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In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States wo....

Breaking Down Healthcare's Silos: University of Kansas Medical Center's Interprofessional Education Fostering 'HIM Without Walls'

Author: O'Dell, Rosann M; Belz, Norbert; Bielby, Judy A; Folck, Kay; Moqbel, Murad; Pulino, Lauren

Source: Journal of AHIMA

Publication Date: September 2015

A faculty member in the health information management (HIM) department at the University of Kansas Medical Center (KUMC) attended a campus retreat in June 2011 that not only energized his personal perspective of HIM, but also shed new light on the future of HIM at the university.

Finding Reliable Health Information on the Internet

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: June 2015

When you search the Internet for information on diseases, are you confident the information you find is reliable and current? Since not everything on the Internet is necessarily accurate, it is important to know how to find reliable and accurate information. A useful place to start....

Are Parkinson's Disease and Parkinsonism the Same Thing?

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2014

OBJECTIVE

The objective of this article is to examine the difference between the terms "Parkinson’s disease" and "Parkinsonism."

CLINICAL INFORMATION

Parkinson’s disease is a motor system disorder. In Parkinson’s disease, brain cells that....

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....

Clinical Documentation Guidance for ICD-10-CM/PCS - Retired

Author: Bielby, Judy A; Comfort, Angie; Reed, Andretta; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2014

Organizations were well on their way to an October 1, 2014 implementation of ICD-10-CM/PCS when Congress passed H.R. 4302, the Protecting Access to Medicare Act of 2014. This bill contained a section stating that the Department of Health and Human Services (HHS) could not adopt the new code set....

What Influenza Codes Are Being Reported By Your Hospital?

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: February 2014

Objective

Many strains of influenza exist. The coding of influenza is becoming increasingly more specific and special coding guidelines exist for the reporting of influenza due to certain identified influenza viruses. The objective of this article is to examine the classificatio....

Reporting and Sequencing of V Codes

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2013

A few months ago, the Centers for Medicare and Medicaid Services (CMS) published the Inpatient Prospective Payment System fiscal year 2014 proposed rule. One of the proposals concerns ICD-9-CM code V45.88 for Tissue Plasminogen Activator (tPA) administration within 24 hours prior to admi....

Coding with Integrity: Top Coding Tips from AHIMA Experts

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: July 2013

The demand for trustworthy data has never been more apparent than it is today, and the coding process plays a critical role in meeting the need for complete, accurate, and reliable healthcare data. Accurate and compliant coding of ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II de....

Essentials on Nonessential Modifiers

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2013

A review of the coding conventions is necessary to prepare for implementation of ICD-10-CM and ICD-10-PCS. The coding conventions for ICD-10-CM are quite similar to ICD-9-CM, so review might not seem necessary, but it is.

The process of coding becomes so ingrained in the expe....

Thoracentesis and Other Pleural Cavity Drainage Procedures

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: March 2013

A thoracentesis is a procedure performed to drain excess fluid from the pleural cavity using a thin needle or plastic tube. It can be performed for diagnostic or therapeutic purposes. The coding of thoracentesis seems fairly straightforward, particularly if specifically documented by the....

Documentation and Reporting of Clostridium Difficile Infections

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: January 2013

Objective

Examine the classification of Clostridium difficile in ICD-9-CM and ICD-10-CM.

Clinical Information

Clostridium difficile (C difficile) is a bacterium that causes serious intestinal conditions such as colitis. It is a spore-formin....

Digoxin Toxicity: Adverse Effect or Poisoning?

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2012

Objective

The objective of this article is to examine the classification of drug toxicity in ICD-9-CM and in ICD-10-CM.

Clinical Information

Digoxin is a medication used to treat conditions such as atrial fibrillation. Toxicity can be an adve....

Big Chill: Just One New ICD-9-CM Code Added During Current Freeze

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: October 2012

New, deleted, and revised ICD-9-CM codes are included every year in the Centers for Medicare and Medicaid Services’ (CMS) annual update to the Inpatient Prospective Payment System (IPPS). But only one new ICD-9-CM code, effective October 1, 2012, has been added to the code set due to the ongo....

One New ICD-9-CM Code Emerges from the Freeze

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: September 2012

New, deleted, and revised ICD-9-CM codes are included every year in the annual update to the Inpatient Prospective Payment System (IPPS). Only one new ICD-9-CM code describing new technology has been added to the code set for this year, effective October 1, 2012: procedure code 00.95 (Inje....

Acute, Subacute, and Chronic Conditions

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2012

The coding of acute, subacute, and chronic conditions can be challenging. Acute conditions are typically sudden in onset or have a rapid onset in severe or sudden symptoms. Acute conditions often have a short course. Conversely, chronic conditions have a much slower course than acute condi....

HAC Codes: An Ethical Dilemma for Discussion

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: July 2012

By Judy Bielby, MBA, RHIA, CPHQ, CCS

Objective: To recognize and address ethical dilemmas in the coding profession. This topic will be available for further discussion in the Communities of Practice (CoP).

Case Scenario: A certified professional coder has recen....

Colonoscopy Performed on Patient with History of Colon Polyps

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2012

Many questions arise in coding colonoscopy services, particularly when performed on patients with a history of colon polyps. Recently, the following question was posted under the topic, "Screening Colonoscopy," in the Coding Community of Practice (CoP):

“When you code....

Reporting Pattern of Use for Alcohol Abuse and Dependence

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: March 2012

The objective of this article is to apply the official coding guidelines in reporting alcohol use, alcohol abuse, and dependence.

Background Information: Fifth-digit subclassification for codes found in ICD-9-CM category 303, alcohol dependence syndrome, and ICD-9-CM subcat....

Mechanical Ventilator: How Do I Code Thee? Let Me Count the Hours (Not Days)

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: January 2012

Two ICD-9-CM procedure codes which have been the subject of much attention ever since they were introduced in October 1991 are codes 96.71 and 96.72 for continuous invasive mechanical ventilation. There is one additional code in ICD-9-CM subcategory 96.7 for continuous invasive mechanical....

Coding and Documentation of Obesity

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2011

Objective: The objective of this article is to examine the differences between the coding of seizure and epilepsy in ICD-9-CM and in ICD-10-CM.

Coding Scenario 1:

A 62-year-old female is admitted for left total hip replacement. The patient is having the....

Diagnosis Coding of Seizures, Epilepsy and Other Related Terms

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: November 2011

Objective: The objective of this article is to examine the differences between the coding of seizure and epilepsy in ICD-9-CM and in ICD-10-CM.

Clinical Information

Epilepsy and seizure disorder are terms which are used interchangeably to mean the same....

Gestational Diabetes

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: October 2011

Objective: To discuss coding for gestational diabetes.

Coding scenarios: Patient A is 30 weeks pregnant and is seen for treatment of gestational diabetes. Patient B is seen for diabetes screening. Patient B is not currently pregnant, does not currently have a diagnosis....

Coding Neoplasms in ICD-10-CM

Author: Bielby, Judy A

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2011

ICD-10-CM codes provide greater detail than ICD-9-CM codes for reporting neoplasms. In many instances, ICD-10-CM neoplasm codes can provide information on whether a neoplasm occurred in a right-sided or left-sided body part. ICD-10-CM also provides codes for reporting neoplasm sites with great....

Keeping Up with the CPT/HCPCS Changes

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: September 2011

Although January 1 is regarded by many professional coders as the date when CPT®/HCPCS code changes are implemented, it is becoming increasingly important for professional coders to pay attention to those new CPT/HCPCS codes which are implemented throughout the year. There may be insta....

Diagnosis Coding of Osteoarthritis of the Hip Secondary to Legg-Calvé-Perthes Disease

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2011

Objective: The objective of this article is to discuss the ICD-9-CM and ICD-10-CM coding of osteoarthritis of the hip secondary to Legg-Calvé-Perthes disease.

Clinical Information

Legg-Calvé-Perthes disease is also commonly referred to in the literatur....

Diagnosis Coding of Charcôt Arthropathy

Author: Bielby, Judy A

Source: CodeWrite | AHIMA newsletter article

Publication Date: July 2011

Objective: The objective of this article is to examine the differences between coding Charcôt arthropathy and Charcôt joint in ICD-9-CM and in ICD-10-CM.

Clinical Information

Charcôt arthropathy is also commonly referred to in the literature as Charcôt....

Getting to Know PubMed: an Overview (2010 update)

Author: Bielby, Judy A; Williams, Margaret

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: August 2010

This practice brief has been retired. It is made available for historical purposes only.

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