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Publication Date: December 2015

Editor’s Note: Read this article’s companion piece “Fighting CDI Fires in ICD-10: Three Burning Questions Every Organization Must Answer” in the December 2015 edition of ICD-TEN, available here.

For most clinical documentation improvement (CDI) sp....

Fighting CDI Fires in ICD-10: Three "Burning Questions" Every Organization Must Answer

Author: Haas, Dianne

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: December 2015

It's an unfortunate reality in the world of clinical documentation improvement (CDI) that the majority of documentation challenges in ICD-10 are the same challenges we faced in ICD-9. These challenges didn't disappear overnight just because we flipped the switch to a new coding classificat....

What's the Skinny? Coding an Excision of a Malignant or Benign Skin Lesion

Author: Sims, Kimberly F

Source: CodeWrite

Publication Date: December 2015

Objective

The objective of this article is to describe how to code an excision of a benign and/or malignant skin lesion.

Clinical Information
....

AHIMA's comments on September 2015 ICD-10-PCS code proposals

Author: Bowman, Sue E

Publication Date: November 2015

Letter to Patricia Brooks, RHIA, Senior Technical Advisor, Centers for Medicare and Medicaid Services, Hospital and Ambulatory Policy Group

AHIMA comments on September 2015 ICD-10-CM code proposals

Author: Bowman, Sue E

Publication Date: November 2015

Letter to Donna Pickett, MPH, RHIA, Medical Classification Administrator, National Center for Health Statistics

ICD-10 Transition: It’s All About the Guidelines

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 11, 2015

Now that ICD-10-CM/PCS has finally been implemented and everyone is using these new code sets, the questions are rolling in. AHIMA’s Engage community is overflowing with questions from coding professionals seeking advice on how to code this or that. Many of the question....

ICD-10 Transition: Five Tools You Can Use to Continue Helping Physicians

Author: Antonios, Sam

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: November 2015

October 1 has passed and we are now in the universe of ICD-10. This was a monumental milestone in the history of US healthcare, but ICD-10 is not an event that has come and gone. In fact, October 1 was just the beginning and things might be temporarily shaky for some physicians before....

Assigning Evaluation and Management Critical Care Codes

Author: Sims, Kimberly F

Source: CodeWrite

Publication Date: November 2015

Objective

The objective of this article is to outline the steps required to assign Evaluation and Management codes for critical care services.

Clinical Information

What is Critical Care?

Critical care can be defined as speci....

Post ICD-10 Implementation: Where Are We Now?

Author: Maccariella-Hafey, Patricia C

Source: CodeWrite

Publication Date: November 2015

We heard deep sighs of relief as October 1, 2015, came and went and ICD-10 was finally implemented in the United States. This has been a long time coming for coding and documentation improvement professionals in the HIM world. At the time of this article's writing, we are two weeks into im....

Don’t Let Preventable CPT Coding Mistakes Cause Heartburn

Author: Clack, Crystal

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

Publication Date: November 2015

Every medical practice should have preventive measures in place to avoid costly coding and billing audits, errors, and subsequent delays in payment. Incorrectly coded claims, missing charges on a patient encounter, and other mistakes can take a substantial bite out of both practice and ph....

"CDI: Miami" Hunts Down Documentation Offenders

Author: Butler, Mary

Publication Date: October 2015

The HIM Problem

To get physician buy-in on clinical documentation specificity, one provider formed an all-physician CDI team

The HIM Problem Solvers

Lorena Chicoye, MD, RPh, corporate medical director, managed care network development and medical....

Road to 10: The Small Physician Practice's Route to ICD-10

Author: U.S. Centers for Medicare & Medicaid Services

Source: U.S. Centers for Medicare & Medicaid Services

Publication Date: October 2015

Rare and Unlikely ICD-10 Codes are Needed

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: October 2015

This summer, if you listened very closely, you could almost hear a vast chorus of coders saying “I told you so,” after a freak accident alarmed local boaters in Southern California. On June 21, an over-excited dolphin accidentally jumped into a California family’s speed boat and broke both ankl....

More Specific Physician Documentation Needed for ICD-10-CM

Author: Burgess, Sheila

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

Publication Date: October 2015

The dawn of October also welcomes the official go-live date for ICD-10-CM/PCS—meaning there is absolutely no time left to waste in preparing for the additional documentation requirements necessary for successful ICD-10 implementation. Over the past several years, the healthcare industry h....

Value of ICD-10 at the Point of Care

Author: Stearns, Michael

Publication Date: September 2015

The ICD-10-CM/PCS code set offers substantial clinical value to healthcare which includes new diagnoses and treatments. There has been a fair amount of emphasis on ICD-10’s value in clinical research and population health, but less on its value at the point of care—while a physician is car....

Last Minute Tips to Prepare for ICD-10 Implementation

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 09, 2015

This is it. The final countdown is on. ICD-10-CM/PCS is just a few short weeks away from finally becoming a reality in the United States. For those of you that have been preparing for years for this day, I bet you are breathing a huge sigh of relief and thinking, “just get it over with alr....

ICD-10-PCS From the Heart: Cardiovascular Procedures

Author: DeVault, Kathryn

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

Publication Date: September 2015

The complexity of ICD-10-PCS, as well as the need for a better understanding of anatomy and physiology and the technique of surgical procedures, has been well documented. The coding of cardiovascular procedures in ICD-10-PCS, in particular, requires focus.

Consider these p....

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....

Adverse Effects, Poisoning, Underdosing, and Toxic Effects

Author: Hansen, Abby

Publication Date: September 2015

As we quickly approach the ICD-10-CM/PCS implementation date, let's take a look at some significant changes and new terminology for adverse effects, poisonings, toxic effects, and now, underdosing. Very soon, we will be using a single combination code to capture the adverse effec....

Top 10 Metrics to Monitor in the First 30 Days

Author: Haugen, Mary Beth

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: September 2015

Technically speaking, anything could happen once we flip the ICD-10 switch on October 1, 2015. That's why it's important to monitor key performance metrics closely in the first 30 days post-implementation. The days and weeks immediately following go-live will provide critical insigh....

ICD-10-CM/PCS Documentation Tips

Author: AHIMA CDI Workgroup

Source: AHIMA Task Force

Publication Date: September 2015

A large library of CDI ICD-10 documentation tips focusing on the language and/or wording that will garnish greater details and specificity of the coded data for a given diagnosis, condition, disease and/or surgical procedure.

ICD-10 CDI DIY: Documentation Tip Sheets

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 12, 2015

Among the most helpful tools for assisting providers through the transition to ICD-10-CM/PCS are documentation tip sheets detailing the specificity needed to assign accurate codes. Many companies are selling tip sheets, but if you are looking to save a few dollars, here’s a step-by-s....

Value-Based Purchasing Programs and Coding Impact: A VBP Primer

Author: Lojewski, Tedi

Source: CodeWrite

Publication Date: August 2015

According to the Centers for Medicare and Medicaid Services (CMS), value-based purchasing (VPB) has been "a long-standing effort to link Medicare's payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital se....

DRG Grouping and ICD-10-CM/PCS

Author: Foley, Margaret M.

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

Publication Date: July 2015

Prior to the October 1, 2015 implementation of ICD-10-CM/PCS, every hospital must examine how the new code set will impact MS-DRG reimbursement. A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimburs....

AHIMA Comments on March 2015 ICD-10-CM code proposals

Author: Bowman, Sue E

Publication Date: June 11, 2015

AHIMA letter to Donna Pickett, MPH, RHIA, Medical Classification Administrator, National Center for Health Statistics

Injection and Infusion Coding Offers High Stakes: Outpatient Coders Must Play Their Cards Right

Author: Flewelling, Charles

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

Publication Date: June 2015

With the consistently rising value of highly skilled outpatient coders, numerous HIM departments are moving to a staffing model that employs coding professionals who are well versed in coding both inpatient and outpatient encounters. Coders in the profession today should possess a mastery....

How Deep Do You Dig into ICD-10-PCS Coding?

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: June 2015

All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.

ICD-10-PCS Scope of Work

On October 1, 2015, hospital inpatient pr....

Electronic Documentation Templates Support ICD-10-CM/PCS Implementation (2015 update)

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2015

Editor’s Note: This Practice Brief supersedes the October 2012 Practice Brief “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation.”

Improving patient care continues to take center stage in the healthcare industry, as demonstrated by an increa....

Rules of the Road Differ for Inpatient and Outpatient Coding

Author: Quick, Tara; Hickman, Stephani

Source: Journal of AHIMA

Publication Date: June 2015

As facilities approach the final laps in the race towards implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), they should heed the yellow caution flag warning of basic challenges with the vast differences between inpatient and....

Tackling the ICD-10-PCS Approaches

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 13, 2015

There are only seven approach values in ICD-10-PCS, so one would think that selecting the correct approach value would be simple, but it’s not! Let’s take a closer look at these seven approaches and then walk through some challenging cases.

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Malignancy: Aftercare or Follow-Up?

Author: Parman, Cindy C

Publication Date: May 2015

Physician documentation has always supported accurate diagnosis code reporting, but never more so than with the transition to ICD-10-CM codes. Specific terminology and the use of key words and phrases is essential, especially with terms such as "aftercare" and "follow-up," which phy....

ICD-10 Gap Analysis Points to Revenue Neutral Transition

Author: Barta, Ann

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

Publication Date: May 2015

The implications of ICD-10-CM/PCS for healthcare reimbursement is a topic at the top of everyone’s mind in the healthcare industry these days. As healthcare organizations continue to prepare for the transition to ICD-10-CM/PCS on October 1, 2015, an essential and important element of a su....

Documentation Issues in ICD-10-CM/PCS

Author: Rhinehart, Ebenetta M

Publication Date: April 2015

Clinical documentation specialists (CDS’s) are experiencing an increased emphasis on the work they do because of the increased specificity required for ICD-10-CM and ICD-10-PCS coding. Currently, unanswered queries are a nuisance and may result in an inaccurate diagnosis-related group&nbs....

Coding Saint Patrick's Day

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 11, 2015

Saint Patrick’s Day is both a cultural and religious celebration that includes displays of the color green, eating and drinking, and parades. One of the greatest places to celebrate this day, outside of Ireland, is the city of Chicago, where the people go all out for Saint Patrick’s D....

2015 ICD-10-CM Coding Guideline Changes

Author: DeVault, Kathryn

Publication Date: March 2015

Although they were minimal, the 2015 ICD-10-CM Coding Guidelines contained some updates that should be reviewed, as they provide additional clarification for coding in ICD-10-CM. A complete set of the 2015 guidelines can be found on the CMS website. Several of the guideline changes and upd....

ICD-10-CM Coding Guidance for Long-Term Care Facilities

Author: Liebner, Carole S; Lowery, Amanda L; Maccariella-Hafey, Patricia C; Usher, Joan L; Ward, Maria; Young, Carol

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2015

Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident's clinical conditions.

ICD-10-CM facilitates the collection and....

Coding Heart Procedures in ICD-9-CM and ICD-10-PCS

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 11, 2015

The coding of heart procedures is done very differently in ICD-9-CM versus ICD-10-PCS. In honor of American Heart Month, this month’s Code Cracker explores the guidelines for coding heart procedures.

There are a few specific guidelines associated with procedures don....

Anemia, Malignancy And Antineoplastic Treatment In ICD-10-CM

Author: Parman, Cindy C

Publication Date: February 2015

Anemia is a condition that develops when the blood lacks sufficient healthy red blood cells or hemoglobin to carry oxygen to body tissues. According to WebMD, anemia is the most common blood condition in the United States, affecting 3.5 million Americans.1 Severe or long-lasting anemia ca....

CPT Updates for CY 2015

Author: Buttner, Patty

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

Publication Date: February 2015

On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....

Understanding The History Component of The E/M Code - Part 2

Author: Maccariella-Hafey, Patricia C

Publication Date: January 2015

This is the second of a two-part series on the history component of the CPT Evaluation and Management code. The first part was published in the December 2014 issue of CodeWrite.

Levels of Evaluation and Management (E/M) services are based on four types of history (Problem F....

Top Ten Challenges of Passing the CCS Examination (And How to Overcome Them)

Author: Horn, Kelli

Source: Journal of AHIMA

Publication Date: January 2015

Hundreds of coders and students desire to take the next step in their career by obtaining the Certified Coding Specialist (CCS) credential. This examination represents high-level achievement and proficiency in inpatient and outpatient coding and associated concepts. Benefits of certificat....

GEMs: Buyers Beware. Crosswalk and Translation Tools Can Bring Unexpected Risks

Author: Reed, Diana

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

Publication Date: January 2015

When it comes to converting superbills and claims from ICD-9-CM to ICD-10-CM, many healthcare providers believe that general equivalence mappings (GEMs) offer a cost effective and simple solution. The ability to purchase relatively cheap automated mappings of specialties’ top codes c....

CDI Tips Developed to Maximize ICD-10-CM/PCS

Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi

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

Publication Date: January 2015

Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of detail....

Staying "Home Alone" Can Result in a Multitude of Injuries

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: December 10, 2014

It’s been 24 years since Kevin McCallister was accidentally left at home while the rest of his family went on vacation in the movie Home Alone. Poor little Kevin has to defend his family home when two con men try to rob it on Christmas Eve. Kevin outsmarts the idiotic burglars with bo....

CDI Tips Developed to Maximize ICD-10-CM/PCS

Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi

Publication Date: December 2014

Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of det....

Understanding the History Component of the E/M Code (Part 1)

Author: Maccariella-Hafey, Patricia C

Publication Date: December 2014

This is the first of a two-part series on the history component of the CPT Evaluation and Management code.

As discussed in the October 2014 CodeWrite article "Introduction to Evaluation and Management Services," evaluation and management (E/M) services are cognitive services....

Are Parkinson's Disease and Parkinsonism the Same Thing?

Author: Bielby, Judy A

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....

ICD-10 and Documentation

Author: U.S. Centers for Medicare & Medicaid Services

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: December 2014

This December, the Centers for Medicare & Medicaid Services (CMS) is working with AHIMA to highlight the importance of documentation in ICD-10. Earlier this month, CMS and AHIMA collaborated to offer a webinar on ICD-10 and documentation, and we wanted to continue the discussion in this mon....

Coding for ICD-10-CM: More of the Basics

Author: Bowman, Sue E; Leon-Chisen, Nelly

Source: U.S. Centers for Medicare & Medicaid Services

Publication Date: December 02, 2014

The objective of this video is to enhance viewers’ understanding of the characteristics and unique features of ICD-10-CM, as well as similarities and differences between ICD-9-CM and ICD-10-CM.

AHIMA Comments on Proposed Procedure Code Modifications Presented at the ICD-10 Coordination and Maintenance Committee Meeting Held September 2014

Author: Bowman, Sue E

Publication Date: November 20, 2014

Comments on the proposed procedure code revisions recommended for implementation

AHIMA Comments on Proposed Diagnosis Code Modifications Presented at the ICD-10 Coordination and Maintenance Committee Meeting Held September 2014

Author: Bowman, Sue E

Publication Date: November 20, 2014

Comments on the proposed diagnosis code revisions recommended for implementation

Coding Injuries in ICD-10-CM (update)

Author: Zeisset, Ann M.

Source: Journal of AHIMA

Publication Date: November 2014

ICD-10-CM provides greater specificity in coding injuries than ICD-9-CM. While many of the coding guidelines for injuries remain the same as ICD-9-CM, ICD-10-CM does include some new features, such as seventh characters.

Chapter 19 Overview

Chapter 19 is titled "In....

Coding Ebola Virus and Enterovirus D68

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 12, 2014

Ebola Virus

The Ebola virus is front page news everywhere you turn. Tracking of the Ebola outbreak in the United States with coded data is imprecise due to the lack of a specific code for Ebola in ICD-9-CM. This is yet another reason that the ICD-10-CM/PCS code sets....

Cost of Converting Small Physician Practices to ICD-10 Much Lower than Reported

Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.

Publication Date: November 2014

The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....

Setting the Facts Straight About ICD-10: What Physicians Need to Know About the Transition

Author: AHIMA

Source: AHIMA Advocacy and Policy

Publication Date: November 2014

While many organizations see the benefits of using ICD-10, including the ability to capture more detailed information, others have concerns, including the costs of implementation. Despite the significant amount of information that has been published about ICD-10 during the last 10 years, many misconceptions persist today. The information below covers basic facts about the ICD-10 transition that are of particular interest to the physician community.

ICD-10's Impact Reaches Far Beyond Coding: Examining the New Code Sets' Revenue Cycle Implications

Author: Arends-Marquez, Alexa; Knight, Nicole; Thomas-Flowers, Dwan

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

Publication Date: November 2014

The implications of ICD-10-CM/PCS (ICD-10) for coding operations are a common topic of industry discussion, but the impact of ICD-10 reaches far beyond coding alone. ICD-10 is embedded in the entire revenue cycle for providers. The conversion will impact almost every aspect of operations,....

ICD-10-CM Coding Challenges in a Physician Setting: Rash

Author: McNicholas, Faith C.

Publication Date: November 2014

Coding in a physician practice can be a challenge. Those who work in this setting will likely agree there are many times coders end up coding an encounter based on the signs and symptoms or just the clinical findings as documented in the patient medical record. Either way, it is important....

New Changes De-Spookify Modifier -59

Author: Wilson, Donna D

Publication Date: October 30, 2014

The proper application of modifier -59 (Distinct Procedural Service) has mystified many a coder. The Centers for Medicare and Medicaid Services (CMS) has recently indicated that modifier -59 is the most commonly used and abused of all the modifiers—mainly due to the fact that it is used to....

ICD-10 Form Letter and Vendor Readiness Questionnaire

Author: AHIMA

Source: AHIMA

Publication Date: October 15, 2014

A MS Word version of this document is available for customizing.

ICD-10-CM Will Improve the Tracking of Breast Cancer

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: October 08, 2014

From pink gloves on the football field to pink night lighting on skyscrapers—not to mention the influx of pink clothing everywhere you look—it’s no secret that October is National Breast Cancer Awareness Month. Most people have been touched by breast cancer in some way&md....

Introduction to Evaluation and Management Services

Author: Huey, Kim

Publication Date: October 2014

Evaluation and management (E/M) are cognitive services in which a physician or other qualified healthcare professional diagnoses and treats illness or injury. Almost all specialties will perform evaluation and management services. Even physicians who generate the bulk of their revenue in....

ABCs of HHS-HCCs: Taking a Closer Look at the Commercial Risk Adjustment

Author: Franklin, Janet

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

Publication Date: October 2014

There are three age-defined models under commercial risk adjustment. These are the Adult Model (ages 21 and up), the Child Model (ages 2–21), and the Infant Model (ages 0–1). The model applicable to a patient is dependent on their age at the end of the benefit year. If a 20-year-old patie....

How Physicians See ICD-10, and Its Effect on Their Practice

Author: AHIMA Staff

Publication Date: September 28, 2014

The United States is one of the last countries to switch from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, 10th Revision, Clinical Modification, Procedure Coding System (ICD-10-CM/PCS). The com....

What Physicians Need to Know About ICD-10-PCS

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 10, 2014

When educating physicians about ICD-10-PCS, the most important factor to be pointed out is that ICD-10-PCS will NOT be replacing CPT. Physicians will still need to report their services using CPT/HCPCS codes. However, physicians need to be aware of the nuances associated with ICD-10-P....

Coding Mastectomy Procedures

Author: Goswami, Chaitali