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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....

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....

Building on the ICD-10-PCS Puzzle

Author: Scott, Nena

Source: CodeWrite | AHIMA newsletter article

Publication Date: June 2016



ICD-10-PCS presents many major challenges, with many obstacles. This procedural system is like putting a puzzle together. Finding the pieces to the puzzle requires the coding professional to read the entire operative report and, if applicable, the entire pathology report.


As....

Why You Should Care About Clinical Documentation

Author: Sims, Kimberly F

Source: CodeWrite

Publication Date: January 2016

Objective


The objective of this article is to look at how specific and detailed documentation written by the physician can assist with coding procedures with the root operation excision.



The introduction of ICD-10 has brought about an increased need to ensure th....

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....

ICD-10-PCS Coding in the Real World

Author: Smith, Donna

Source: AHIMA Convention

Publication Date: September 26, 2010

Introduction

ICD-10-Procedure Coding System (PCS) is a completely different method of assigning codes to surgical procedures, but it has many advantages over its counterpart ICD-9-CM. First of all it is a straightforward system allowing for expansion as new procedures are developed; whil....

CPT Update 2011

Author: Smith, Gail I.; Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2011


Each year CPT adds codes to reflect new procedures and surgical techniques. For example, new codes were added in the surgical section to identify procedures performed using balloon catheters.

In addition, CPT continues to make editorial changes and add coding guidelines within the t....

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....

Preparing for ICD-10- CM/PCS Implementation: Impact on Productivity and Quality

Author: Stanfill, Mary H; Hsieh, Kang Lin; Beal, Kathleen; Fenton, Susan H.

Source: Perspectives in Health Information Management

Publication Date: July 2014


Abstract


Coding productivity is expected to drop significantly during the lead-up to and in the initial stages of ICD-10-CM/PCS implementation, now expected to be delayed until October 1, 2015. This study examined the differences in coding productivity between ICD-9-CM and ICD-10-....

Value of ICD-10 at the Point of Care

Author: Stearns, Michael

Source: Journal of AHIMA - website

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....

Modifers – ‘Friend or Foe’

Author: Swindle, Jennifer

Source: AHIMA Convention

Publication Date: October 02, 2011

ABSTRACT:

Background: The need for modifiers to further and appropriate identify accurate coding information to all payers is critical for appropriate and accurate reimbursement. Failure to use modifiers can have a negative impact on a physician or an organizations’ revenue as witho....

Back to Basics: APC Payment Methodology

Author: Tomak, Tracey

Source: CodeWrite | AHIMA newsletter article

Publication Date: April 2017



In August of 2000, the Centers for Medicare and Medicaid Services (CMS) introduced the Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS). The objective of the APC payment system was to control costs and increase efficiencies for outpatient ser....

IRF PPS Coding Challenges

Author: Trela, Patricia

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

Publication Date: May 2007


Inpatient rehabilitation facility (IRF) coding can be a challenge due to the Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS), which was implemented in 2002 to cover patients paid under Medicare Part A. IRF PPS requires completion of the IRF-Patient Assessment In....

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....

Coding Radiology Services

Author: Walk, Gerri

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2009


Because coding and radiology departments often share accountability for the quality of outpatient radiology coding, it is important that coding professionals share coding issues and charge capture expectations with radiology staff. This article outlines methods to improve the quality of coded....

Seventh Character Application for Injuries in the Principal Diagnosis and the Impact to Data Quality

Author: Wall, Kathleen E.

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 25, 2016



By now, we’ve all had practice assigning 7th characters for injuries. And, by now, we all know that in theory the guidance seems very clear—but the application of this new concept is not clear at all. Why is there so much confusion and why does it matter? What are the short- and long-term....

FY 2017 Updates to ICD-10-PCS

Author: Ward, Maria

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

Publication Date: November 2016



Many changes come with the first update of the new ICD-10 Procedure Coding System (ICD-10-PCS) for fiscal year (FY) 2017. The higher-than-usual volume of changes was to be expected since the update system has been in a holding pattern for several years due to implementation delays. And al....

Effectiveness of ICD-10-CM in Capturing Public Health Diseases

Author: Watzlaf, Valerie J.M.; Garvin, Jennifer Hornung; Moeini, Sohrab; Firouzan, Patricia Anania

Source: Perspectives in Health Information Management

Publication Date: June 2007

This research study examined the usefulness of the ICD-10-CM system in capturing public health diseases (reportable diseases or the nationally notifiable infectious diseases, leading causes of death, and morbidity/mortality related to terrorism), when compared to ICD-9-CM. It also examined agreement levels of coders when coding public health diseases in both ICD-10-CM and ICD-9-CM.

Effective and Efficient Public Health Reporting Using ICD-10-CM and ICD-10-PCS

Author: Watzlaf, Valerie J.M.; Garvin, Jennifer Hornung; Moeini, Sohrab; Firouzan, Patricia Anania

Source: AHIMA Convention

Publication Date: October 31, 2006

Effective Public Health Reporting Using ICD-10-CM
Valerie JM Watzlaf, PhD, FAHIMA, RHIA, Jennifer Hornung Garvin, PhD, FAHIMA, RHIA, CTR, CCS, CPHQ, Sohrab Moeini, BSIS, and Patti Firouzan, MSIS, RHIA
Impact
Introduction

The emergence of ICD-10-CM brings anticipation about....

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