Author: Hundal, Ripandeep K

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

Publication Date: April 2016

Wounds are injuries that break the skin or other body tissues. They include cuts, scrapes, scratches, and punctured skin. Wounds are typically due to accidental injury but may also result from surgery, stitches, or chronic disease processes.1


Wound care involves evaluation,....

Author: Palkie, Brooke; Kerr, Katie MA, RHIA

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

Publication Date: October 2018

By Katie Kerr, MA, RHIA, and Brooke Palkie, EdD, RHIA


The World Health Organization (WHO) released ICD-11 in June 2018, 18 years after the launch of ICD-10. It has been hailed as a vast improvement and was released in a completely electronic format th....

Author: Brouch, Kathy L.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2003

For more information on physician queries, see the "Developing a Physician Query Process" practice brief in the October 2001 Journal of AHIMA and in the FORE Library: HIM Body of Knowledge in the Communities of Practice at www.ahima.org.
Is obtaining an answer to a coding question a daunting t....

Author: Arner, Kathy

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

Publication Date: February 2007

Coding for facility and professional services on the same encounter can be confusing. This article outlines the differences in guidelines between the two coding types.

The Setting Factor


Over and over, coding professionals have been tol....

Author: Stearns, Mike; Fuller, Jan C.

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

Publication Date: November 2014

The International Classification of Diseases (ICD) and SNOMED CT are similar in that both systems have alphanumeric codes associated with clinical concepts. But the systems differ in their purpose and structure, and are best used in different ways in healthcare. For starters, ICD is a cla....

Author: DeVoe, Megan

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2018

By Megan DeVoe, CCS


Editor’s Note: This is the final article in a three-part series on how to master the information available on the Centers for Medicare and Medicaid Services website.


Have you ever wondered how a code bec....

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

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

Publication Date: July 2014

Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

Author: Warren, Judith J.; Bakken, Suzanne

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2002

HIM professionals can learn a lot from the nursing profession’s development of classification systems, terminology models, and quality indicators. Compared to other healthcare classification systems such as ICD-9-CM or CPT-IV, the nursing systems have not been widely used for reimbursemen....

Author: Albaum-Feinstein, Andrea L.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2000

Editor's note: This is the second part in a two-part series on diagnostic coding for mental healthcare.

Documentation differences between DSM-IV and ICD-9-CM continue to challenge coders in mental health settings. Efforts to minimize these differences are evident in curren....

Author: Ward, Maria

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

Publication Date: May 2017

Coding respiratory cases can sometimes lead to coding professionals getting bogged down in the circle of sequencing instructions, inclusions, and exclusions. This article will help readers gain a better understanding of the differences in the diagnoses that all come with a majority of the....

Author: Vlahos, Nikos F.; Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2003

Coding professionals routinely code abdominal or pelvic adhesions. Recent advances in treatment and a newly approved ICD-9-CM procedure code, however, bring the topic to the forefront. Is your knowledge current?

This article will explain what pelvic adhesions are, the surgical techn....

Author: Cooper, Steve

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2004

Recent legislation included in both the Benefits Improvement and Protection Act (BIPA) and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 has affected the content and implementation processes for Medicare coverage determinations. This column reviews differenc....

Author: Cook, Jane; D'Amato, Cheryl; Garrett, Gail S.; Ruhnau-Gee, Becky; Hyde, Linda A.; Novak, Natalie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009

Present on admission indicators, hospital-acquired conditions, serious reportable events, and “wrong” surgical events are each hot topics. However, they also can be a hot topic together, because a number of these reporting requirements are interrelated. HIM professionals must under....

Author: Huff, Garry L.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2003

Diabetes mellitus represents a group of disorders that are characterized by hyperglycemia. The clinical and ICD-9-CM classification of diabetes mellitus have evolved as understanding of insulin physiology has expanded. This article will explain diabetes mellitus and its ICD-9-CM classification....

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2005

Last issue’s article presented some ways that DRG criteria redefine well-established clinical entities such as respiratory failure and sepsis. This article will discuss two other incompatibilities between DRG criteria and clinical practice: the clinical distinctions required by the DRG s....

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2005

A major frustration among coding professionals, particularly in the inpatient setting, is the difficulty in translating physician documentation into diagnostic related group (DRG) data. Some hospitals have attempted to improve their coding effectiveness by establishing time-consuming physician....

Author: Rihanek, Theresa

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

Publication Date: June 2014

Traumatic brain injury (TBI) has received considerable attention by the media recently, especially bringing attention to the prevalence of TBI in sports-related activities. According to the Centers for Disease Control and Prevention (CDC), “A TBI is a bump, blow or jolt to the head o....

Author: Giannangelo, Kathy

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

Publication Date: June 2007

Every profession has its own body of knowledge. This specialized knowledge leads the profession to create a language of its own, also.

The HIM profession has a distinct language and body of knowledge. Through them HIM professionals deliver a unique service to the healthcare industry.....

Author: Smith, Gail I.; Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010

The coding world is not immune to technology advancements. Computer-assisted coding (CAC) technology is changing how the coding process is accomplished across all healthcare settings. CAC technology continues to integrate into a coding professional's daily life. This article focuses on the too....

Author: Endicott, Melanie

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

Publication Date: July 2016

The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper repo....

Author: Rose, Angela Dinh

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2012

In August 2012, the Department of Health and Human Services (HHS) announced its much-anticipated final ruling on the implementation deadline for the ICD-10-CM/PCS classification system-October 1, 2014.1 The transition to this highly awaited coding system will require appropriate planning,....

Author: Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2004

Transvenous intrahepatic portosystemic shunt (TIPS) is a relatively new procedure used to treat complications of severe liver disease such as bleeding esophageal varices. This extensive procedure is typically performed by interventional radiologists and involves the placement of a stent in the....

Author: Garrett, Gail S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011

The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 was signed into law on June 25, 2010. One of its provisions revised the three-day payment policy, or the so-called "three-day DRG window."

This article highlights the changes to the three-da....

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2004

Some people might believe that selecting the right clinical code number is roughly equivalent to the process of finding a phone number to order a pizza.
You can use a book with an index, or its electronic equivalent, to locate the numbers required, then push some buttons and the “s....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2012

The transition to ICD-10-CM/PCS will provide coding professionals with the opportunity to enhance and improve their coding skills. However, it will also require coders brush up on their anatomy and physiology knowledge. This is the perfect time to gain a better understanding of the differences....

Author: Bronnert, June

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

Publication Date: September 2006

Patients or residents are admitted to long-term care (LTC) facilities for a variety of reasons. While there, many receive some type of therapy, from physical to speech, during their stay. This article reviews the various procedures that may be provided to a resident at an LTC facility as well....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2011

The ICD-10-CM/PCS transition will provide coding professionals with the opportunity to enhance their coding skills. However, it will also require most coders brush up on their anatomy and physiology knowledge. Now is the perfect time to gain a better understanding of the differences between IC....

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....

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....

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....

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....

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....

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....

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....

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.

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. <....

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....

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....

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....

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....

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....

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....

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....

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....

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,....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Author:

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2001

Author:

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2001

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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....

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....

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....

Part 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....

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....

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....

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....

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....

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....

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....

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....

Author: Lojewski, Tedi

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2008

Since the implementation of the Outpatient Prospective Payment System (OPPS), the Centers for Medicare and Medicaid Services (CMS) has required hospitals to report facility resources for emergency department (ED) visits using CPT evaluation and management (E/M) codes.

However, CMS re....

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....

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....

Author: Wiedemann, Lou Ann

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

Publication Date: July 2007

Section 5001(a) of the Deficit Reduction Act introduced a new data reporting standard for hospitals submitting Medicare claims. The present on admission (POA) indicator will be a requirement for inpatient Medicare claims submitted by all hospitals on October 1, 2007.

This a....

Author: Grzybowski, Darice

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2004

For the past 20 years, licensed inpatient psychiatry units and free-standing inpatient psychiatric hospitals have been exempt from DRG-based prospective payment for Medicare patients. This year that’s changing.


Beginning in 2004, the Centers for Medicare and Medicaid....

Author: Whitaker, Paul

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

Publication Date: April 2007

With the recent talk of implementing a severity adjusted payment methodology, facilities must begin considering how they will prepare for this transition. Some healthcare organizations are concerned that the process is resource intensive, time consuming, and tedious.

Organi....

Author: Reed, Andretta

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

Publication Date: April 2017

This article highlights pneumonia and chronic obstructive pulmonary disease (COPD) code selections and proper sequencing based on healthcare provider documentation, ICD-10-CM Official Guidelines for Coding and Reporting, and ICD-10-CM conventions. As additional coding guidance continues to....

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2003

The 2003 Current Procedural Terminology (CPT) includes approximately 428 code changes, so as always, it is important to stay current. To assist you in using the new edition, the following provides a brief summary of the changes for 2003. The complete list of changes can be found in Appendix B....

Author: Bowman, Jim; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2004

An advanced type of e-HIM™ application, in late development, is a computer program that can automatically generate specific clinical codes from medical records variously termed computer-aided coding, computer-assisted coding, or computerized autocoding (CAC). CAC technology may be based....

Author: Sher, Bonnie C.

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

Publication Date: June 2006

In elementary school, we were taught that adjectives and adverbs amplify stories, providing extra detail. Take for example the following sentence: "The girl ran." What does it really tell us about the girl? If we add some adjectives, an adverb, and even a prepositional phrase, we get a clearer....

Author: Ward, Maria

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

Publication Date: March 2015

On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Medicare Physician Fee Schedule (PFS) Final Rule. Because of section 101 of the Protecting Access to Medicare Act (PAMA) of 2014, no changes to the fee schedule will occur until April 1, 2015. At t....

Author: Kennedy, James S.

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

Publication Date: July 2006

This year ICD-9-CM expanded code 276.5, Volume depletion, and created the more specific codes 276.51, Dehydration, and 276.52, Hypovolemia, at the request of the American Academy of Pediatrics.1 As treatments for these conditions differ and accurate coding must reflect illness severity and mort....

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....

Author: Schnitzer, Gregory L.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2001

Nearly two years ago, the AHIMA Coding Futures Task Force predicted that coders would eventually need to go beyond assignment of diagnostic and procedural codes.1 The task force was right-and that future is now for coders in certain specialties. Natural language processing (NLP), in which comp....

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2000

Do you know your APCs? July 1, 2000, is the start date for the Ambulatory Payment Classification (APC) prospective payment system for Medicare reimbursement. CPT coding skills will directly affect revenue as the current Ambulatory Surgery Center (ASC) methodology is abandoned and mor....

Author: Miller, Jackie

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2008

Coding biliary procedures requires in-depth knowledge of anatomy as well as coding guidelines. This article outlines the correct coding for biliary procedures in outpatient and physician settings.



The Biliary System




The biliary system consist....

Author: Gold, Robert S.; Brown, Margi

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2004

Part 1 of 2: The CPT Aspect

Concentrating on lesions in the integumentary system, this article provides some basic and user-friendly information for the coder to have at hand in the day-to-day world of coding.

Coding for lesions in the integumentary system requires a good under....

Author: Gold, Robert S.; Brown, Margi

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2005

Part 2 of 2: The Diagnosis Aspect and More CPT Notes


As noted in part 1 (Nov./Dec. 2004), lesion coding can be confusing. Terms are often vague or used interchangeably. Thus good documentation is absolutely crucial for the correct coding of both diagnosis and procedure. It’s go....

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,....

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....

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....

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2005

For 2005, CPT added a number of codes to reflect the continuing evolution of reconstructive knee procedures, especially those that address resurfacing of the articular surface of the joint following loss of normal chondral tissue. The fact that chondral tissue is avascular and has limited rege....

Author: Schraffenberger, Lou Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2010

The new ICD-9-CM procedure codes go into effect October 1, 2010, for fiscal year 2011. This article highlights the new and revised codes for inpatient procedures performed in healthcare facilities across the United States.

The 2011 addenda with the all the changes to the ICD-9-CM pr....