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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....

Clinical Documentation Improvement in the Outpatient Setting

Author: Arrowood, Danita; Johnson, Laurie M.; Wieczorek, Michelle M.

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

Publication Date: July 2015



Clinical documentation improvement (CDI) programs have proven their worth with over a decade of success and continued role expansion in the inpatient setting. As the healthcare industry prepares for new initiatives such as value-based purchasing, electronic health records (EHRs), and ICD-1....

Injection and Infusion Coding Offers High Stakes: Outpatient Coders Must Play Their Cards Right

Author: Flewelling, Charles

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

Publication Date: June 2015



With the consistently rising value of highly skilled outpatient coders, numerous HIM departments are moving to a staffing model that employs coding professionals who are well versed in coding both inpatient and outpatient encounters. Coders in the profession today should possess a mastery....

A Relook at POA Indicators

Author: Martin, Ginny

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2015



Accurate assignment of the present on admission (POA) indicator has new significance with the inception of value-based purchasing (VBP). Coding and the supporting medical record documentation are being used to identify the hospital-acquired conditions and patient safety indicators on whic....

Malignancy: Aftercare or Follow-Up?

Author: Parman, Cindy C

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2015




Physician documentation has always supported accurate diagnosis code reporting, but never more so than with the transition to ICD-10-CM codes. Specific terminology and the use of key words and phrases is essential, especially with terms such as "aftercare" and "follow-up," which phy....

Coding Saint Patrick's Day

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 11, 2015




Saint Patrick’s Day is both a cultural and religious celebration that includes displays of the color green, eating and drinking, and parades. One of the greatest places to celebrate this day, outside of Ireland, is the city of Chicago, where the people go all out for Saint Patrick’s D....

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