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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....

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....

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....

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....

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....

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....

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....

Preparing the Physician Office for HIPAA

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2001




Change has been a constant factor in coding and reimbursement with the intensified focus on billing, compliance, and cost control. Out of necessity, coding professionals in physician settings have learned to be organized, adaptable, and armed with the latest information. The mandates....

Preparing for the CAC Transition

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2011


One of the biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the "use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare p....

Overview of the ESRD PPS

Author: Nelson, Tanai S

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010


In August the Centers for Medicare and Medicaid Services established a new prospective payment system (PPS) for end-stage renal disease (ESRD) facilities. The ESRD PPS will provide a single payment to ESRD facilities for renal dialysis services and other items and services related to home dial....

Obstetric Coding in ICD-10-CM/PCS

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2010


ICD-10-CM/PCS will capture a greater level of specificity for obstetric coding. This article highlights some of the new features in coding obstetric cases with ICD-10-CM/PCS.
OB Diagnoses Coding with ICD-10-CM

Obstetric cases require diagnosis codes from chapter 15 of ICD-10-CM,....

Next Generation of E/M Guidelines

Author: Hill, Emily

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2000


Few non-clinical issues have inspired as much discussion, revision, and anxiety as the evaluation and management (E/M) services and their accompanying documentation guidelines. E/M services have produced a cottage industry focused on ensuring that medical records contain necessary docu....

New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization

Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Nemchik, Scot; Sheridan, Patty Thierry

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

Publication Date: March 2017



To quantify the impact of ICD-10-CM/PCS (ICD-10) on coding productivity, Ciox Health, in partnership with the University of Pittsburgh’s Department of Health Information Management, School of Health and Rehabilitation Sciences, conducted a previous study published in the August 2016....

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