Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2002

The future of coding systems in healthcare transactions is brighter than many might think. Because of the rapid changes in healthcare services, technology, and the industry as a whole, there are more coding systems emerging that may affect the work of clinical coding professionals in the futur....

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2001

Is the Web a part of your work day? Make sure it is. From purchasing products to distance learning to online coding, coding professionals can find all kinds of resources online to meet their needs.

A Look at the Future

In a recent survey, health system CEOs were ask....

Author: Batres, Janie

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2012

With emerging technologies like electronic health record systems (EHRs) and computer-assisted coding (CAC) gaining traction in the healthcare industry, coding professionals are being presented with more challenges and opportunities than ever before. The shift from paper-based records to electr....

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2001

Feeling the pain of claims processing with backlogs and high dollar amounts in accounts receivable? Is your practice at risk for fraud and federal sanctions? Coding and claims processing software may be the antidote to medical practice business ailments. There are several products ava....

Author: Cox, William G.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2004

Effective January 1, 1988, a provision of the Balanced Budget Act of 1977 (Section 4511) removed restrictions on settings where nurse practitioners, physician assistants, and clinical nurse specialists provide services. The definition of a clinical nurse specialist was also modified to requir....

Author: Huff-Allen, Angela; Wills-Dubose, Sarah

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004

Millions of people are afflicted with chronic sinusitis annually. Most patients can be effectively treated with antibiotics, but for those who cannot, surgery is often recommended.
Endoscopic sinus surgery (ESS) is one of the fastest growing procedures performed in the field of otolaryng....

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2012

There is much to do before we reach ICD-10 go-live in our organizations-including engaging the medical staff. Physician engagement is important in all healthcare settings and initiatives, but it will be essential in an organization's successful transition to ICD-10.

Obtaining engage....

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2011

Coding malnutrition has always been a challenge, especially since MS-DRGs were implemented. However, with Recovery Audit Contractors and other regulatory auditing being initiated across the country, providers and HIM professionals must be proactive rather than reactive when coding this conditi....

Author: Bryant, Gloryanne H.

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

Publication Date: November 2007

This year the Office of Inspector General (OIG) issued two reports relating to wound care services and Medicare payments. As the OIG has included wound care services as part of its 2007 work plan, coding and HIM professionals should review each report and re-assess their organization̵....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012

More and more HIM department managers are turning to remote coding. However, before implementing this staffing model, managers must answer several questions regarding the privacy and security of patient information, including:
What are the compliance risks?
How will privacy and secu....

Author: Lopez, Barbara A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010

Establishing a clinical documentation improvement (CDI) program is an organization-wide, transformational process that affects a hospital’s culture, reaching across all disciplines and touching every colleague and the way they perform their jobs. Many factors can lead healthcare organizations....

Author: Austin, Peg; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2001

Data quality has never been more scrutinized than it is today. Health Care Financing Administration rules and contractual obligations from various insurance companies complicate the notion of correct coding. At the same time, numerous trade associations publish coding guidelines that....

Author: Gibbs, Sally

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

Publication Date: February 2017

How does a healthcare system with 24 hospitals, 40 physician offices, and 50 free-standing ambulatory surgery centers that spans from the entire state of California to just over the Oregon border continue to keep their coding and billing staff current with the latest coding guidelines and....

Author: Land, Daniel

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

Publication Date: February 2016

On October 1, 2015 the updates to the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting went into effect. There were no changes to the ICD-10-CM Guidelines at that time. Fifty new ICD-10-PCS codes were added, which brings the total to 71,974 PCS codes for FY 2016. Thir....

Author: D'Amato, Cheryl; Garrett, Gail S.; Johnson, Laurie M.

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

Publication Date: November 2007

The final rule for the fiscal year 2008 inpatient prospective payment system (IPPS) went into effect October 1, 2007. The rule includes ICD-9-CM code changes, implementation of the new Medicare severity-adjusted (MS) DRG system, and a number of quality-related changes that affect how Medic....

Author: Linder, Karen M

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

Publication Date: April 2016

Rochester Regional Health is an integrated health services organization serving the people of western New York and the Finger Lakes region. The system provides care from 150 locations, including five hospitals; more than 100 primary and specialty practices, rehabilitation centers, and ambu....

Author: Ward, Maria

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

Publication Date: November 2017

Every year as the summer months arrive, coding professionals, healthcare providers, documentation improvement specialists, and other healthcare professionals wait expectantly for the release of all the Centers for Medicare and Medicaid Services (CMS) coding updates. This year is no differe....

Author: Wilson, Donna D

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2009

The Centers for Medicare and Medicaid Services (CMS) expects to have four Recovery Audit Contractors (RACs) operating by 2010. Each RAC will be responsible for identifying overpayments and underpayments in a region of the country. Based on the results of the demonstration program, the permanen....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2013

With the oncoming swell of ICD-10-CM/PCS (ICD-10) and computer-assisted coding (CAC), coders may be wondering what the future holds for their career. Some worry that the transition to ICD-10 will be very challenging for long-term coders who have been using ICD-9-CM for several decades. The....

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2004

The physician section of the 2004 OIG work plan includes a focus on appropriate use of modifiers used to bypass National Correct Coding Initiative edits and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedur....

Author: Hutchinson, Mark R.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2003

There are 206 bones in the human body and each is susceptible to fracture. The choices in fracture management are complex and based on a number of issues including fracture type, fracture pattern, specific bone, age of fracture, age of patient, associated injuries, and physician preference. Co....

Author: Fortune, Nicola

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2004

The International Classification of Functioning, Disability, and Health (ICF) provides a framework for the conceptualization, classification, and measurement of human functioning and disability. The World Health Assembly endorsed the ICF in May 2001.1 It is now recognized as a reference membe....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2004

V codes, described in the ICD-9-CM chapter “Supplementary Classification of Factors Influencing Health Status and Contact with Health Services,” are often misunderstood in reporting healthcare services. These codes are designed for occasions when circumstances other than a disease....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2011

Editor's note: This column supercedes the February 2004 article "From V Codes to Z Codes: Transitioning to ICD-10."

V codes, described in the ICD-9-CM chapter "Supplementary Classification of Factors Influencing Health Status and Contact with Health Services," are designed for occasi....

Author: Johnson, Laurie M.; Garrett, Gail S.

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

Publication Date: November 2006

The Inpatient Prospective Payment System (IPPS) final rule for fiscal year 2007 will prove challenging for inpatient providers. The rule (published in the August 18 Federal Register and available at www.access.gpo.gov/su_docs/fedreg/a060818c.html) includes some of the most comprehensive changes....

Author: Schwab, Linda

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008

The final rule for the FY 2009 hospital inpatient prospective payment system (IPPS) went into effect October 1, 2008. Although there are relatively few changes to MS-DRGs and the complication and comorbidity (CC) and major CC (MCC) lists, the final rule signals that the Centers for Medicare an....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2009

The final rule for the FY 2010 Hospital Inpatient Prospective Payment System was released on July 31, 2009. Changes in the rule went into effect with inpatient discharges of October 1, 2009, and are reflected in Grouper Version 27.0.

The changes to MS-DRGs and the complication and co....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010

The final rule for the FY 2011 Hospital Inpatient Prospective Payment System was released July 30, 2010. Changes in the rule went into effect with October 1, 2010, inpatient discharges.

The changes to MS-DRGs and the complication and comorbidity (CC) and major complication and comorb....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2011

The final rule for the FY 2012 Hospital Inpatient Prospective Payment System was released August 1, 2011. Changes in the rule went into effect with October 1, 2011, inpatient discharges.
MS-DRG Documentation and Coding Adjustment

The Centers for Medicare and Medicaid Services....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012

Limited updates were made to ICD-10-PCS for fiscal year 2012 as set forth under the partial code freeze established by the ICD-9-CM Coordination and Maintenance Committee.1 The freeze is intended to aid the transition to the new code set by limiting updates for 2012 and 2013 to essential chan....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2013

Updates have been released for the 2013 ICD-10-CM code set, approved by the ICD-9-CM Coordination and Maintenance Committee, as well as the 2013 ICD-10-CM/PCS updates maintained by the Centers for Medicare and Medicaid Services (CMS). There were minimal changes to the draft code sets in li....

Author: Clack, Crystal

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

Publication Date: February 2016

When the first edition of the Current Procedural Terminology (CPT) was released in 1966, there were only 3,554 codes. In 2016, CPT, published by the American Medical Association (AMA), is celebrating its 50th birthday with 10,000 CPT codes. This year’s CPT updates include 140 codes added,....

Author: Rugg, Donna

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

Publication Date: November 2016

The ICD-10 Coordination and Maintenance Committee’s code freeze, first implemented after the October 1, 2011 annual update, has finally thawed. For fiscal year (FY) 2017 the ICD-10-CM classification is back on track with annual code and guideline updates. Due to the thousands of new/....

Author: Ward, Maria

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

Publication Date: November 2016

Many changes come with the first update of the new ICD-10 Procedure Coding System (ICD-10-PCS) for fiscal year (FY) 2017. The higher-than-usual volume of changes was to be expected since the update system has been in a holding pattern for several years due to implementation delays. And al....

Author: Linder, Karen M

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

Publication Date: November 2017

Fiscal year (FY) 2018 ICD-10-CM updates will keep coding professionals busy with approximately 360 new codes, 142 deletions, and 226 code revisions posted by the National Center for Health Statistics (NCHS) on the Centers for Disease Control and Prevention (CDC) website. Due to the numerou....

Author: Johnson, Laurie M.

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

Publication Date: November 2018

By Laurie M. Johnson, MS, RHIA, FAHIMA


Since the implementation of ICD-10-CM/PCS in October 2015, the periodic coding updates have included many changes. For FY 2019, the diagnosis update includes a more manageable number: 279 new codes, 143 revised....

Author: Reed, Diana

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

Publication Date: January 2015

When it comes to converting superbills and claims from ICD-9-CM to ICD-10-CM, many healthcare providers believe that general equivalence mappings (GEMs) offer a cost effective and simple solution. The ability to purchase relatively cheap automated mappings of specialties’ top codes c....

Author: Blackford, Gwendolyn; Whitehouse, Rosanne

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

Publication Date: October 2007

Obtaining codeable clinical documentation at the point of care in a large teaching facility can be challenging. However, the HIM department at the University of Michigan Health System (UMHS) in Ann Arbor, MI, took on the task, implementing a clinical documentation improvement program (CDI....

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: January 1997

Under DRGs, coding enjoys considerable status and prestige due to its direct impact on an acute care facility’s financial success. In an era of major changes in our healthcare delivery system and reimbursement methodologies, will the limelight gradually shift away from coding to something else....

Author: Deakle, Mary S; DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013

Several changes to the prospective payment system went into effect at the start of 2013, including coding changes affecting the M1024 Rule.


Reimbursement for home healthcare agencies (HHA) was converted to a prospective payment system by the Centers for Medicare and Medicaid....

Author: Romano, Patrick S.; Elixhauser, Anne; McDonald, Kathryn M; Miller, Marlene R

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2002

Two years ago, the Institute of Medicine (IOM) published “To Err Is Human,” describing the enormous burden of medical errors in the United States.1 It was estimated that deaths due to medical errors exceeded deaths from motor vehicle accidents, breast cancer, or AIDS and that the cos....

Author: Blevins, Ida K.

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

Publication Date: October 2006

Home health agencies are required to use the ICD-9-CM Official Guidelines for Coding and Reporting for Medicare Outcome and Assessment Information Set (OASIS) reporting for MO230 (principal/primary listed diagnosis) and MO240a–MO240f (secondary/additional diagnoses). The stipulation too....

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2008

The long-anticipated update to the Home Health Prospective Payment System (PPS), released in the August 29, 2007, Federal Register, goes into effect January 1, 2008. The final rule encompasses a wide range of changes for home health agencies.
An Overview of the Final Rule
....

Author: Haik, William E

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

Publication Date: February 2015

It is a well known fact that ICD-9-CM diagnosis and procedure codes impact hospital reimbursement and compliance. But there is an additional code that often flies under the radar—the discharge status code. Inaccurate discharge status code assignments for Medicare post-acute care transfers....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2014

With only a few weeks left in 2013, the Hospital Outpatient Prospective Payment System (OPPS) final rule for calendar year (CY) 2014 was released on November 27, 2013 and went into effect on January 1, 2014. The final rule is normally provided to the public around the first week of Novemb....

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: June 2015

All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.

ICD-10-PCS Scope of Work


On October 1, 2015, hospital inpatient pr....

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2000

Determining when a symptom, definitive diagnosis, or both should be coded can be challenging for coding professionals. This challenge is complicated by the varying rules regarding the coding of symptoms versus definitive diagnoses, according to the type of encounter and the particular service r....

Author: Orenstein, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2003

In the past 10 years, coronary stenting has become an effective technique for percutaneous treatment of atherosclerotic heart disease. Although stenting has successfully reduced the rate of restenosis, the incidence of in-stent restenosis continues to be a major complication of the procedure.....

Author: Land, Daniel

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

Publication Date: October 2017

Coding professionals are the guardians of the patient’s story; they translate the language of medicine into coded data. The accuracy of this translation is essential for many reasons beyond today’s reimbursement. Coded data is used for clinical decision making, healthcare polic....

Author: Kostick, Karen M.

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

Publication Date: May 2016

On October 1, 2015, the ICD-10-CM coding classification was implemented in the United States. This article provides a coding update on how to report injuries resulting from terrorism, which is now classifiable under ICD-10-CM. In the US, ICD-10 (mortality coding) and ICD-10-CM (morbidity c....