377 results.
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Coding Root Operations with ICD-10-PCS: Understanding Drainage, Extirpation, and Fragmentation
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....
Coding Root Operations with ICD-10-PCS: Understanding Excision and Resection
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....
Coding Root Operations with ICD-10-PCS: Understanding Fusion, Alteration, and Creation
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
Coding Root Operations with ICD-10-PCS: Understanding Insertion, Supplement, and Removal
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....
Coding Root Operations with ICD-10-PCS- Understanding Restriction Occlusion and Dilation
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....
Coding Root Operations with ICD-10-PCS: Understanding Transplantation, Reattachment, Transfer, and Reposition
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....
Coding Sepsis and SIRS
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....
Coding’s Impact on Suicide Prevention
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....
Coding Technology Today: AHIMA Survey Sheds Light on Coding's Progress toward Automation
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....
Coding Under the HIPAA Umbrella
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....
Coding UTI to Sepsis in ICD-9-CM and ICD-10-CM
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....
Coding Worldwide: Gain a Global Perspective with IFHRO
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....
Committee Considers ICD-9-CM Changes for 2002
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....
Committee Debates ICD-10-PCS Implementation
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....
Communication with a Side of Encouragement, Please: Effective Communication Strategies for a Smooth CDI Program implementation Transition
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....
Continuing on the Intriguing ICD-10 Journey
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....
Covering the Bases of Coding Compliance
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....
CPT-5 Supports Performance Measurement, Technology
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....
CPT Category III Codes Cover New, Emerging Technologies: New Codes Developed to Address Issues in Light of HIPAA
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....
CPT Changes for 2000
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....
CPT Changes for 2001
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:....
CPT Changes for 2002
Author: O'Hara, Karen
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2002
Coders need to keep their resources currentincluding 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....
CPT Code Updates for 2012
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....
CPT Code Updates for 2013
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....
CPT Receives Update for 2014
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....
CPT Update 2011
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....
CPT Updates for CY 2015
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....
CY 2011 Changes to the Hospital OPPS
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....
CY 2012 OPPS Update
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....
CY 2013 OPPS Update
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....
CY 2017 OPPS Update
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....
CY 2018 OPPS Update
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....
Dangerous E/M Coding Practices: Identifying and Remedying Common Sources
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.....
Data Analytics: The Power of Coded Data
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....
Data Capture for Performance Measures: What Coders Need to Know
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....
Deciphering Dialysis Access Maintenance Coding
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....
Determining Surgical Complications
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.
Developing a Coding Quality Improvement Program
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....
Developing an ICD-10-CM/PCS Coder Training Strategy
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....
Developing Facility-specific Productivity Measures
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....
Device or No Device? Coding Impella/IABP External Ventricular Support and the Impact on MS-DRG Assignment
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....
Differentiating Procedure Approach in ICD-10-PCS: Fifth Character Captures Specificity
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....
Dissecting the Operative Report for Accurate ICD-10-PCS Code Assignment
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.
Diverse Local Group Collaborates on Compliance Issues: Workgroup Focuses on Code Sets, Transactions
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 Iowas 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....
DIY: Grow Your Own Coders. Organizations Develop Programs to Internally Cultivate Coders
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....
Documenting Pharmacogenomic Testing with CPT Codes
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....
Don’t Let Preventable CPT Coding Mistakes Cause Heartburn
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....
Do You Want Fries With That? Decoding All the 'Extras' in Physician Visits
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....
DRG Changes for FY 2006
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....
DRG Grouping and ICD-10-CM/PCS
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....
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