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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-CM-PCS Coalition Letter to US House of Representatives Leadership

Author: Advanced Medical Technology Association; AHIMA; American Medical Informatics Association (AMIA); Blue Cross and Blue Shield; Cepheid; Health IT Now Coalition; Medical Device Manufacturers Association (MDMA); 3M Health Information Systems; Roche Diagnostics Corporation; Siemens Health Services

Source: AHIMA testimony and comments

Publication Date: May 17, 2013

Coalition letter supporting the October 2014 adoption of ICD-10-CM for reporting diagnoses by all health care providers and ICD-10-PCS for hospital reporting of inpatient procedures, collectively referred to as ICD-10, with opposition to further delaying full compliance with the planned adoption of ICD-10.

ICD-10-CM Official Coding Guidelines

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


One of the keys to a successful transition to ICD-10-CM/PCS is a thorough understanding of the ICD-10-CM Official Coding Guidelines, which were posted to the National Center for Health Statistics Web site in January 2009. Similar to the ICD-9-CM coding guidelines, the ICD-10-CM guidelines are....

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....

ICD-10-CM and ICD-10-PCS Preview Exercises

Author: Barta, Ann

Source: AHIMA book

Publication Date: January 02, 2010


Description:   ICD-10-CM and ICD-10-PCS are on their way, and it is imperative that coding professionals be prepared for the transition to the new coding system. This workbook will prepare current coding professionals for the increased knowledge required by the implement....

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....

HIV/AIDS in ICD-10-CM

Author: Parman, Cindy C

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2014



Human immunodeficiency virus (HIV) attacks the immune system, the body's natural defense system. And of course, without a strong immune system the body has trouble fighting off disease. Both the virus itself and the resulting infection are called HIV. The final stage of HIV infection is a....

Hiring Tips for ICD-10 Help

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2013


Staff up or suffer. That is one message HIM professionals are hearing regarding the upcoming ICD-10-CM/PCS transition. Clinical documentation specialists will be needed to ensure clinicians adequately document provided care that validates the new, more detailed ICD-10 codes. Coders with ICD-10....

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....

Heart of the Matter: ICD-10-PCS Cardiac Coding

Author: Land, Daniel

Source: Journal of AHIMA

Publication Date: January 2017



A robust knowledge of anatomy and cardiac surgery techniques, a comprehensive understanding of coding guidelines, and an eye for precision are key components of correct ICD-10-PCS cardiac coding.


This article will review ICD-10-PCS Official Guidelines for Coding and Reportin....

Health Plans: Tasks for 5010 & ICD-10-CM/PCS Compliance

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009


The transition to 5010 and ICD-10-CM/PCS will be a challenge for Health Plans. A key to success in this transition is thorough and advance preparation as well as coordination of concomitant efforts to comply with 5010 and ICD-10. Payers may be tempted to focus on the 5010 compliance project fir....

Healthcare Industry Stakeholders Letter to Secretary Sebelius concerning Adoption of ICD-10-CM/PCS

Author: Advanced Medical Technology Association; AHIMA; American Hospital Association; American Medical Informatics Association (AMIA); Blue Cross and Blue Shield; College of Healthcare Information Management Executives; Health IT Now Coalition; Medical Device Manufacturers Association (MDMA); 3M Health Information Systems; Roche Diagnostics Corporation; Siemens Health Services; Wellpoint

Source: AHIMA testimony and comments

Publication Date: March 12, 2014

Joint letter to CMS Administrator Marilyn Tavenner expressing continued support for the October 2014 adoption of ICD-10-CM and ICD-10-PCS.

Guidelines for Achieving a Compliant ICD-10-PCS Query

Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2016



Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.




The complex and highly specific nature of ICD-10-PCS has changed....

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....

Getting the Best from Your ICD-10 Vendor

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: May 2011



May 10, 2011


Payers and providers must work their way through the transition to ICD-10-CM/PCS only once, and by the end, few will likely choose to do it again. System vendors and consultants, however, will have been through many, many implementations before it’s all over.

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....

FY 2017 Updates to ICD-10-CM

Author: Rugg, Donna

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

Publication Date: November 2016



The ICD-10 Coordination and Maintenance Committee’s code freeze, first implemented after the October 1, 2011 annual update, has finally thawed. For fiscal year (FY) 2017 the ICD-10-CM classification is back on track with annual code and guideline updates. Due to the thousands of new/....

FY 2016 CPT Updates

Author: Clack, Crystal

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

Publication Date: February 2016



When the first edition of the Current Procedural Terminology (CPT) was released in 1966, there were only 3,554 codes. In 2016, CPT, published by the American Medical Association (AMA), is celebrating its 50th birthday with 10,000 CPT codes. This year’s CPT updates include 140 codes added,....

FY 2012 ICD-10-PCS Updates

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012


Limited updates were made to ICD-10-PCS for fiscal year 2012 as set forth under the partial code freeze established by the ICD-9-CM Coordination and Maintenance Committee.1 The freeze is intended to aid the transition to the new code set by limiting updates for 2012 and 2013 to essential chan....

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

....

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....

Four CDI challenges Emerge in ICD-10

Author: Fee, James P

Source: Journal of AHIMA - website

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....

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-....

Experts Suggest Beginning ICD-10 Implementation Today

Author: AHIMA

Source: AHIMA Today

Publication Date: October 05, 2009


There is no time like the present to begin planning for the national coding switch to ICD-10-CM/PCS, according to several HIM professionals presenting here at convention.

Coding staff don’t need to start poring over new code books yet. But other preparations must be made for a facili....

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