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Disorders of the Breast

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: May 1996

Carcinoma

Breast cancer is the most common form of cancer in women. Risk factors include a personal or family history of breast cancer, delayed childbearing, and personal history of benign breast disease.
A tumor may be identified by mammogram or self-examination. Many tumors are d....

Myocardial Infarctions: Frequently Asked Questions

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: July 1996

Myocardial Infarctions

Many coders still have questions regarding the correct coding and sequencing of myocardial infarctions (MI), particularly in relation to the use of the fifth digits, transfers, underlying diagnosis, and performance of procedures. The following information is provide....

ICD-9-CM Revisions -- Effective October 1, 1996

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: October 1996


The revisions to ICD-9-CM became effective with discharges occurring on or after October 1, 1996. Highlights of the changes are summarized below. Since not every revision is described in this article, it is important to review the official authorized addendum published in a special edition of....

Hypertensive Disorders of Pregnancy

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: September 1997


Hypertension complicates at least 10 percent of all pregnancies. The hypertensive disorder of pregnancy most likely to result in significant adverse clinical outcomes is preeclampsia.

Preeclampsia
Preeclampsia is unique to pregnancy and is characterized by elevated blood press....

ICD-9-CM Revisions (effective 10/1/97)

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: November 1997


The revisions to ICD-9-CM became effective with discharges occurring on or after October 1, 1997. Highlights of the changes are summarized below. Since every revision is not described in this article, it is important to review the Official Authorized Addendum. The complete addendum is publish....

Testing ICD-10-PCS

Author: Brooks, Patricia E.

Source: Journal of AHIMA

Publication Date: May 1998



HCFA conducted a formal test of ICD-10-PCS (procedure coding system) in order to determine if it would be a practical replacement for the current ICD-9-CM, Procedures. This coding system was developed after an open competition contract was awarded to 3M/HIS. In order to avoid any con....

No Uncertain Terms

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: May 1998


HIM professionals think of classification systems such as ICD-9-CM as tools for everyday use. But these familiar systems are evolving and changing rapidly—as Donna Pickett, RRA, is well aware.

Pickett is medical systems administrator for the Office of Data Standards, ....

Development of the ICD-10 Procedure Coding System (ICD-10-PCS)

Author: Averill, Richard F.; Mullin, Robert L.; Steinbeck, Barbara A.; Goldfield, Norbert I; Grant, Thelma M.

Source: Journal of AHIMA

Publication Date: May 1998


The ICD-10 Procedure Coding System (ICD-10-PCS) has been developed as a replacement for Volume 3 of ICD-9-CM. This article will describe the development and structure of ICD-10-PCS‹as well as describe the modifications that have been made to the system as a result of extensive review and test....

What is Gulf War Syndrome (Part II)

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: September 1998


Presidential Advisory Committee on Gulf War Veterans' Illnesses

President Clinton established the Presidential Advisory Committee on Gulf War Veterans' Illnesses in May 1995 to ensure an independent, open, and comprehensive examination of health concerns related to Gulf War service....

FY1999 Inpatient PPS Changes: ICD-9-CM Revisions

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: October 1998


All of the inpatient DRG and other inpatient Prospective Payment System (PPS) changes described below became effective with discharges occurring on or after October 1, 1998. Complete details of these changes can be found in the Federal Register.1
Transfers to Postacute Settings

....

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....

1999 CPT Revisions

Author: Willard, Dianne

Source: Journal of AHIMA

Publication Date: January 1999


This article will summarize some of the major additions and revisions in the 1999 Current Procedural Terminology (CPT). A complete review of all the code and guideline changes -- including the rationale for these changes -- can be found in the November 1998 issue of the CPT Assistant newslette....

Benchmarking with National ICD-9-CM Coded Data

Author: Osborn, Carol E.

Source: Journal of AHIMA

Publication Date: March 1999


As HIM professionals, we want to be assured that we are providing the highest quality data for reimbursement and research purposes. We can review coded data internally, but this does not give us a clear picture of the total information that is being submitted to the Health Care Financing Admin....

Sign of the Changing Times: CPT 1999

Author: Mallett, Sherri; Smith, Gail I.

Source: Journal of AHIMA

Publication Date: June 1999


This year brought with it 686 changes to CPT. While this is a moderate number in comparison to previous years, several of the changes have significant impact on code assignment. The purpose of this article is to highlight some of the areas of significant change. (See "1999 CPT Revisions" in t....

Group Builds Consensus on Laboratory Test Policies

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: July 1999


The Balanced Budget Act of 1997 (BBA) mandated that the Health Care Financing Administration (HCFA) use a negotiated rulemaking process to develop national administrative and coverage policies for clinical diagnostic laboratory tests under Medicare Part B. The BBA stipulates that the p....

Brief History of ICD-10-PCS

Author: Mullin, Robert L.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 1999


The International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) was developed as a replacement for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) volume 3, Procedures. This version of ICD, in use since J....

Trend Watch: Coding for Nonphysician Services

Author: Hill, Emily

Source: Journal of AHIMA

Publication Date: January 2000


From physician assistants to nurse practitioners, the number of healthcare professionals offering patient care services has increased dramatically in recent years. With this increase comes a challenge to coders—accurately reporting the services provided by these prof....

Using CPT Modifier -25 for Professional Billing

Author: Yoder, Lois M.

Source: Journal of AHIMA

Publication Date: January 2000


You may want to consider a focused review of how your practice assigns CPT modifier -25, "a significant, separately identifiable Evaluation & Management (E&M) service by the same physician on the same day of the procedure or other service."1 The Health Care Financing Admini....

Clarifying Selected CPT Modifiers

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2000


Coding for professional services is complicated enough when coding professionals are charged with assisting the physician to select the best five-digit number for the services rendered. It becomes even more complex when circumstances of the case require the CPT code to be modified. Add....

Making a Proactive Transition to APCs

Author: Willett, Lyn

Source: Journal of AHIMA

Publication Date: July 2000


There's no doubt APCs are going to change the way your facility operates, but do you know how? By taking a look at your existing systems, you'll get a better idea of how to prepare for changes. This article spotlights specific functions to consider and optimize for the new outpatient prospect....

Building a Better CPT

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: November 2000


The Health Insurance Portability and Accountability Act (HIPAA) presents numerous challenges to HIM processes and systems. Not least among these areas is coding. Among the concerns is whether the CPT system will be sufficient to meet the demands of HIPAA. The American Med....

ICD-9-CM Code Revision for 2001

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2000


Effective October 1, 2000, 100 new ICD-9-CM diagnosis codes and nine new ICD-9-CM procedure codes have been implemented. Because there were no ICD-9-CM revisions last year, these new codes are the result of two years’ worth of revisions. Coding professionals should familiarize themselves with....

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....

CPT Changes for 2001

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2001




CPT 2001 Professional Edition (CPT® 2001) is complete and should be landing on your desk soon. As an introduction to the new book, this article provides a brief summary of the changes in 2001. A complete listing of the code and guideline changes can be found in CPT Changes 2001:....

Coding Under the HIPAA Umbrella

Author: Russo, Ruthann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2001





Although coding professionals are not ultimately responsible for ensuring appropriate release of patient-protected information, it is important that they understand that coded data is not only one of the most desired pieces of information in the patient’s record, it is also the....

Common E/M Documentation Issues

Author: Udell, Curtis

Source: Brief Encounter

Publication Date: July 02, 2001


One of the constant challenges facing managers today is evaluating physician documentation and then helping their physicians to improve the content of their patient notes, particularly for evaluation and management (E/M) services.

While physicians may have unique style or flair to t....

Review of E/M Guidelines

Author:

Source: Brief Encounter

Publication Date: July 02, 2001


The Evaluation and Management guidelines are found in the Medicare Carriers Manual in the following sections. You may download the entire manual from the Center for Medicare and Medicaid Services or CMS (formerly HCFA) Web site by going to http://www.hcfa.gov/, click on Medicare, select laws an....

E/M Options in the Outpatient Arena

Author: Jones, Lolita M.

Source: Journal of AHIMA

Publication Date: July 2001


Under the Medicare ambulatory payment classification (APC) system, hospitals must establish criteria for mapping the medical care rendered in the emergency department and hospital-based outpatient settings to appropriate CPT medical visit codes. Do you know how to establish a sound rationale f....

Look at Modifiers for Hospital Use

Author: Philippou, Karla E.

Source: Brief Encounter

Publication Date: July 02, 2001


Modifiers have been a continuing problem in the hospital setting. Although modifiers were mandated for hospital use in June 1998, many hospitals were unable to comply until the implementation of Ambulatory Payment Categories, (APCs), on August 1, 2000. The initial problems were related to info....

Navigating the Physician Services Maze

Author: Skurka, Margaret A.

Source: Journal of AHIMA

Publication Date: July 2001


As HIM professionals know, accurate and complete documentation is critical for providing care and supporting reimbursement. This is particularly true-and yet particularly problematic-in the area of E/M coding. Medical practices report and are paid for their services using E/M coding, yet there....

Solving the E/M Conundrum: a Special Report

Author: Scichilone, Rita A

Source: Journal of AHIMA

Publication Date: July 2001


Evaluation and Management (E/M) codes, introduced in 1992 for reporting physician visit services, are linked to a number of perplexing questions for coders. In different settings, they are used differently and with varying sets of criteria. Given the numerous coding and compliance issues relate....

AHIMA Testifies in Support of ICD-10

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: July 2001


The "replacement [of ICD-9-CM, Volume 3] with a new procedural coding system for inpatient services is absolutely necessary and ICD-10-PCS meets the criteria for such a replacement system," said Linda Kloss, MA, RHIA, AHIMA's executive vice president and CEO. Kloss also argued that &q....

Teaching Physician Guidelines

Author: Graff, Jean Stevens

Source: Brief Encounter

Publication Date: September 02, 2001


Working in an orthopedic clinic, I understand the great need for my newly created position. I am employed at a teaching hospital as a medical record auditor charged with the task of educating physicians on the art of coding and documentation. My job is to ensure compliance with the Medicare ma....

CPT "Monopoly" To Be Examined

Author:

Source: Journal of AHIMA

Publication Date: October 2001


Senate Minority Leader Trent Lott (R-MS) has forwarded a letter to HHS Secretary Tommy Thompson criticizing the American Medical Association's "statutory monopoly" on current procedural terminology (CPT) codes. Lott said that Congress will look at the CPT issue when it considers....

ICD-9-CM Codes Ready for 2002

Author: Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2001


For those reporting ICD-9-CM codes for all diagnoses coding, and hospitals reporting ICD-9-CM volume III for procedures, fall is the time to review and implement the changes and revisions for fiscal year 2002.

The ICD-9-CM coding changes for fiscal year 2002 were released in the Augus....

CPT Changes for 2002

Author: O'Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2002


Coders need to keep their resources current—including updating the Current Procedural Terminology (CPT) codes every year with the annual CPT book. This article provides a brief summary of the changes made to the CPT 2002 code set. The complete list of changes can be found in Appendix B of....

Anthrax: What Every Coder Should Know

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2002


The inhalation anthrax identified by a Florida physician in October 2001, during the recent series of bioterrorist attacks, was the first case of reported inhalation anthrax in the United States in more than 25 years.1 With the threat of anthrax as a biological weapon, correct coding could be....

Testimony of the American Health Information Management Association to the National Committee on Vital and Health Statistics on Medical Code Sets

Author: Prophet, Sue

Source: AHIMA testimony and comments

Publication Date: February 06, 2002

February 6, 2002
Opening Comments

Good morning Mr. Chairman, members and staff of the National Committee on Vital and Health Statistics (NCVHS) Standards and Security subcommittee, ladies and gentlemen.   I am Sue Prophet, director of coding policy and compliance for the American Heal....

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