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Year in Review: Highlights from 2014

Author: Sheber, Sarah

Source: Journal of AHIMA - website

Publication Date: December 2014



The Journal of AHIMA’s ongoing web series “HIM Frontlines,” explores pressing obstacles that health information management (HIM) professionals encounter in a rapidly changing healthcare environment. Major federal initiativs such as the “meaningful use” EHR Incentive Program, HITECH-HIPAA,....

Working Smarter with Computer-Assisted Coding

Author:

Source: AHIMA Today

Publication Date: October 05, 2009

Clinical Coding Community Sessions Explore Worklow Efficiencies and Quality Benefits

Today’s code assignment and workflow processes can be inefficient, error prone, and costly. Presenters at Saturday’s Clinical Coding Community Meeting described the latest in computer-assisted coding (CA....

Working Smarter with APCs

Author: Thoman, Deborah J.

Source: Journal of AHIMA

Publication Date: May 2001




Are HIM professionals ready to make the most of APCs? This article suggests some strategies to improve the way we work with APCs, focus on complete and accurate coding, and improve our expertise.
Are HIM professionals ready for the next step in APCs? Are we ready to use APC data....

Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement

Author: Whittle, Kelly

Source: Journal of AHIMA

Publication Date: September 2016



It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....

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....

Where We've Been, Where We're Going

Author: Scichilone, Rita A

Source: Journal of AHIMA

Publication Date: July 1999



As conditions in the healthcare industry have become more challenging, many jobs have evolved. Not least among them in the HIM world is the role of the coder. In more ways than one, coding professionals are making their mark in the industry. And today, changes in coding requirements are pa....

When Health Information and Fiscal Management Meet

Author: Dunn, Rose T

Source: Journal of AHIMA

Publication Date: January 2001




HIM professionals have skills that can allow them to contribute to the bottom line in many ways. The author describes areas where HIM expertise can make a difference in evaluating an organization's fiscal performance through analysis of services driven by health information.
HI....

When Good Chargemasters Go Bad

Author: Leeds, Erica

Source: AHIMA Convention

Publication Date: October 10, 2001



Introduction: What Is a Chargemaster?

A chargemaster is a master list of services, supplies, and drugs used for patient care. A chargemaster used by outpatient facilities (emergency rooms, clinics, same-day surgery centers, and so on) will have the associated HCPCS codes and rev....

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....

What's Up With Sepsis...Again

Author: Easterling, Sharon

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2016



BACKGROUND


Much discussion among medical, coding, and clinical documentation professionals has followed the recent release of the Sepsis-3 (Sep-3) definition, "Life-threatening organ dysfunction caused by a dysregulated host response to infection," published in JAMA: The Jour....

What is Gulf War Syndrome (Part II)

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: September 1998


Presidential Advisory Committee on Gulf War Veterans' Illnesses

President Clinton established the Presidential Advisory Committee on Gulf War Veterans' Illnesses in May 1995 to ensure an independent, open, and comprehensive examination of health concerns related to Gulf War service....

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 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

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....

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 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....

Vanishing Supervisor

Author: Brandt, Mary D.

Source: Journal of AHIMA

Publication Date: March 2004


The bottom line is calling. Here’s how to decide if your HIM department has the right number of supervisors.
Down-sizing, right-sizing, streamlining. It doesn’t really matter what you call it, but it has had a significant impact on healthcare operations and staffing. Organizat....

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....

US Organizations Look Ahead

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2008


Transitioning to ICD-10-CM may seem like a distant problem. But SSM Integrated Health Technologies began its preparations about three years ago. Its reason is simple: “Something of this magnitude, you don’t want to be scurrying,” says Anne Stuckel, SSM’s manager of clini....

US Must Adopt ICD-10-CM and ICD-10-PCS

Author: AHIMA

Source: AHIMA position statement

Publication Date: July 21, 2005

Immediate Action to Upgrade Medical Code Set Standards Needed


AHIMA's Position


The Department of Health and Human Services (HHS) must immediately initiate the regulatory process for adoption and implementation of ICD-10-CM and ICD-10-PCS code sets (referred to as ICD-1....

Using MedPAR Data as a Measure of Urinary Tract Infection Rates: Implications for the Medicare Inpatient DRG Payment System

Author: Stringham, Jerry; Young, Nancy

Source: Perspectives in Health Information Management

Publication Date: December 2005


Abstract


A valuable metric of hospital performance is the rate of nosocomial infections, particularly urinary tract infections (UTIs). Current measurement techniques are expensive to administer and are not widely available. Determining a measurement index of nosocomial UTI incide....

Using Intrinsic and Extrinsic Metrics to Evaluate Accuracy and Facilitation in Computer-Assisted Coding

Author: Resnik, Philip; Niv, Michael; Nossal, Michael; Schnitzer, Gregory L.; Stoner, Jean; Kapit, Andrew; Toren, Richard

Source: AHIMA Computer-Assisted Coding Meeting

Publication Date: September 06, 2006

Computer-assisted coding (CAC) evaluation can be viewed from two related but distinct perspectives: accurately identifying codes, and more generally facilitating the process of human coding and information flow within and among healthcare organizations. The first perspective calls for intrinsic metrics, grounded in comparison with a gold standard. The second perspective calls for extrinsic techniques, grounded in the real-world task. We discuss this distinction and present an experimental evaluation of CAC using both intrinsic and extrinsic measures.

Using CPT Modifier -25 for Professional Billing

Author: Yoder, Lois M.

Source: Journal of AHIMA

Publication Date: January 2000


You may want to consider a focused review of how your practice assigns CPT modifier -25, "a significant, separately identifiable Evaluation & Management (E&M) service by the same physician on the same day of the procedure or other service."1 The Health Care Financing Admini....

Using CDI to Meet Federal Quality Measures

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2013



Clinical documentation is the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has been an ongoing challenge to health informati....

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?....

Use Data Mining Findings as a Tool to Support CDI Education

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

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

Publication Date: July 2014



Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

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....

Understanding the New Role of the Coder Under OPPS/APCs

Author: Shah, Jugna

Source: AHIMA Convention

Publication Date: October 15, 2004

Background

Coding originated a long time ago as a way to classify causes of death, but has evolved to capture much more information. Coders now play a critical role in helping organizations to capture appropriate reimbursement and remain compliant with government rules and regulations. Si....

Understanding National Coverage Policies: Navigating the Maze of HACs, Serious Reportable Events, and Wrong Surgical Sites

Author: Cook, Jane; D'Amato, Cheryl; Garrett, Gail S.; Ruhnau-Gee, Becky; Hyde, Linda A.; Novak, Natalie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


Present on admission indicators, hospital-acquired conditions, serious reportable events, and “wrong” surgical events are each hot topics. However, they also can be a hot topic together, because a number of these reporting requirements are interrelated. HIM professionals must under....

Understanding HIPAA Transactions and Code Sets

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2001


The recently published final regulations for transactions and code sets under HIPAA are the light at the end of the tunnel in the quest for uniform healthcare standards-and the first step on a long road to HIPAA implementation. What are the standard transactions and code sets? This article tak....

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....

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....

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....

UB-04 Data Set and Claim Form

Author: Bowman, Sue E

Source: AHIMA testimony and comments

Publication Date: January 29, 2005


January 29, 2005

To: National Uniform Billing Committee c/o George Argus, Chairman

RE: UB-04 Data Set and Claim Form

Dear Chairman Argus:
This letter is sent to provide comment from the American Health Information Management Association (AHIMA) on the new....

Tying Together CDI, ICD-10, and Healthcare Data Analytics: How CDI Programs and ICD-10 Are Impacting Data Analytics—and The Benefits Healthcare Organizations Are Seeing

Author: Bradley, Paul

Source: Journal of AHIMA

Publication Date: October 2016



A year in and ICD-10 is almost approaching the point of old news.


Of course—I’m kidding! Nothing could be further from the truth. From a data analytics perspective, the impact of ICD-10 is only beginning to be realized and understood.


For one, this first year....

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