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CDI is about Relationships

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2016



“Alone we can do so little; together we can do so much,” said Helen Keller. This quote was part of Keller’s vaudeville circuit speech, but the sentiment holds true for those of us in the spotlight of HIM.


Our goal is to tell the patient’s story accurat....

Disease Groupings: What are They, How are They Used, and How Do They Compare Internationally?

Author: Lucyk, Kelsey; Lu, Mingshan; Sajobi, Tolulope; Quan, Hude

Source: Perspectives in Health Information Management

Publication Date: July 2016


Abstract


The purpose of this article is to review diagnosis-related group (DRG) systems by introducing the concept of disease groupings, describing the country-specific DRGs based on the International Classification of Diseases (ICD), and comparing country-specific disease classif....

Mapping Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): Lessons Learned from Applying the National Library of Medicine’s Mappings

Author: Nandigam, Hari; Topaz, Maxim

Source: Perspectives in Health Information Management

Publication Date: July 2016


Abstract


The Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) are two commonly used standardized health terminologies in the United States. In fall 2015, healt....

Building on the ICD-10-PCS Puzzle

Author: Scott, Nena

Source: CodeWrite | AHIMA newsletter article

Publication Date: June 2016



ICD-10-PCS presents many major challenges, with many obstacles. This procedural system is like putting a puzzle together. Finding the pieces to the puzzle requires the coding professional to read the entire operative report and, if applicable, the entire pathology report.


As....

Unlocking the Benefits of ICD-10 through Data Analytics

Author: Ewing, Crystal

Source: Journal of AHIMA

Publication Date: June 2016



The reality of the ICD-10-CM/PCS implementation and the fact that it was, by all measures, a success, is the payoff of years of hard work. It’s the product of lessons learned from the implementation of 5010 and the outcome of diligence on the part of healthcare professionals, providers, a....

Semantic Content in EHR Systems

Author: Bhattacharyya, S. B; Warner, Diana

Source: Journal of AHIMA

Publication Date: June 2016



An electronic health record (EHR) can greatly help the timely delivery of efficient healthcare if the information it contains is adequate, accurate, and accessible in a timely manner. An EHR is a longitudinal record of an individual’s health journey made up of electronic documents from va....

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....

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....

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....

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....

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....

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....

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....

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....

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