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DSM-5 vs. ICD-10-CM

Author: Foley, Dianna

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 10, 2016




The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) both present ways to classify diseases. In the case of DSM-5, it is strictly for mental dis....

External Cause Codes in ICD-10-CM

Author: Fuller, Jan C.

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2014



The increased specificity in ICD-10-CM is reflected in a substantial increase in external cause codes. The traditional “E code” has been replaced with V, W, X and Y codes. While the purpose of the codes remains the same, the ICD-10-CM codes provide a level of detail not possible in ICD-9-....

Changes Ahead in Data Standards

Author: Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: June 2011


HIM professionals are most familiar with the data standards mandated through HIPAA. However, the data standard adoption process is also now part of the requirements for EHR technology in the meaningful use program.

Understanding the data standards adoption process under HIPAA and th....

ICD-10: Our Red-Letter Day

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: June 2012



The first day of school. The day of your wedding. The first day of a new job. Each of these are big, memorable dates that first loom on calendars and then linger long in memory.


For many of us in the HIM profession, October 1, 2013, was a red-letter day too-the original impl....

Coding Mastectomy Procedures

Author: Goswami, Chaitali

Source: CodeWrite | AHIMA newsletter article

Publication Date: September 2014



OBJECTIVE

The purpose of this article is to enable you to understand and correctly implement the coding principles, concepts, and guidelines associated with various mastectomy procedure codes.


SURGICAL INFORMATION

Mastectomy is the surgical procedure in....

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....

Observation Services

Author: Hapner, Peggy

Source: AHIMA Convention

Publication Date: September 25, 2010



Observation is a necessary, though cumbersome, service provided in hospitals today. Many facilities would like to see observation eliminated because it is a logistical nightmare, particularly when it comes to charges and reimbursement.

The most stringent rules about observation....

Optimizing Anatomy and Physiology Review for ICD-10

Author: Henderson, Kellie

Source: AHIMA Convention

Publication Date: September 25, 2010

Overview

As we move into the ICD-10 landscape an increased knowledge of anatomy and physiology is a critical requirement for success. Every coder has a different level of knowledge they draw from today. Identifying knowledge gaps and shoring up our defenses will provide us with informati....

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....

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....

Help! I am Encoder-Dependent!

Author: Horn, Kelli

Source: CodeWrite | AHIMA newsletter article

Publication Date: March 2014



Many coders in the workforce preparing to take their CCS examination acknowledge that they are dependent on encoders. While this is beneficial in performing daily job duties, it can be a hindrance to successfully passing the examination. The four-hour examination requires that exam-takers....

Assigning Advance Care Planning Codes

Author: Huey, Kim

Source: CodeWrite

Publication Date: May 2016



Physicians have a new opportunity to bill and be paid separately for a counseling service they may already be performing. Advance Care Planning codes 99497-99498 were introduced in Current Procedural Terminology (CPT®) in 2015 but were not paid by Medicare until January 1, 2016. CPT code 9....

2017 CPT Coding Update

Author: Huey, Kim

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

Publication Date: March 2017



The 2017 update to the CPT code set brings fewer new codes than in previous years but more guideline changes and clarifications, as well as revisions in code description. One Appendix is deleted and a new one is created. There are a total of 149 new CPT codes, 498 revised codes, and 81 del....

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....

Coding Complex Bariatric Surgery

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2005


Bariatric, or weight-loss, surgery is a rapidly evolving specialty. From jejunocolic and jejuno-ileal bypass procedures, through the days of minimally invasive procedures such as gastric balloons and endoscopic-banded gastroplasty, to today’s procedures that involve both gastroplasty and....

Keeping up to Date: 2005 CPT Surgery Changes

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2005


CPT changes for 2005 affect all portions of the manual, although there are very few changes in the pathology and laboratory section. This article will focus on the changes for the surgery section. The January and February 2005 issues of CodeWrite (available through the Coding Community of Prac....

2006 CPT Coding Update

Author: Hull, Susan

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

Publication Date: January 2006


A number of changes to CPT codes take effect January 1, 2006. These changes affect category I, II, and III codes, with a total of 277 additions, 110 deletions, and 71 code revisions.
Evaluation and Management

Within the evaluation and management (E/M) section, the codes for fol....

Changes Abundant for CPT 2004

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004


Changes for CPT 2004 affect all chapters, and it’s important to stay up to speed. This article presents a summary of CPT changes for 2004. Because a number of the procedures may be unfamiliar to some coding professionals, AHIMA has provided online links to descriptive articles on these s....

Fracture Treatment Poses Coding Challenge: Multiple Treatment Options Require Special Attention

Author: Hutchinson, Mark R.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2003


There are 206 bones in the human body and each is susceptible to fracture. The choices in fracture management are complex and based on a number of issues including fracture type, fracture pattern, specific bone, age of fracture, age of patient, associated injuries, and physician preference. Co....

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....

2008 CPT Coding Update

Author: Jorwic, Therese M

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2008


The new CPT codes took effect January 1, 2008. Changes include 244 additions, 314 revisions, and 50 deletions. A comprehensive list of changes can be found in appendix B of the CPT book. Highlights of the changes by section are outlined here.
Evaluation and Management

A revised....

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....

Coding Bunionectomy

Author: Kapoor, Alka

Source: CodeWrite | AHIMA newsletter article

Publication Date: March 2014



Bunionectomy is a surgical procedure to excise a bunion. After reading this article you should be able to understand the concepts of assigning the correct CPT code for bunionectomy.



The online Encyclopedia of Surgery defines a bunion as "an enlargement of the joint at....

Too Many Coding Systems, Too Much to Do: Different Clinical Classification and Clinical Terminology Systems Uniquely Impact IT, Quality Management

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2014



The notion of managing and being accountable for the health status of defined populations requires much more sophisticated clinical data collection methods and skills than most healthcare organizations have today. Numerous “coding systems” have been used for decades to successf....

Internal Radiation Brings Hope to Prostate Cancer Patients: With Brachytherapy Treatment Come New HCPCS Codes

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


In 2003, the American Cancer Society estimates that 220, 900 men will be diagnosed with prostate cancer in the US, making it the second leading cause of cancer deaths in men.1 Today in the US, patients with prostate cancer have access to less invasive surgical cancer treatment plans. This arti....

ICD-10-CM Update 2012

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2012


This article highlights the 2012 ICD-10-CM update as approved by the ICD-9-CM Coordination and Maintenance Committee. The 2012 ICD-10-CM update includes the addition of new codes that already exist in ICD-9-CM, implemented in the FY 2012 ICD-9-CM update or recently incorporated into ICD-10 th....

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