377 results.
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Problem List Coding in e-HIM
Author: Fraser, Greg
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2005
In 1968 Larry Weed, MD, introduced the idea that a complete and accurate problem list is an essential component of the medical record.1 The problem-oriented medical record (POMR), in which all data contained in the medical record can be linked to a list of problems, has been almost universally....
Putting an End to Emergency Room Injection/Infusion Coding Confusion
Author: Clack, Crystal
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2016
Injection and Infusion CPT codes are a topic that many outpatient emergency room (ER) coding professionals would like to fantasize into a state of intergalactic oblivion, but the codes are here to stay. Injection and infusion codes cover only seven pages in the 975-page 2016 CPT coding boo....
Putting Productivity Plans to Work
Author: Dunn, Rose T
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2001
This is the last in a series of three "Coding Notes" articles addressing productivity measurement and incentive plans for coding professionals. The April Journal of AHIMA (vol. 72, no. 4) article discussed the general principles of developing facility-specific productivity m....
Quality Queries for Quality ICD-10-PCS Codes
Author: Maimone, Carol
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2016
Physician queries have historically been an effective communication tool used by health information management (HIM) coding professionals to clarify documentation in the health record for accurate code assignment. The goal for any coding professional is to have all final coded diagnoses an....
Quest for Quality and Comparability in the National Healthcare Database: Announcing A Payer’s Guide to Health Care Data Quality and Integrity
Author: AHIMA Coding Policy and Strategy Committee
Source: Journal of AHIMA - Coding Notes
Publication Date: September 1996
As the computer-based patient record slowly becomes a reality, the need has never been greater for a national cooperative effort to recognize and apply uniform terminology and coding guidelines for both the clinical community and fiscal intermediaries. AHIMA’s Coding Policy and Strategy Commit....
RAC Forensics 101. Part 1: Medical Record Requests and the Discussion Period
Author: Easterling, Sharon
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2011
Thirteen months after the Recovery Audit Contractor (RAC) process was implemented nationwide, healthcare organizations are still learning how to best manage the audit process. The initial reviews were automated, but since that time RACs have also begun complex coding reviews and medical necess....
RAC Forensics 101: Part 2: The Results Letter and the Discussion Call
Author: Easterling, Sharon
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2011
Healthcare organizations are still struggling to manage the Recovery Audit Contractor (RAC) process implemented last year. This article is the second in a series that discusses the provider portal, the discussion period, and the review results letter. Part 1, published in the January issue, di....
RAC Forensics 101Part 3: Denials Management
Author: Easterling, Sharon
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2011
The denials management process is the final step in the RAC process and can be the most time-consuming portion, depending on the circumstances of each case. Providers may appeal a RAC decision either through the discussion period or the formal Medicare Appeals Process.
Becoming know....
RAC Inpatient Coding Denials: Key Areas of Improper Payment in permanent program
Author: Wilson, Donna D
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2012
The Recovery Audit Contractor (RAC) demonstration program found that "most of the overpayment amounts collected by the RACs (about 85 percent) were from inpatient hospital providers," and "almost half of the improper payments were the result of incorrect coding."1 Things have changed with....
Reading Up on LOINC: What Coders Need to Know
Author: Sheide, Amy; Wilson, Patricia S
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2013
What do coders need to know about Logical Observation Identifiers Names and Codes (LOINC)? A health records coder is unlikely to come across a LOINC code when looking for the correct ICD-9-CM code to reflect the documentation provided. A compliance officer may not see a LOINC code when eva....
Reducing Outpatient Billed as Inpatient Errors
Author: Malone, Sue M.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2008
From 2006 to 2007, the Colorado Foundation for Medical Care (CFMC), the quality improvement organization (QIO) for Colorado, led a project to reduce the outpatient billed as inpatient billing error rate in five area hospitals. This article discusses the findings from the project, as well as be....
Reliable Coded Data Require a Reliable Coding Process Framework
Author: Bielby, Judy A
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: October 2014
A poorly managed coding process can thwart the effective use of coded diagnosis and procedure data. Take for example Hospital A, a fictitious hospital that does not effectively manage their coding processes. At this hospital, the coding professionals are concerned primarily with the impact....
Relieving the Shortage of Coding Professionals
Author: Uppena, Mary
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2000
As coding professionals move into management, other HIM-related professions, or retire, coding supervisors are left with staffing shortages that impede productivity. Record numbers of experienced coding professionals are and will be needed, and recruitment efforts to find this new staf....
Reporting Codes Accurately
Author: Giannangelo, Kathy
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2005
Coding professionals routinely review records and, when appropriate, query physicians to clarify a condition. Once the specifics are known, ICD-9-CM is used to determine the appropriate codes to record a patient’s diagnosis and report the healthcare claim. Coding professionals know that....
Reporting the Severity of Decubitus Ulcers
Author: Gronek, Julie A.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2005
Decubitus ulcers, commonly called pressure sores or bedsores, may range from a mild discoloration of the skin, which disappears in a few hours after repositioning, to a deep wound extending into the bone, which requires resource-intensive wound management.
Though the code for decubi....
Resolving Coding Issues for Coding Clinic: How the Editorial Advisory Board Answers Coding Questions
Author: Bower-Jernigan, Patricia L
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2008
Coding professionals rely on the American Hospital Association’s Coding Clinic to resolve issues and questions they have in their daily coding duties. Accordingly, the editorial advisory board process for resolving coding questions for Coding Clinic advice is extensive.
The pro....
Resolving Coding Questions: Where to Find Answers to Coding Questions
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2010
WHEN CODING Questions arise, coding professionals should evaluate all possible resources, including querying physicians, networking with other coding professionals, and seeking official coding advice. These techniques help ensure consistent healthcare diagnostic and procedure coding.
Reviewing Diagnostic Coding for Mental Disorders
Author: Albaum-Feinstein, Andrea L.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2000
Editor's note: This is the first part in a two-part series on diagnostic coding for mental healthcare. Part II will discuss the differences between DSM-IV and ICD-9-CM coding systems.
Coding and documentation and the development and implementation of an effective HIM compliance pro....
Reviewing the Details of Coding Septicemia
Author: Limjoco, Cesar M.; Youmans, Karen
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2000
In March 1999, the Office of Inspector General (OIG) released an executive summary on "Medicare Payments for Septicemia." The Health Care Financing Administration (HCFA) contracted with two clinical data abstraction centers to validate a national random sample of claims from all Medicare inpat....
Rheumatoid Arthritis
Author: Prophet, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: November 1998
Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints, the tissue around the joints, and other organs in the body. An autoimmune disease is one in which the body tissues are mistakenly attacked by the body's own immune system. Patients have antibodies in....
Role of Coding and Documentation in the Quality Payment Program
Author: DeVault, Kathryn; Easterling, Sharon; Huey, Kim
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2017
In the current era of healthcare transformation, the continuing importance of documentation and coding cannot be overstated. With the multitude of acronyms being added to the healthcare vocabulary, one may wonder where documentation and coding fits in. It’s important to remember that....
Sample Coding Incentive Plan
Author:
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2001
Sample Coding Incentive Plan 2
Author:
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2001
SARS Tops Healthcare Concerns
Author: Kennedy, James S.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2003
HIM professionals serve a vital public health role as they capture and report illnesses, including the newly discovered Severe Acute Respiratory Syndrome (SARS). Accurate reporting of SARS and its comorbid or complicating conditions facilitates optimal disease tracking, use of resources, and p....
Sepsis, Related Terms Cause Confusion for Coders: Set the Record Straight About Sepsis, SIRS, Septic Shock
Author: Prophet-Bowman, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2003
Sepsis, severe sepsis, SIRS, and septic shock have long been a source of confusion for coders. New ICD-9-CM codes established recently for Systemic Inflammatory Response Syndrome (SIRS), and additional proposed code revisions have added to the confusion regarding the differentiation among these....
Sepsis Under the ICD-10-CM Microscope
Author: Kulanko, Jill
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2015
Sepsis is arguably the most challenging condition to code correctly in ICD-9-CM. The condition itself is complex and the definitions regarding sepsis, SIRS, and severe sepsis have evolved over time, keeping coders on their toes. The guidelines are also difficult to understand. Complicatin....
Sharing Resources for Coding Quality Improvement
Author: Mills, Sharon
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2000
Hospital leaders who truly understand the challenge of achieving high-quality coding and are willing to commit resources to promote continuous quality improvement can be difficult to find. However, four years ago, visionary leaders in a not-for-profit healthcare system recognized that....
Six Months and Counting: Are You Ready for ICD-10-CM/PCS Implementation?
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2015
With just six months until the implementation of ICD-10-CM and ICD-10-PCS, now is the time for HIM professionals to re-evaluate the state of their facility’s implementation plan and make any necessary adjustments to ensure a successful transition. Previous delays may have slowed down....
SNOMED CT Helps Drive EHR Success
Author: Giannangelo, Kathy; Berkowitz, Lyle
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2005
With the advent of electronic health record (EHR) systems, IT solutions are needed to ease the recording of standard codes for clinical encounters. The basis for these products is a standard terminology, without which the full benefits of an EHR are unlikely to be realized. One expert notes th....
SNOMED CT Integral Part of Quality EHR Documentation
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2012
The use of many distinct standardized clinical vocabulary terminologies and classifications is integral to the development of a nationwide health IT infrastructure that allows for electronic use and exchange of health information. SNOMED CT is one of the key clinical terminologies designated f....
Society for Clinical Coding Comes Around as CoP
Author: D'Amato, Cheryl; Hoag, Patience J.; Crocker, Elsa; Neville, Deborah; Carpenter-Barbee, Cheryl; Bartell, Laurie
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2002
Remember the glorious Knights of the Round Table who made Camelot famous? King Arthur created a meeting place with special significance, a roundtable at which every seat had equal worth. AHIMA has embraced the spirit of this concept in a program known as coding roundtables, which are designed....
Solving LTC Coding Challenges
Author: Laakso, Roslyn C.; Gottschalk, Reesa; Uppena, Mary
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2002
After an acute illness or injury, patients are often transferred from the hospital to a skilled care bed or nursing facility for continued care. In rural areas, the local hospital and skilled nursing facility are often located within the same building and may even be the very same bed (many r....
Sorting Out the Inpatient Rehabilitation PPS
Author: Youmans, Karen
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2001
FRGs, RIC, CMGs, FIM, MDS-PAC, IRF, RPPS, UDSMR...What do these letters mean? They are all part of the inpatient rehabilitation prospective payment system (RPPS). This article will explain the history and key pieces of this system.
A Brief History of PPS
As we know,....
Spring Training for Outpatient Hospital Coding Compliance
Author: Scichilone, Rita A
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2001
While this month's first "Coding Notes" article covers the bases of coding compliance across the continuum of care, this article offers some hard-hitting rules for playing the compliance game in outpatient hospital coding and reporting.
Staying abreast of all of the regulat....
Staying Alert on Sleep Medicine Coding
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2011
The field of sleep medicine is rapidly expanding, and its coding and reimbursement are attracting more attention from federal and state governments, public health organizations, scientists, payers, auditors, the transportation industry, and healthcare consumers. Emerging topics in the area of....
Steps to Internal Audits for Physician Office Records
Author: Zeisset, Ann M.; Scichilone, Rita A
Source: Journal of AHIMA - Coding Notes
Publication Date: October 1999
Physician offices face the challenge of submitting correct coding information through the billing process. Ensuring timely reimbursement at the highest level for which services were provided, correct coding also proves there are no fraudulent activities occurring at the facility. Performing a....
Stevens-Johnson Syndrome
Author: Prophet, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: March 1998
The term "erythema multiforme" was first used by von Hebra in 1866 to describe a disease characterized by symmetrically distributed, pleomorphic, evolving cutaneous lesions, located primarily on the extremities, and by a proclivity for recurrence. In 1922, Stevens and Johnson....
Strategies for Remote Coding Success: Remote Coding Program Helps Norman Regional Retain Quality Coders
Author: Miller, Amy; Ridpath, Debra
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2010
Remote coding is helping organizations attract and retain experienced coding professionals at a time when highly skilled coding professionals are in short supply. Successfully implementing a remote coding program requires that facilities have their entire clinical documentation online and qual....
Summary of ICD-9-CM Coordination and Maintenance Committee Meeting
Author: AHIMA Coding Policy and Strategy Committee
Source: Journal of AHIMA - Coding Notes
Publication Date: September 1996
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 June 6, 1996, in Washington, DC. NCHS’s Donna Pickett, RRA, and HCFA’s Patricia Brooks, RRA, cochaired the meeting.
Summary of ICD-9-CM Coordination and Maintenance Committee Meeting
Author: Prophet, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: September 1997
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 June 5, 1997, in Baltimore, MD. NCHS's Donna Pickett, RRA, and HCFA's Patricia Brooks, RRA, cochaired the meeting. <....
Summary of ICD-9-CM Coordination and Maintenance Committee Meeting
Author: Prophet, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: March 1998
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 December 4-5, 1997, in Baltimore, MD. Donna Pickett, RRA, from NCHS, and Patricia Brooks, RRA, from HCFA, cochai....
Summary of ICD-9-CM Coordination and Maintenance Committee Meeting
Author: Prophet, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: February 1999
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 2, 1998, in Baltimore, MD. Donna Pickett, RRA, from NCHS, and Patricia Brooks, RRA, from HCFA, cochaired the....
Summary of ICD-9-CM Coordination and Maintenance Committee Meeting
Author: Prophet, Sue
Source: Journal of AHIMA - Coding Notes
Publication Date: September 1998
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 June 4, 1998, in Baltimore, MD. NCHS's Donna Pickett, RRA, and HCFA's Patricia Brooks, RRA, co-chaired the meeting. P....
Taking a Closer Look at 2003 ICD-9-CM, DRG Changes
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2002
The ICD-9-CM coding changes and DRG changes for fiscal year 2003 include 106 new diagnosis codes, 41 new V codes, 16 new E codes, 25 new procedure codes, and 19 invalid diagnosis codes. Released in the August 1, 2002, Federal Register, these changes went into effect October 1, 2002, with disch....
Taking a Closer Look at Physician-based Coding
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2002
Since 1997, AHIMA has offered a Certified Coding Specialist--Physician-based credential (CCS-P) for HIM professionals who are employed in the physician setting. In recent interviews, an office manager, coding manager, coding coordinator, and two physician-based consultants shared their coding....
Taking the Sting out of Injection and Infusion Coding
Author: Endicott, Melanie
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2012
Injection and infusion coding is a challenging area, thanks to vast instructional notes, hierarchy rules, and payer-specific policies.
Current Procedural Terminology (CPT) defines the terms “injection” and “infusion” as:
Injection—delivers a dosage in one “shot,” r....
Telemedicine: Bridging Gaps in Healthcare Delivery
Author: Majerowicz, Anita; Tracy, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2010
Traditionally, healthcare has been provided in the physician’s office, hospital, or outpatient clinic. Patient care has been based primarily on face-to-face contact, with the exchange of information via conversation.
However, technology is changing how and where care is delivered. M....
The Circulatory System and ICD-10-CM/PCS
Author: Barta, Ann
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2011
Many coding professionals will need to learn new terminology and brush up on their anatomy and physiology (A&P) knowledge to prepare for the ICD-10-CM/PCS transition. Although it is still too early for intense training on the new code sets, now is the time for coding professionals to gain....
The DRG Shift: A New Twist for ICD-10 Preparation
Author: Long, Peri L
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2012
Every generation has a few defining moments they can look back upon-big news events, clothing and fashion trends, hair styles, and maybe even a dance craze or two.
Today's healthcare industry is currently experiencing a defining moment of its own: preparations for the transition to the In....
The Importance of Histology in Neoplasm Coding
Author: Bumgarner, Charlotte CDIP, CCS; Latva, Jennifer CCS, COC, CPC, CGSC
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2018
By Charlotte M. Bumgarner, CDIP, CCS, and Jennifer C. Latva, CCS, COC, CPC, CGSC
CODERS OFTEN RELY on a neoplasm’s behavior and location for ICD-10-CM code assignment, rather than first referencing histological type. This oversight can lead....
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