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Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement

Author: Whittle, Kelly

Source: Journal of AHIMA

Publication Date: September 2016



It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....

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....

When Documentation Supports a Procedural Complication Diagnosis

Author: Reed, Andretta

Source: CodeWrite

Publication Date: April 2016



The challenges of reporting Present on Admission (POA) indicators on inpatient accounts continue after ICD-10 implementation. With diagnoses that link to Hospital Acquired Conditions (HACs), coding professionals must ensure the correct code and POA indicator are chosen. The reporting not o....

What's Up With Sepsis...Again

Author: Easterling, Sharon

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2016



BACKGROUND


Much discussion among medical, coding, and clinical documentation professionals has followed the recent release of the Sepsis-3 (Sep-3) definition, "Life-threatening organ dysfunction caused by a dysregulated host response to infection," published in JAMA: The Jour....

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....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Who Has the Official Guidelines for Interpretation of Coding Guidelines or Appropriateness of Code Assignment?
For ICD-9-CM coding questions and guidelines we look to Cooperating Parties for ICD-9-CM. The National Center for Health Statistics and the Health Care Financing Administration receiv....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where Can I Find Coding Guidelines for Use in Long Term Care or for Skilled Nursing Facility Reporting?

The official coding guidelines (see earlier question regarding who has the official guidelines for code assignment) are applicable in long term care. These guidelines have been develope....

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....

US Organizations Look Ahead

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2008


Transitioning to ICD-10-CM may seem like a distant problem. But SSM Integrated Health Technologies began its preparations about three years ago. Its reason is simple: “Something of this magnitude, you don’t want to be scurrying,” says Anne Stuckel, SSM’s manager of clini....

US Must Adopt ICD-10-CM and ICD-10-PCS

Author: AHIMA

Source: AHIMA position statement

Publication Date: July 21, 2005

Immediate Action to Upgrade Medical Code Set Standards Needed


AHIMA's Position


The Department of Health and Human Services (HHS) must immediately initiate the regulatory process for adoption and implementation of ICD-10-CM and ICD-10-PCS code sets (referred to as ICD-1....

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....

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