1543 results.
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Benefits and Barriers for Outpatient CDI Programs
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 27, 2016
Many hospitals that have implemented clinical documentation improvement (CDI) programs have seen a reduction of claim denials and an improvement in appropriate reimbursement payments and accurate quality scores. For these reasons, CDI programs have become very....
Coding Diabetes Mellitus with Associated Conditions
Author: Sanvik, Gina
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 11, 2016
There has been some confusion among coding professionals regarding interpretation of the coding guideline of “with.” An area that contains many instances of using this guideline in ICD-10-CM is coding Diabetes Mellitus with associated conditions. There are 53 instances of....
AHIMA Comments on March 2016 ICD-10-CM code proposals
Author: Bowman, Sue E
Source: AHIMA testimony and comments | AHIMA Advocacy and Policy
Publication Date: May 04, 2016
AHIMA’s comment letter on ICD-10-CM proposals discussed at the March 2016 ICD-10 Coordination and Maintenance (C&M) Committee and being considered for implementation October 2017.
Coding Administration of Vaccinations With or Without Counseling
Author: Monestime, Judy
Source: CodeWrite
Publication Date: May 2016
The purpose of this article is to describe how to code administration of vaccinations with or without provider counseling.
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....
Interpreting "With" in ICD-10-CM
Author: Endicott, Melanie
Source: CodeWrite
Publication Date: May 2016
This article updates and replaces the April 2016 CodeWrite article with the same title, based on new Coding Clinic advice.
Codewrite (May 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: May 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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....
ICD-10-CM Coding for Injury Resulting from Terrorism
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2016
On October 1, 2015, the ICD-10-CM coding classification was implemented in the United States. This article provides a coding update on how to report injuries resulting from terrorism, which is now classifiable under ICD-10-CM. In the US, ICD-10 (mortality coding) and ICD-10-CM (morbidity c....
Lessons Learned from Training an International Workforce
Author: Strafer, Paul; Milligan, Cassie
Source: Journal of AHIMA
Publication Date: May 2016
In an increasingly interconnected world, offshore coding has piqued the interest of many health information management (HIM) directors hoping to cut costs, alleviate staffing shortages, and tap into a new pool of talented individuals. Coding companies have worked earnestly to train overse....
Continuing on the Intriguing ICD-10 Journey
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....
Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016
Author: Bonner, Dari; Fancher, Karen M
Source: Journal of AHIMA
Publication Date: May 2016
Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI s....
Mentoring is Vital in Developing New Coding Professionals
Author: Ritter, Jennifer
Source: Journal of AHIMA - website
Publication Date: May 01, 2016
An often discussed theme in the health information management (HIM) profession as well as the 2015 AHIMA Convention is the ability for facilities to grow their own coding professionals. As coding resources continue to be scarce, having an in-house coding training program on any scale is a....
Resolving Conflict in the CDI-Coding Professional Relationship
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: April 27, 2016
If a couple were to decide they wanted to build a house, they would need to communicate regularly to complete the home and make sure it fit the needs of both of them. If one of them were to say, “We need three bedrooms,” and the other one instead said, “No, we must have four bedrooms,” the....
Coding Sepsis vs. Septic Shock
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: April 2016
The definitions and clinical criteria of sepsis and septic shock have been revised, per an article published February 23, 2016 in the Journal of the American Medical Association (JAMA). The recommendations from the 19 physician members of the task force that wrote the new definitions were:....
AHIMA Comments on Proposed Procedure Code Modifications Presented at the ICD-10 Coordination and Maintenance Committee Meeting Held March 2016
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: April 2016
Comment letter to Patricia Brooks, RHIA, Centers for Medicare and Medicaid Services, Hospital and Ambulatory Policy Group, Division of Acute Care
ICD-TEN: Top Emerging News (April 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: April 2016
emerging news, educational opportunities, practical information on coding with the new ICD-10-CM/PCS, preparatory steps for implementation
Inevitability of ICD-10 Billing Challenges in Skilled Nursing Facilities
Author: Sywyj, Lynn
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: April 2016
To what seems like everyone's surprise, the transition to ICD-10 happened, and yet the world is still spinning and skilled nursing facilities are still receiving payment. However, just because payment is now flowing with relatively minor scrutiny doesn't mean things will stay thi....
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....
CodeWrite (April 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: April 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Finding the New Normal with ICD-10-CM/PCS
Author: Linder, Karen M
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2016
Rochester Regional Health is an integrated health services organization serving the people of western New York and the Finger Lakes region. The system provides care from 150 locations, including five hospitals; more than 100 primary and specialty practices, rehabilitation centers, and ambu....
Wound Care in the Outpatient Setting
Author: Hundal, Ripandeep K
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2016
Wounds are injuries that break the skin or other body tissues. They include cuts, scrapes, scratches, and punctured skin. Wounds are typically due to accidental injury but may also result from surgery, stitches, or chronic disease processes.1
Wound care involves evaluation,....
Effects of ICD-10 on Coding Productivity
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.....
Get the ICD-10 'Next Steps Toolkit'
Author: AHIMA Staff
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: March 2016
Now that you have made the switch to ICD-10, you can look for opportunities to analyze your progress. By tracking and comparing key performance indicators (KPIs), you can identify and address issues with productivity, reimbursement, claims submission, and other processes.
....
Coding Uncertainty in the Outpatient Setting: Tumor Markers and Abnormal Findings
Author: AHIMA Staff
Source: CodeWrite
Publication Date: March 2016
Many patients report to the office or outpatient department with specific symptoms or problems that require evaluation. However, not all patient care is that straightforward; there are certain patients that present with abnormal test findings in the absence of a definitive diagnosis. Section IV....
Calendar Year 2016 OPPS Rule Update
Author: Clack, Crystal
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2016
On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) finalized changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) payment system for calendar year (CY) 2016. The OPPS payment rates and policies impact approximately 4,000....
ICD-10 Opens Documentation Gaps
Author: Diop, Karen
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2016
We studied. We practiced. We prepared. We had extensions—first a year, then two. More time to practice. Then, at long last, October 1, 2015 arrived, bringing with it the much-anticipated new code sets ICD-10-CM and ICD-10-PCS. Despite much hand wringing and nay saying, the implementation....
CodeWrite (March 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: March 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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....
Potential Impact of the ICD-10 Underdosing Classification System
Author: Wall, Kathleen E.
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: February 17, 2016
The implementation of the ICD-10 classification system has provided an opportunity to capture data that has not been previously captured. The classification of “underdosing of drugs” can provide valuable information regarding not only the fact that a drug was underdosed, but also why. Thin....
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,....
Gauging Stakeholder Response to ICD-10
Author: Comfort, Angie; Maimone, Carol; Rugg, Donna
Source: Journal of AHIMA
Publication Date: February 2016
Starting with services provided on or after October 1, 2015, health systems across the country transitioned to coding with the International Classification of Diseases, 10th Revision (ICD-10). Implementation of ICD-10 is intended to deliver both immediate and long-term benefits including....
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....
CodeWrite (February 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: February 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Feedback on Discussion Draft to Improve Health Information Technology
Author: Gordon, Lynne Thomas
Source: AHIMA testimony and comments | AHIMA Advocacy and Policy
Publication Date: January 29, 2016
Letter to Senator Lamar Alexander, Chairman, and Senator Patty Murray, Ranking Member, Senate Committee on Health, Education, Labor and Pensions
Documentation Detective: Seven Steps to CDI Foundational Success
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: January 27, 2016
When an architect draws up plans for a building, they pay close attention to the details of the foundation. This provides the support to the building and prevents it from crashing down at any moment. If the building later has structural damage it is easy to fix when the foundation is not i....
ICD-10: How to Move Your Coding Professionals to the Head of the Class [Sponsored Article]
Author: Godbey-Miller, Barbara
Source: Journal of AHIMA - website
Publication Date: January 2016
This article is published in sponsorship with Berkeley Research Group (BRG).
The year preceding the ICD-10 compliance date was filled with a myriad of challenges for health information management professionals, from department heads to coders, regarding ICD-10 implementation.....
Using CDI Programs to Improve Acute Care Clinical Documentation to Support ICD-10-CM/PCS - Retired
Author: Combs, Tammy
Source: AHIMA practice brief
Publication Date: January 2016
Editor's note: This brief replaces the 2001 practice brief "Documentation Requirements for the Acute Care Inpatient Record, and the 2013 and 2014 versions of the practice brief "Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS."
Code Cracker: New Year, New Code Set, New Opportunities
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: January 13, 2016
I am so excited that ICD-10 is finally here—now we can stop wondering when it’s actually going to be implemented and roll up our sleeves to get to work! Now that it’s officially here and everyone is using it, we can really start to dig into the details and take advantage....
Documenting Pharmacogenomic Testing with CPT Codes
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....
HIM Directors Face Outsourcing Realities: Five New Relationship-building Strategies to Consider in 2016
Author: Saponaro, Charlie
Source: Journal of AHIMA
Publication Date: January 2016
Often viewed as the backbone of a facility’s revenue cycle, health information management (HIM) outsource vendors have seen an explosion in demand as the healthcare industry has transitioned to ICD-10-CM/PCS. Many HIM service companies have seen an increase in volume and client reque....
Don't Let Gastroesophageal Coding Cause Heartburn: Using GERD to Discuss Coding Symptoms Versus Diagnosis
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....
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....
CodeWrite (January 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: January 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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....
Fighting CDI Fires in ICD-10: Three "Burning Questions" Every Organization Must Answer
Author: Haas, Dianne
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: December 2015
It's an unfortunate reality in the world of clinical documentation improvement (CDI) that the majority of documentation challenges in ICD-10 are the same challenges we faced in ICD-9. These challenges didn't disappear overnight just because we flipped the switch to a new coding classificat....
What's the Skinny? Coding an Excision of a Malignant or Benign Skin Lesion
Author: Sims, Kimberly F
Source: CodeWrite
Publication Date: December 2015
Objective
The objective of this article is to describe how to code an excision of a benign and/or malignant skin lesion.
Clinical Information
....
CodeWrite (December 2015)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: December 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Clinical Documentation Improvement: the CDI Journey
Author: AHIMA CDI Workgroup
Source: AHIMA
Publication Date: November 2015
Infographic and glossary depicting the clinical documentation improvement journey
AHIMA's comments on September 2015 ICD-10-PCS code proposals
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: November 2015
Letter to Patricia Brooks, RHIA, Senior Technical Advisor, Centers for Medicare and Medicaid Services, Hospital and Ambulatory Policy Group
AHIMA comments on September 2015 ICD-10-CM code proposals
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: November 2015
Letter to Donna Pickett, MPH, RHIA, Medical Classification Administrator, National Center for Health Statistics
ICD-10 Transition: It’s All About the Guidelines
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: November 11, 2015
Now that ICD-10-CM/PCS has finally been implemented and everyone is using these new code sets, the questions are rolling in. AHIMA’s Engage community is overflowing with questions from coding professionals seeking advice on how to code this or that. Many of the question....
ICD-10 Transition: Five Tools You Can Use to Continue Helping Physicians
Author: Antonios, Sam
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: November 2015
October 1 has passed and we are now in the universe of ICD-10. This was a monumental milestone in the history of US healthcare, but ICD-10 is not an event that has come and gone. In fact, October 1 was just the beginning and things might be temporarily shaky for some physicians before....
Assigning Evaluation and Management Critical Care Codes
Author: Sims, Kimberly F
Source: CodeWrite
Publication Date: November 2015
Objective
The objective of this article is to outline the steps required to assign Evaluation and Management codes for critical care services.
Clinical Information
What is Critical Care?
Critical care can be defined as speci....
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....
CodeWrite (November 2015)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: November 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Don’t Let Preventable CPT Coding Mistakes Cause Heartburn
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....
ICD-10 Moves Healthcare One Step Closer to Improved Documentation
Author: Diop, Karen
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: November 2015
Change has become a constant in healthcare. With the introduction of electronic health record (EHR) systems, core measures, the “meaningful use” EHR Incentive Program, value-based purchasing, and the ICD-10-CM/PCS code sets, the healthcare industry has been bombarded by wave after wave in....
"CDI: Miami" Hunts Down Documentation Offenders
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: October 2015
The HIM Problem
To get physician buy-in on clinical documentation specificity, one provider formed an all-physician CDI team
The HIM Problem Solvers
Lorena Chicoye, MD, RPh, corporate medical director, managed care network development and medical....
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....
CodeWrite (October 2015)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: October 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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....
Road to 10: The Small Physician Practice's Route to ICD-10
Author: U.S. Centers for Medicare & Medicaid Services
Source: U.S. Centers for Medicare & Medicaid Services
Publication Date: October 2015
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....
Aligning Computer-Assisted Coding and Information Governance Efforts
Author: Weinberg, Jason; Peterson, Stephanie; Marc, David; Sandefer, Ryan
Source: Journal of AHIMA
Publication Date: October 2015
AHIMA defines information governance as “the enterprise-wide framework for managing information throughout its lifecycle and supporting the organization’s strategy, operations, regulatory, legal, risk and environmental requirements.”1 AHIMA recognizes that successful heal....
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....
More Specific Physician Documentation Needed for ICD-10-CM
Author: Burgess, Sheila
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: October 2015
The dawn of October also welcomes the official go-live date for ICD-10-CM/PCS—meaning there is absolutely no time left to waste in preparing for the additional documentation requirements necessary for successful ICD-10 implementation. Over the past several years, the healthcare industry h....
Building Clarity on the Two-Midnight Rule
Author: Harris, Shelly; Kelly, Jeannie
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: October 2015
As the Centers for Medicare and Medicaid Services’ (CMS’) Probe and Educate Initiative draws to a close and the 2016 Outpatient Prospective Payment System (OPPS) proposed rules are released for comment, questions remain for the healthcare industry regarding expectations for selecting pati....
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....
Last Minute Tips to Prepare for ICD-10 Implementation
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: September 09, 2015
This is it. The final countdown is on. ICD-10-CM/PCS is just a few short weeks away from finally becoming a reality in the United States. For those of you that have been preparing for years for this day, I bet you are breathing a huge sigh of relief and thinking, “just get it over with alr....
ICD-10-PCS From the Heart: Cardiovascular Procedures
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2015
The complexity of ICD-10-PCS, as well as the need for a better understanding of anatomy and physiology and the technique of surgical procedures, has been well documented. The coding of cardiovascular procedures in ICD-10-PCS, in particular, requires focus.
Consider these p....
Sepsis Under the ICD-10-CM Microscope
Author: Kulanko, Jill
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2015
Sepsis is arguably the most challenging condition to code correctly in ICD-9-CM. The condition itself is complex and the definitions regarding sepsis, SIRS, and severe sepsis have evolved over time, keeping coders on their toes. The guidelines are also difficult to understand. Complicatin....
Adverse Effects, Poisoning, Underdosing, and Toxic Effects
Author: Hansen, Abby
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2015
As we quickly approach the ICD-10-CM/PCS implementation date, let's take a look at some significant changes and new terminology for adverse effects, poisonings, toxic effects, and now, underdosing. Very soon, we will be using a single combination code to capture the adverse effec....
Documentation and Coding in a Risk-based Environment: Obstacles to Be Aware Of
Author: Easterling, Sharon
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2015
With the implementation of the Value-Based Purchasing Model (VBP) and, more recently, statements in the Sustainable Growth Rate (SGR) fix, it remains clear that healthcare is going through a time of change. We must recognize risk in not only patient health management and outcomes, bu....
Top 10 Metrics to Monitor in the First 30 Days
Author: Haugen, Mary Beth
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: September 2015
Technically speaking, anything could happen once we flip the ICD-10 switch on October 1, 2015. That's why it's important to monitor key performance metrics closely in the first 30 days post-implementation. The days and weeks immediately following go-live will provide critical insigh....
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.
CodeWrite (September 2015)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: September 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
AHIMA Comments on CY 2016 Home Health Prospective System Proposed Rule
Author: Gordon, Lynne Thomas
Source: AHIMA testimony and comments
Publication Date: August 2015
Letter to Andrew Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services, Department of Health and Human Services
AHIMA Comments on CY 2016 Outpatient Prospective Payment System Proposed Rule
Author: Gordon, Lynne Thomas
Source: AHIMA testimony and comments
Publication Date: August 2015
Letter to Andrew Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services, Department of Health and Human Services
ICD-10 CDI DIY: Documentation Tip Sheets
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 12, 2015
Among the most helpful tools for assisting providers through the transition to ICD-10-CM/PCS are documentation tip sheets detailing the specificity needed to assign accurate codes. Many companies are selling tip sheets, but if you are looking to save a few dollars, here’s a step-by-s....
CodeWrite (August 2015)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: August 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Value-Based Purchasing Programs and Coding Impact: A VBP Primer
Author: Lojewski, Tedi
Source: CodeWrite
Publication Date: August 2015
According to the Centers for Medicare and Medicaid Services (CMS), value-based purchasing (VPB) has been "a long-standing effort to link Medicare's payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital se....
Preventing Fraud and Abuse in Clinical Documentation
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: July 2015
The HIM Problem: The US Department of Health and Human Services’ Office of the Inspector General (OIG) is expected to increase enforcement activities surrounding clinical documentation and fraud. Training and awareness are key in preventing penalties.
The HIM Problem Solver:....
Maintaining Productivity During the Transition to ICD-10
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 08, 2015
Coding productivity is predicted to take a dip during the transition to ICD-10. That dip can be a minor speed bump or a gigantic crater, depending on many factors—which can be mitigated in these last few months leading up to implementation.
Training
The most ef....
Best Practices in the Art and Science of Clinical Documentation Improvement
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2015
Editor’s Note: This Practice Brief has been updated. See the latest version here. This version is made available for historical purposes only.
Clinical documentation improvement (CDI) is an entire discipline focused on improving the clinical clarity of the health record. Prac....
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 Frontier of Clinical Documentation Improvement
Author: Birnbaum, Cassi L
Source: Journal of AHIMA
Publication Date: July 2015
The health information management (HIM) profession reached a new milestone in 2014 with over 79 percent of clinical documentation improvement (CDI) programs now led by HIM professionals.
The 2014 AHIMA Workforce Survey revealed strong similarities between the priorities of....
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....
Clinical Documentation Improvement's Main Ingredient: 'Physicians First'
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2015
What’s the main ingredient in your clinical documentation improvement (CDI) program? CDI programs are not new to healthcare, and depending on the organization they can look different from facility to facility. Over the past 10 years CDI programs have increased in size and scope due to cha....
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....
DRG Grouping and ICD-10-CM/PCS
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....
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