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Taking the Next Step Forward for ICD-10

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2004


In November 2003 the National Committee on Vital and Health Statistics (NCVHS) agreed to recommend that the secretary of Health and Human Services (HHS) adopt the ICD-10-CM and the ICD-10-PCS classification standards as replacement for the ICD-9-CM classification currently used in the US.

Changes Abundant for CPT 2004

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004


Changes for CPT 2004 affect all chapters, and it’s important to stay up to speed. This article presents a summary of CPT changes for 2004. Because a number of the procedures may be unfamiliar to some coding professionals, AHIMA has provided online links to descriptive articles on these s....

Analysis of Final Rule for 2004 Revisions to the Medicare Hospital Outpatient Prospective Payment System

Author: AHIMA Policy and Government Relations Team

Source: AHIMA regulation analysis

Publication Date: December 02, 2003


The final rule regarding calendar year 2004 revisions to the Medicare hospital outpatient prospective payment system (PPS) was published in the November 7, 2003 issue of the Federal Register (the proposed rule was published in the August 12, 2003 issue). This rule becomes effective on January....

ABNs--Always Been Neglected

Author: Dunn, Rose T

Source: AHIMA community resource

Publication Date: November 14, 2003


For something that has been around for nearly 2 decades and supported by regulation since 1965, Advance Beneficiary Notices (ABNs) continue to cause headaches today. The use of written notices has been available since the enactment of PL 92-603 in 1972. The specific format called an Advance B....

Understanding Diabetes Mellitus

Author: Huff, Garry L.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2003


Diabetes mellitus represents a group of disorders that are characterized by hyperglycemia. The clinical and ICD-9-CM classification of diabetes mellitus have evolved as understanding of insulin physiology has expanded. This article will explain diabetes mellitus and its ICD-9-CM classification....

CPT Category III Codes Cover New, Emerging Technologies: New Codes Developed to Address Issues in Light of HIPAA

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....

Long-term Acute Care: the Effect of PPS

Author: Smith, Pam

Source: Journal of AHIMA

Publication Date: October 2003


Just when I thought I’d seen and done it all in the HIM world, a new opportunity for coders appeared in long-term acute care hospitals (LTCHs). HIM professionals have been employed in LTCHs since the inception of long-term acute care, but the change from cost-based reimbursement to inclus....

Internal Radiation Brings Hope to Prostate Cancer Patients: With Brachytherapy Treatment Come New HCPCS Codes

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


In 2003, the American Cancer Society estimates that 220, 900 men will be diagnosed with prostate cancer in the US, making it the second leading cause of cancer deaths in men.1 Today in the US, patients with prostate cancer have access to less invasive surgical cancer treatment plans. This arti....

Advances in Burn Reconstruction Complicate Coding: Get Familiar with Terminology, Techniques for Accurate Coding

Author: Erhardt, Walter L.; Medal, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


Recent advances in the science of wound healing are making an impact on the treatment of burns. This is particularly evident not only in the way burn wounds are being managed initially, but also in how these wounds are being reconstructed. While these scientific advances make this field an exc....

Pneumonia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).
Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).
Describe preadmission treatment tha....

Septicemia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., hypoxemia, tachycardia, leukopenia, bradypnea, leukocytosis, etc.).
Identify causative organism, if known (e.g., pneumococcal, E. coli, aerobacter aerogenes, etc.).
List infection source, if known (e.g., UTI, pneumonia, postoperative wound, etc.....

From Coder to Knowledge Engineer

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: July 2003

“Find a job that really holds your interest and one that will challenge you. If you’re not challenged daily, there’s something wrong.” —Judy Sample, RHIT, CCS, knowledge engineer
at Inference Systems International, Inc.
Combining her interests in coding and tec....

Sepsis, Related Terms Cause Confusion for Coders: Set the Record Straight About Sepsis, SIRS, Septic Shock

Author: Prophet-Bowman, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2003


Sepsis, severe sepsis, SIRS, and septic shock have long been a source of confusion for coders. New ICD-9-CM codes established recently for Systemic Inflammatory Response Syndrome (SIRS), and additional proposed code revisions have added to the confusion regarding the differentiation among these....

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....

Observation Services Present Compliance Challenges

Author: Prophet-Bowman, Sue

Source: Journal of AHIMA

Publication Date: March 2003


Observation services have been a top fraud and abuse target of the Office of Inspector General (OIG) of the Department of Health and Human Services, primarily due to the complexity of the Medicare billing regulations and the potential for abuse. New regulations regarding reimbursement for thes....

Major Changes for Heart Failure Codes in 2003: New Codes Put Sharper Focus on Diagnosing, Preventing Heart Failure

Author: Casey, Patricia E.; Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2003


Are you up to date with the latest revisions to the heart failure codes? A revision of the heart failure codes, effective October 1, 2002, was originally presented at the May 2001 ICD-9-CM Coordination and Maintenance Committee meeting. At that meeting, representatives from Kaiser Permanente e....

ICD-9-CM Coordination and Maintenance Committee Discusses Code Proposals for FY2004

Author: AHIMA Policy and Government Relations Team

Source: AHIMA Advocacy and Policy

Publication Date: December 13, 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), met on December 5-6, 2002 in Baltimore, MD. Donna Pickett, RHIA, from NCHS, and Patricia Brooks, RHIA, from CMS, cochair....

Analysis of Final Rule for 2003 Revisions to the Medicare Hospital Outpatient Prospective Payment System

Author: AHIMA Policy and Government Relations Team

Source: AHIMA regulation analysis

Publication Date: November 24, 2002

The final rule regarding calendar year 2003 revisions to the Medicare hospital outpatient prospective payment system (PPS) was published in the November 1, 2002 issue of the Federal Register.   This rule becomes effective on January 1, 2003.   This analysis will cover significant....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

What Documentation Source Is Used to Assign Diagnosis Codes for Outpatient Testing?
A completed medical record is the best source of diagnosis coding, without regard to setting. However, recently there was confusion concerning whether the reason for testing found on a requisition for the test....

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....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where Can I Find a Sample Job Description and the Standard Productivity Rate for a Coder?

Because of the wide variety of duties included in the tasks for a coding professional, AHIMA does not publish a standard job description and has found it impossible to create meaningful coding produ....

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 the APC regulations?

The HCFA regulations are found in the November 13, 2000 Federal Register, Vol. 65. No.219 pp.67798-68005. Go to http://www.access.gpo.gov/su_docs/fedreg/a001113c.html, and scroll down to Health Care Financing Administration.

HCFA has impleme....

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