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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....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: When a patient who was assaulted names her assailant, should the nurse or physician include the assailant's name in the medical record?
A: It is not uncommon for a healthcare provider to document in the record what the patient says when the information has some bearing on his or....

Journal Q&A (10/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 2000

Q: Can an emergency room exam serve as an inpatient history and physical?
A: It's important to understand the intent of the standards and regulations for hospitals and the practice standards for content of a history and physical (H&P) exam. The 2000 Joint Commission on Accreditation ....

Catching Up with PEPP

Author: Bryant, Gloryanne H.; Fletcher, Robin

Source: Journal of AHIMA

Publication Date: September 2000


A year ago, the Journal of AHIMA reported on the newly created Payment Error Prevention Program (PEPP), which went into effect in August 1999. What has happened since then?
Best Billing Practices

PEPP was created to reduce Medicare prospective payment system (PPS) ....

Setting the Standard in Assisted Living

Author:

Source: Journal of AHIMA

Publication Date: July 2000


Have you found yourself in the position of developing or reviewing health information and documentation policies for an assisted living facility? If so, you know that it is not easy to find resources or standards for this growing industry. However, both the Joint Commission on Accredit....

Practice Solutions for Today

Author:

Source: Journal of AHIMA

Publication Date: July 2000


Editor's note: APCs, risk management, knowledge management...all of these are practice issues that will affect the way HIM professionals work in the future. But practice solutions exist right now in our day-to-day work environments as well. Here are a few successful practice sol....

Documentation Errors Result in Medicare Overpayment

Author: Hammen, Cheryl

Source: Journal of AHIMA

Publication Date: July 2000



The objective of the Office of the Inspector General's (OIG) fiscal year 1999 audit was to determine whether medical fee-for-service claims complied with Medicare rules and regulations. The OIG examined claims for accurate documentation and coding, medical necessity, and to ensure that c....

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