definitions and descriptions used to describe the procedures performed. Coding professiona....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2013

Editor's note: This is the fifth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.


In the Journal of AHIMA's continuing Coding Notes series focusing on the 31 root operations of ICD-10-PCS, this article will focus on the definitions of four root ope....

Author: Wiedemann, Lou Ann

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

Publication Date: April 2007

Coding a chart with a sepsis diagnosis can prove challenging for coders. The coding guidelines for sepsis as well as ambiguous provider documentation can often mean an extended length of time reviewing a chart only to place it on hold for a physician query. This column outlines the clinic....

Author: Hansen, Abby

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

Publication Date: September 2018

By Abby Hansen, MHA, RHIA, CCS, CCS-P


The Centers for Disease Control and Prevention (CDC) reports that suicide rates have increased by more than 30 percent since 1999. In 2014, suicides accounted for 42,773 deaths in the United States; 2015....

Author: Friedman, Beth

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

Publication Date: April 2006

In 1999 an AHIMA task force predicted coding's future using four scenarios based on advances in technology, management, the regulatory environment, and consumer awareness. These scenarios suggested that by 2010, the coder's role would include clinical nosology (classification of dise....

Author: Russo, Ruthann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2001

Although coding professionals are not ultimately responsible for ensuring appropriate release of patient-protected information, it is important that they understand that coded data is not only one of the most desired pieces of information in the patient’s record, it is also the....

Author: Boyle, Ginger; Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2011

Multiple factors contribute to urinary tract infections (UTIs); common causes are aging and medications, especially in combination.

Aging is associated with changes in kidney structure and muscle strength. The kidneys lose their ability to filter waste from the blood. Muscles in the....

Author: Brouch, Kathy L.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2002

Many HIM professionals may not know that there is an international health records organization, but the International Federation of Health Records Organizations (IFHRO) has been in existence since 1968.


The Federation presents great opportunities for AHIMA members who wish to b....

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2001

by Sue Prophet, RHIA, CCS



The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Health Care Financing Administration (HCFA), met on November 17, 2000, in Baltimore, MD. Donna Pickett, RHIA, from NCHS, and Patri....

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2001

Proposed changes, if approved, would not become effective until October 1, 2002.

The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Fina....

Author: Flood, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2012

Clinical documentation improvement (CDI) programs are spreading rapidly across the United States-and for good reason. They help facilities improve the level of documentation that goes into the patient medical record, leading to fewer errors and an overall improvement for continuity of care. Bu....

Author: Bielby, Judy A

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

Publication Date: May 2016

In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States wo....

Author: Hapner, Peggy

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2001

As HIM professionals already know, data quality-one of the basic tenets of compliance-depends on comprehensive documentation and accurate code assignments. Because coding plays a major role in payment, reporting data accurately, managing data flow and data collection, and training st....

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2001

Among the needs the CPT-5 Project addresses are changes to enhance the use of CPT by practicing physicians, managed care and other payer organizations, and researchers. The project has made recommendations for improvements in the structure and processes of the CPT codes with deliberate emphasi....

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003

In 1998, the American Medical Association (AMA) initiated the CPT-5 Project. This project was a broad-based and comprehensive effort to make needed and practical enhancements to the CPT code set that would address challenges presented by emerging user needs and HIPAA. One of the initiatives tha....

Author: Kirschner, Celeste G.; Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2000

The American Medical Association's CPT 2000 Coding Symposium was held recently in Chicago to discuss the more than 300 revisions in the 2000 Current Procedural Terminology (CPT). Here is a brief summary of the changes. 
A complete listing of the code and guideline changes can be foun....

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2001

CPT 2001 Professional Edition (CPT® 2001) is complete and should be landing on your desk soon. As an introduction to the new book, this article provides a brief summary of the changes in 2001. A complete listing of the code and guideline changes can be found in CPT Changes 2001:....

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2002

Coders need to keep their resources current—including updating the Current Procedural Terminology (CPT) codes every year with the annual CPT book. This article provides a brief summary of the changes made to the CPT 2002 code set. The complete list of changes can be found in Appendix B of....

Author: O’Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012

The 2012 updates to the CPT code set include 278 new codes, 139 code revisions, and 98 code deletions. This brings the total number of CPT codes to 9,641.

All major sections of the CPT code set, as well as the introduction and appendix A, have undergone changes. Beginning with the i....

Author: Miller, Jackie

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013

The CPT code set has undergone extensive revisions for 2013, with codes, guidelines, and modifiers being revamped and updated. HIM coding professionals should download and review the CPT 2013 errata on the AMA website before starting to use the new codes. This download can be accessed at w....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2014

On January 1, 2014, the American Medical Association’s Current Procedural Terminology (CPT) was updated with additions, revisions, and deletions. In total, 175 new codes were added, 107 codes were revised, and 47 codes were deleted. In addition, editorial changes and coding guideline addi....

Author: Smith, Gail I.; Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2011

Each year CPT adds codes to reflect new procedures and surgical techniques. For example, new codes were added in the surgical section to identify procedures performed using balloon catheters.

In addition, CPT continues to make editorial changes and add coding guidelines within the t....

Author: Buttner, Patty

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

Publication Date: February 2015

On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....

Author: Karban, Karen M

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2011

The final rule for the calendar year 2011 Hospital Outpatient Prospective Payment System (OPPS) was released November 24, 2010. Changes in the rule went into effect with January 1, 2011, outpatient hospital-based services.

The changes to OPPS continue to reflect packaging adjustments....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012

The final rule for calendar year 2012 Hospital Outpatient Prospective Payment System (OPPS) was released on November 30, 2011. The rule went into effect for outpatient hospital-based services January 1, 2012.

This article outlines the updates in the final rule.
Financial Impact....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013

As 2012 drew to a close, US healthcare facilities began the daunting task of reviewing the Centers for Medicare and Medicaid Services’ (CMS) hospital outpatient prospective payment system (OPPS) update to ensure their chargemaster and systems were up-to-date with the 2013 changes. Th....

Author: Comfort, Angie

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

Publication Date: February 2017

As last year drew to a close, facilities began the looming task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule to ensure their chargemaster and systems were up-to-date with the 2017 changes. The final rule for calendar year (CY) 2017 was released on Novem....

Author: Sanvik, Gina

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2018

Untitled Document



CY 2018 OPPS Update


By Gina Sanvik, MS, RHIA


Facilities had the ominous task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule at the beginning of the year to ensure their chargemaste....

Author: Stanfill, Mary H

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

Publication Date: March 2006

Code assignment for physician evaluation and management (E/M) services is inherently problematic because of the multiple coding rules and reporting guidelines that must be applied and the subjectivity of the codes. Consistent E/M coding practices are critical in the physician practice setting.....

Author: Thomas, Felicia A; Harding, Wahiyda A

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

Publication Date: October 2018

By Felicia A. Thomas, RHIT, CCS, CPC, CIC, CPC-I, CCDS, and Wahiyda Harding, MSA, RHIA, CCS


To understand the power of coded data, let’s first take a look at its definition. Data analytics is the science of examining raw data with the purpose of drawing conclus....

Author: Hoag, Patience J.

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

Publication Date: January 2007

These days, cost control, efficiency of care, and quality outcomes are hot topics in every healthcare setting. One way to achieve quality outcomes and cost-efficient healthcare is through performance measures. This article provides a brief overview of HEDIS® and other performance measures....

Author: Buck, Stacie L

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2008

One year after the introduction of two new HCPCS codes for dialysis declotting procedures, confusion remains as to when to report these codes and how to report them in conjunction with other interventions performed during dialysis access maintenance. This article discusses the many facets of d....

Author: Bronnert, June

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

Publication Date: July 2006

All surgical procedures involve potential risks, which is why patients are asked to sign an informed consent. Conditions that arise after a procedure may be considered complications. Coding professionals must be able to determine if a condition is a complication per ICD-9-CM guidelines.

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2012

The increased need for accurate coded data for healthcare delivery, reimbursement, compliance, and regulatory accountability has brought about a corresponding need for data quality monitoring and regular evaluation programs. Maintaining data quality is an ongoing effort that affects many aspec....

Author: Majerowicz, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2011

Although the ICD-10-CM/PCS implementation deadline is two and a half years away, it is not too early to begin planning coder training. Solid training plans will ensure a smooth transition and minimize the transition's impact on productivity. A well-planned training strategy will ensure that co....

Author: Dunn, Rose T

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2001

Coder productivity has become a popular topic among coders and HIM department managers and is frequently discussed on bulletin boards and listservs. Unfortunately, during the last few years, especially with the advent of APCs, it has become more difficult to establish productivity m....

Author: DeVoe, Megan

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

Publication Date: June 2017

The Impella® device (2.5 and 5.0) provides percutaneous external ventricular support for high-risk patients who cannot undergo traditional open cardiovascular procedures in the inpatient hospital setting. Like intra-aortic balloon pumps (IABPs) that have been used for decades, these de....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2009

One of ICD-10-PCS’s goals is to ensure a complete picture of a patient’s procedure. Completeness means that there is a unique code for all substantially different procedures, including the same procedure performed using a different approach.

All ICD-10-PCS codes are seven....

Author: DeVault, Kathryn

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

Publication Date: June 2016

The implementation of ICD-10-PCS has created new challenges in coding surgical procedures. While coding professionals have always been expected to read and interpret all surgical documentation, ICD-10-PCS has increased the level of understanding necessary for accurate code assignment.

Author: Becker, Joanne

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2003

Sometimes starting small can mean big results. A few months ago, I joined Iowa’s regional HIPAA Strategic National Implementation Process (SNIP) workgroup. The goal of local and regional SNIP workgroups is to create as much collaboration as possible to ensure compliance by all covered ent....

Author: Endicott, Melanie

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

Publication Date: April 2014

There are two major challenges currently plaguing the coder workforce. The first is new graduates are finding it difficult to land jobs due to a lack of experience. Second, healthcare organizations are struggling to recruit experienced coders to fill vacancies.


Recruiting....

Author: Hefti, Erik ; Blanco, Javier G

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

Publication Date: January 2016

The “personalized medicine” paradigm is at the forefront of discussions about the future of healthcare, and a wealth of new data concerning how human genetic variation contributes to drug response has the potential to change the practice of medicine. The promise of treating pat....

Author: Clack, Crystal

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

Publication Date: November 2015

Every medical practice should have preventive measures in place to avoid costly coding and billing audits, errors, and subsequent delays in payment. Incorrectly coded claims, missing charges on a patient encounter, and other mistakes can take a substantial bite out of both practice and ph....

Author: Davies, Sharon

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

Publication Date: September 2016

Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the p....

Author: Leary, Renee; D'Amato, Cheryl

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2005

The final Medicare DRG changes for fiscal year (FY) 2006, which were published in the August 12, 2005, Federal Register, include 16 new DRGs, the deletion of 10 existing DRGs, and numerous changes to DRG assignments of current diagnosis and procedure codes. These DRG changes, along with other....

Author: Foley, Margaret M.

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

Publication Date: July 2015

Prior to the October 1, 2015 implementation of ICD-10-CM/PCS, every hospital must examine how the new code set will impact MS-DRG reimbursement. A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimburs....