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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....

Nothing Lasts Forever: How Physicians Can Prepare for the End of the One-Year Amnesty from Post Payment Reviews Due to Unspecified Codes

Author: Lee, Christine

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

Publication Date: May 2016




Just as ocean tides shift with the earth's gravitational pull, physician practice administrators align staff and focus resources to address their organizations' most pressing concerns. This year, the tsunami grabbing administrators' attention is the conclusion of a one-year grace peri....

Interpreting "With" in ICD-10-CM

Author: Endicott, Melanie

Source: CodeWrite

Publication Date: April 2016



This article has been updated based on new Coding Clinic advice.


The ICD-10-CM Official Guidelines for Coding and Reporting states the following at I.A.15:



The word "with" should be interpreted to mean "associated with" or “due to” when it appe....

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....

Understanding CDI Metrics

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 24, 2016


Understanding clinical documentation improvement (CDI) metrics can be confusing, especially when you first start reviewing them.


Let’s dive a little deeper into the topic and take a closer look at some frequently reported CDI metrics and evaluate how these measures can reflect the....

Coding Zika Virus

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....

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,....

Using Additional Diagnoses to Improve Productivity

Author: Martin, Ginny

Source: CodeWrite

Publication Date: February 2016



ICD-10 has now been in effect for several months and coding professionals have become more familiar with the new codes and guidelines. The initial training and education is complete and ongoing quality reviews are being done to analyze coding accuracy. But what else can this data tell us?....

Revisiting Unrelated Surgical Procedures (MS-DRGs 981-989)

Author: Wilson, Donna D

Source: CodeWrite

Publication Date: February 2016



Make a fresh start in the new year by revamping coding compliance plans to include a second level review of all claims that group into MS-DRGs 981-989 (Operating Room Procedure/Unrelated to Principal Diagnosis). Historically, MS-DRGs 981-989 have been "low hanging fruit" for outside audito....

Putting the ICD-10-CM/PCS GEMs into Practice (2016 update) - Retired

Author: Archer, Anita; Campbell, Angela; D'Amato, Cheryl; McLeod, Melissa; Rugg, Donna

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2016


Editor's Note: This Practice Brief supersedes the May 2013 and March 2010 Practice Briefs titled "Putting the ICD-10-CM/PCS GEMs into Practice."


Mappings between ICD-9-CM and ICD-10-CM/PCS will play a critical role in the successful utilization of ICD-10-CM/PCS. The Centers for Me....

Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement

Author: Kittinger, Benjamin J; Matejicka, Anthony II; Mahabir, Raman C

Source: Perspectives in Health Information Management

Publication Date: January 2016


Abstract


Emphasis on quality of care has become a major focus for healthcare providers and institutions. The Centers for Medicare and Medicaid Services has multiple quality-of-care performance programs and initiatives aimed at providing transparency to the public, which provide th....

So You Think You Know Diabetes Mellitus?

Author: DeVault, Kathryn

Source: CodeWrite

Publication Date: January 2016




According to the American Diabetes Association, 9.3 percent of the population—29.1 million people—have diabetes mellitus. This is an increase from 8.3 percent in 2010. Of the 29.1 million who have it now, it's estimated approximately 8.1 million people are undiagnosed.1

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....

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....

Post ICD-10 Implementation: Where Are We Now?

Author: Maccariella-Hafey, Patricia C

Source: CodeWrite

Publication Date: November 2015



We heard deep sighs of relief as October 1, 2015, came and went and ICD-10 was finally implemented in the United States. This has been a long time coming for coding and documentation improvement professionals in the HIM world. At the time of this article's writing, we are two weeks into im....

ICD-10 Two Weeks In: How’s it Going?

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: October 2015




Two-plus weeks into the transition to ICD-10-CM/PCS, the chaos predicted by many groups that protested the code sets’ implementation for years has not come to fruition. In fact, preliminary reports from providers, commercial payers, and coding consultants indicate quite the oppo....

IPPS — Final Rule Fiscal Year 2016

Author: Wilson, Donna D

Source: CodeWrite

Publication Date: October 2015



Like clockwork, the Centers for Medicare and Medicaid Services (CMS) published the Inpatient Prospective Payment System (IPPS) final rule in the August 17, 2015 Federal Register. These changes to the regulations apply to approximately 3,400 acute care hospitals and will go into effect Octo....

Editorial: The Need for Mentoring and Training

Author: Brownfield, Cathy

Source: CodeWrite

Publication Date: October 2015




The current demand for coders is extremely high, making it more important than ever for new coders to enter our industry. Many of us are asked, "How do I get into coding?" We then see posts on message boards from students who just graduated saying they can't find a job because they ha....

Understanding HIM’s Impact on Quality at the National Level

Author: Munn, Catherine; Backman, Cecilia; Costello, Stephanie; Wise, Lee A; Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: October 2015



The future of healthcare continues to evolve with the introduction of alternative reimbursement models. The industry is moving from traditional fee-for-service models to those focused on quality of care and documented outcome improvements. The Patient Protection and Affordable Care Act of....

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....

Physician Coding Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: September 2015

This provider practice coding toolkit provides multiple tools and resources to help providers successfully navigate through the many changes in today’s healthcare environment.

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....

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.

Clinical Definition Standards Case Study

Author: Lusk, Katherine

Source: Journal of AHIMA

Publication Date: July 2015



With the October 1, 2014 date for prospective payment for inpatient pediatric Medicaid discharges looming, Children’s Health System of Texas identified an organizational need to reboot and formalize its clinical documentation improvement (CDI) program. The journey began with three co....

New CDI Challenge: Adjusting to Quality, Not Quantity

Author: Murphy, Brian

Source: Journal of AHIMA

Publication Date: July 2015



It’s no secret that healthcare is undergoing a profound transformation. While fee-for-service delivery remains the current model for acute care hospital payment, the transition to paying for quality over quantity is happening before our eyes.


In January, the Centers for Me....

Closing the Loop on Quality and CDI: Refocusing Programs to Ensure an Accurate Picture of Clinical Care

Author: Gurrieri, Joseph J; Milligan, Cassie; Strafer, Paul

Source: Journal of AHIMA

Publication Date: July 2015



The ultimate goal of most CDI programs is to improve the quality of patient care through more accurate and complete clinical documentation. A potential increase in revenue is, of course, a positive byproduct of doing so—which makes sense. If organizations can demonstrate severity of illne....

Reinvigorating Your CDI Program

Author: Geissler, Kristen; Dion, Joni

Source: Journal of AHIMA

Publication Date: July 2015



Long gone are the days of “grab and go” coding, finding the CC/MCC to push reimbursement to the next level and then moving on to the next record. Today, in addition to reimbursement, clinical data drives quality initiatives, hospital and physician profiles, and medical necessit....

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