377 results.
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Wound Care in the Outpatient Setting
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,....
WHO Releases ICD-11 Preview
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....
Where to Find Answers to Your Coding Questions
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....
When Guidelines Depend on the Setting: Comparing, Contrasting Facility Reporting and Professional Fee Coding
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....
What’s the Difference? SNOMED CT and ICD Systems are Suited for Different Purposes
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....
Utilizing the CMS Website for Additional Coding Direction
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....
Use Data Mining Findings as a Tool to Support CDI Education
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....
Update on Standardized Nursing Data Sets and Terminologies
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 professions 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....
Understanding the Complexities of Coding for Mental Disorders
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....
Understanding Respiratory Diagnoses
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....
Understanding Pelvic Adhesions: How to Get Up to Date with Procedures, Codes
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....
Understanding New Medicare Coverage Determinations
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....
Understanding National Coverage Policies: Navigating the Maze of HACs, Serious Reportable Events, and Wrong Surgical Sites
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....
Understanding Diabetes Mellitus
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....
Trouble with DRGs: Part 2
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....
Trouble with DRGs
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....
Traumatic Brain Injury Coding in ICD-10-CM
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....
Translating HIM into a Terminology Management Career
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.....
Transitioning to CAC: The Skills and Tools Required to Work with Computer-assisted Coding
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....
Transitioning from Coding to CDI Offers New Career Opportunities
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....
Transitioning a Physician Practice to ICD-10
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,....
Tips for TIPS: Transvenous Intrahepatic Portosystemic Shunt
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....
Three-Day Window Updates
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....
Three Cs for Better Coding: Coding Community Council Takes Expertise Online
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....
The Respiratory System and ICD-10-CM/PCS
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....
Therapy Coding in Long-Term Care Facilities
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....
The Musculoskeletal System and ICD-10-CM/PCS
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....
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....
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 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....
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....
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....
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 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....
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....
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....
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....
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....
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....
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....
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,....
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....
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....
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....
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....
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....
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....
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....
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....
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....
Sample Coding Incentive Plan 2
Author:
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2001
Sample Coding Incentive Plan
Author:
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2001
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....
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....
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....
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.
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....
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....
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....
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....
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....
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....
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....
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....
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 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 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....
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....
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....
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....
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....
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....
Principles for Emergency Department Coding Guidelines
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....
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....
Preparing for POA Reporting: How One Facility Educated Its Staff on the Importance of the New Requirement
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....
PPS Brings Change to Inpatient Psychiatric Facilities
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....
Positioning Your Facility for Severity Adjusted Coding
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....
Pneumonia and COPD Reporting in the Inpatient Setting
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....
Plenty of CPT Changes for 2003: Latest on Additions, Revisions, and Deletions
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....
Physicians Cast Wary Eye at Computer-Assisted Coding
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....
Physician Office Modifiers Provide Added Detail for Coders
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....
Physician Fee Schedule Released for 2015
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....
Pathophysiology of Hypovolemia and Dehydration
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....
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....
Outwit, Outlast, Outcode: Surviving in the Autocoding Era
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....
Outpatient Prospective Payment Becomes A Reality
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....
Outpatient and Physician Reporting of Biliary Procedures
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....
One Little Lesion -- so Many Choices
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....
One Little Lesion -- so Many Choices
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....
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....
New Procedures for Joint Resurfacing of the Knee
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....
New ICD-9-CM Procedure Codes for FY 2011
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....
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