Author: Fenton, Susan H.; Gamm, Larry D.

Source: AHIMA Computer-Assisted Coding Meeting

Publication Date: October 05, 2007

Author: Fenton, Susan H.; Gamm, Larry D.

Source: AHIMA Foundation | AHIMA eContent

Publication Date: May 02, 2007

Author: Bryant, Gloryanne H.

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

Publication Date: November 2007

This year the Office of Inspector General (OIG) issued two reports relating to wound care services and Medicare payments. As the OIG has included wound care services as part of its 2007 work plan, coding and HIM professionals should review each report and re-assess their organization̵....

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2011

Coding malnutrition has always been a challenge, especially since MS-DRGs were implemented. However, with Recovery Audit Contractors and other regulatory auditing being initiated across the country, providers and HIM professionals must be proactive rather than reactive when coding this conditi....

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2012

There is much to do before we reach ICD-10 go-live in our organizations-including engaging the medical staff. Physician engagement is important in all healthcare settings and initiatives, but it will be essential in an organization's successful transition to ICD-10.

Obtaining engage....

Author: Huff-Allen, Angela; Wills-Dubose, Sarah

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004

Millions of people are afflicted with chronic sinusitis annually. Most patients can be effectively treated with antibiotics, but for those who cannot, surgery is often recommended.
Endoscopic sinus surgery (ESS) is one of the fastest growing procedures performed in the field of otolaryng....

Author: Simmons, Cortnie R.

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: February 02, 2011

This is the first in a series of articles focusing on body systems, the systems' common medical terminology, and some differences in the systems' ICD-10-CM/PCS code assignments.

So here we are in 2011, a little bit closer to October 2013, and by now every coding professional should k....

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....

Author: King, Mitchell S.; Lipsky, Martin S; Sharp, Lisa

Source: Journal of AHIMA

Publication Date: July 2002

As the government turns its high beams on fraudulent billing, physician E/M coding is raising questions. With several studies spotlighting the difficulty physicians have in applying CPT E/M codes, the authors wanted to know if credentialed coders had the same problem. Here’s what they fou....

Author: American Hospital Association; AHIMA

Source: AHIMA

Publication Date: June 24, 2003

Author: Cox, William G.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2004

Effective January 1, 1988, a provision of the Balanced Budget Act of 1977 (Section 4511) removed restrictions on settings where nurse practitioners, physician assistants, and clinical nurse specialists provide services. The definition of a clinical nurse specialist was also modified to requir....

Author: American Hospital Association; AHIMA

Source: AHIMA

Publication Date: June 24, 2003

Author: American Hospital Association; AHIMA

Source: AHIMA

Publication Date: June 24, 2003

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: February 2013

Members of the AHIMA staff and ICD-10 Implementation Coalition recently met with the incoming House of Representatives Energy and Commerce Committee and Health Subcommittee Vice Chairman, Michael Burgess, MD. Discussion included considerations for how to reach out to those physician groups....

Author: Boppre, Debra

Source: AHIMA online training

Publication Date: April 07, 2011

Seminar Date: April 7, 2011

Faculty: Debra Boppre, RHIA, CCS, CCS-P

Description

E/M Auditing: Establishing an Effective Audit Program focuses on developing the required skills to accurately validate physician practice E/M services from a compliance perspective. This....

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2015

Editor’s Note: This Practice Brief supersedes the October 2012 Practice Brief “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation.”


Improving patient care continues to take center stage in the healthcare industry, as demonstrated by an increa....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2012

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 10, 2016

In the years leading up to ICD-10-CM/PCS implementation, doomsdayers chanted horror stories of expected productivity losses of up to 50 percent. Now that we are nearly six months post-implementation, I’ve yet to hear about an instance where such a prediction came true.....

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.

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....

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....

Author: Foley, Margaret M.

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

Publication Date: July 2015

Prior to the October 1, 2015 implementation of ICD-10-CM/PCS, every hospital must examine how the new code set will impact MS-DRG reimbursement. A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimburs....

Author: Davies, Sharon

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

Publication Date: September 2016

Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the p....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2012

In an industry facing several distractions from various government initiatives and regulation changes, ICD-10-CM/PCS became the center of attention from April 16-17 as top experts and interested parties gathered in Baltimore, MD to discuss the ongoing transition to the new code set at the 2012....

Author: Clack, Crystal

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

Publication Date: November 2015

Every medical practice should have preventive measures in place to avoid costly coding and billing audits, errors, and subsequent delays in payment. Incorrectly coded claims, missing charges on a patient encounter, and other mistakes can take a substantial bite out of both practice and ph....

Author: Sims, Kimberly F

Source: Journal of AHIMA

Publication Date: January 2016

More than 60 million American adults experience heartburn at least once a month, and more than 15 million adults suffer daily from heartburn.1 Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter (LES) is weak or relaxes inappropriately, allowing the stomach’s....

Author: Hefti, Erik ; Blanco, Javier G

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

Publication Date: January 2016

The “personalized medicine” paradigm is at the forefront of discussions about the future of healthcare, and a wealth of new data concerning how human genetic variation contributes to drug response has the potential to change the practice of medicine. The promise of treating pat....

Author: Clark, Margi

Source: Brief Encounter

Publication Date: July 02, 2001

Here are some specific suggestions for improving the clarity and usefulness of physician record entries to support Evaluation and Management code levels.
History
Chief complaint with adjectives (8)
Site, description, severity, duration, timing (when) context (what is patient do....

Author: Rhinehart, Ebenetta M

Source: CodeWrite | AHIMA newsletter article

Publication Date: April 2015

Clinical documentation specialists (CDS’s) are experiencing an increased emphasis on the work they do because of the increased specificity required for ICD-10-CM and ICD-10-PCS coding. Currently, unanswered queries are a nuisance and may result in an inaccurate diagnosis-related group&nbs....

Author: Perez, Mario A. III; Tully, Melinda

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction

Public, consumer, and regulatory demands for meaningful and useful quality of care information call for a response from healthcare providers and HIM professionals. Healthcare leaders must treat public performance reporting and report cards as a strategic opportunity to act pr....

Author: U.S. Centers for Medicare & Medicaid Services

Source: Government (U.S.)

Publication Date: May 09, 2006

Author: DeVault, Kathryn

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

Publication Date: June 2016

The implementation of ICD-10-PCS has created new challenges in coding surgical procedures. While coding professionals have always been expected to read and interpret all surgical documentation, ICD-10-PCS has increased the level of understanding necessary for accurate code assignment.

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....

Author: Simmons, Cortnie R.

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: June 02, 2011

While the last article we discussed the musculoskeletal system, this article will be discussing diseases of the eye and ear. The eye and ear are two of the most complex sensory organs. The eye is composed of structures that are not only related to vision but other sensory organs as well. The e....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2009

One of ICD-10-PCS’s goals is to ensure a complete picture of a patient’s procedure. Completeness means that there is a unique code for all substantially different procedures, including the same procedure performed using a different approach.

All ICD-10-PCS codes are seven....

Author: Sanvik, Gina

Source: Journal of AHIMA - website

Publication Date: June 08, 2016

While working on the team for AHIMA’s Code-CheckTM Coding Question Service, I’ve noticed several questions related to providing clarification in ICD-10-CM for a fracture in a patient with known osteoporosis.


ICD-10-CM expands the code selection to more than 150 pa....

Author: Scichilone, Rita A

Source: Journal of AHIMA

Publication Date: July 1999

Coding for diagnostic services performed in physician offices and clinics requires an understanding of some special reporting guidelines. Here are some helpful tips.
The Question of Ownership

Reporting laboratory and radiology procedures depends on ownershi....

Author: Cogley, Janis

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

The origins of using diagnosis codes in hospitals and other healthcare settings goes back to the early 1950s when the US Public Health Service and the Veterans Administration extended the concept of using the International Classification of Diseases to hospital indexing of m....

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....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: May 31, 2016

Prior to the implementation of ICD-10-CM/PCS, Chloe Phillips, MHA, RHIA, director, HIM and clinical revenue at Brookwood Baptist Health, and her team had a decision to make. Would her organization continue using CPT codes on outpatient and physician claims, or would they dual code them usi....

Author: Majerowicz, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2011

Although the ICD-10-CM/PCS implementation deadline is two and a half years away, it is not too early to begin planning coder training. Solid training plans will ensure a smooth transition and minimize the transition's impact on productivity. A well-planned training strategy will ensure that co....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2010

This practice brief has been retired. It is made available for historical purposes only.

Author: AHIMA Coding Team

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2001

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author:

Source: AHIMA Advantage

Publication Date: December 2009

Author: Lefert, Charlotte

Source: Long Term Care Insights | AHIMA newsletter article

Publication Date: February 2009

Determining the principal diagnosis in long term care facilities can be challenging. With the adoption of HIPAA, definitive guidance for coders in nursing homes was established. It is important that staff performing the task of ICD-9-CM coding is aware and adhere to the requirements and gu....

Author: AHIMA Coding Products and Services Team

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2004

This practice brief has been retired. It is made available for historical purposes only.

Author: Smith, Gail I.

Source: AHIMA Convention

Publication Date: October 01, 2011

Author: DeVault, Kathryn

Source: Journal of AHIMA

Publication Date: July 2012

The conversion to ICD-10 impacts all segments of healthcare, including data management processes.

The 2012 ICD-10 Summit provided attendees and presenters alike the opportunity to learn from the experiences of their peers and hear first-hand accounts of ICD-10 implementation successe....

Author: Stanfill, Mary H

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

Publication Date: March 2006

Code assignment for physician evaluation and management (E/M) services is inherently problematic because of the multiple coding rules and reporting guidelines that must be applied and the subjectivity of the codes. Consistent E/M coding practices are critical in the physician practice setting.....

Author: Comfort, Angie

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

Publication Date: February 2017

As last year drew to a close, facilities began the looming task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule to ensure their chargemaster and systems were up-to-date with the 2017 changes. The final rule for calendar year (CY) 2017 was released on Novem....

Author: Bhuttar, Vijaya Kumar

Source: Journal of AHIMA

Publication Date: June 2011

Payers that are not ready to migrate from legacy systems are looking at tactical solutions for making their existing systems ICD-10 compliant in the near term. Most solutions involve a crosswalk between old and new code sets, created from four basic options.

For a long time, le....

Author: Buttner, Patty

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

Publication Date: February 2015

On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....

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....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2014

On January 1, 2014, the American Medical Association’s Current Procedural Terminology (CPT) was updated with additions, revisions, and deletions. In total, 175 new codes were added, 107 codes were revised, and 47 codes were deleted. In addition, editorial changes and coding guideline addi....

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....

Author: Miller, Jackie

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013

The CPT code set has undergone extensive revisions for 2013, with codes, guidelines, and modifiers being revamped and updated. HIM coding professionals should download and review the CPT 2013 errata on the AMA website before starting to use the new codes. This download can be accessed at w....

Author: O’Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012

The 2012 updates to the CPT code set include 278 new codes, 139 code revisions, and 98 code deletions. This brings the total number of CPT codes to 9,641.

All major sections of the CPT code set, as well as the introduction and appendix A, have undergone changes. Beginning with the i....

Author: Buttner, Patty

Source: CodeWrite | AHIMA newsletter article

Publication Date: June 2016

This year has brought many new additions to Current Procedural Terminology (CPT®) coding. This article discusses several new codes related to percutaneous biliary procedures. A new range of 14 codes for percutaneous biliary procedures has been introduced in the Digestive System subse....

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....

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:....

Author: Kirschner, Celeste G.; Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2000

The American Medical Association's CPT 2000 Coding Symposium was held recently in Chicago to discuss the more than 300 revisions in the 2000 Current Procedural Terminology (CPT). Here is a brief summary of the changes. 
A complete listing of the code and guideline changes can be foun....

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003

In 1998, the American Medical Association (AMA) initiated the CPT-5 Project. This project was a broad-based and comprehensive effort to make needed and practical enhancements to the CPT code set that would address challenges presented by emerging user needs and HIPAA. One of the initiatives tha....

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2001

Among the needs the CPT-5 Project addresses are changes to enhance the use of CPT by practicing physicians, managed care and other payer organizations, and researchers. The project has made recommendations for improvements in the structure and processes of the CPT codes with deliberate emphasi....

Author: Piselli, Caroline; von Saleski, Bernice; Belley, Susan; Garrett, Gail S.; Zak, Cindy

Source: AHIMA Convention

Publication Date: September 27, 2010

Introduction:

Caroline Piselli, Moderator

As the countdown to ICD-10 reaches 3 short years, this comprehensive overhaul of healthcare informatics moves front and center for HIM professionals. ICD-10 is on the one hand a massive logistical and technical challenge for every fac....

Author:

Source: AHIMA Advantage

Publication Date: June 2009

Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.

Source: Journal of AHIMA - website

Publication Date: November 2014

The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....

Author: Butler, Rhonda R.

Source: Journal of AHIMA

Publication Date: November 2009

Like the rest of us, MS-DRGs have to transition to ICD-10-CM/PCS. The conversion is off to a good start, with a preliminary version already available. The project offered an early test of the General Equivalence Mappings and provides a conversion process for other applications.

In m....

Author: Rihanek, Theresa; DeVault, Kathryn

Source: Journal of AHIMA

Publication Date: May 2012

Many healthcare organizations use historical coded data in governance and planning activities, contracting, quality improvement, research, and trending. The upcoming implementation of ICD-10-CM/PCS will require organizations to identify the types of coded data that will require conversion in o....

Author: Bielby, Judy A

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

Publication Date: May 2016

In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States wo....

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....

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2001

Proposed changes, if approved, would not become effective until October 1, 2002.

The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Fina....

Author: Prophet, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2001

by Sue Prophet, RHIA, CCS



The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Health Care Financing Administration (HCFA), met on November 17, 2000, in Baltimore, MD. Donna Pickett, RHIA, from NCHS, and Patri....

Author: Bowman, Sue E

Source: AHIMA testimony and comments

Publication Date: April 12, 2006

Comments on the proposed procedure code revisions recommended for implementation in October 2006

Author: Bowman, Sue E

Source: AHIMA testimony and comments

Publication Date: April 12, 2006

Comments on the proposed diagnosis code revisions recommended for implementation

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 10, 2016

Zika virus is a mosquito-borne virus that was first identified in Uganda in 1947 in rhesus monkeys. There has recently been a rise in incidences of the Zika virus in Brazil. More than 13 countries in the Americas have reported sporadic Zika virus infections, indicating....