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Take Note of "Notes"

Author: Foley, Dianna

Source: AHIMA newsletter article | CodeWrite

Publication Date: October 2017




For the past several months, coding professionals and clinical documentation improvement (CDI) specialists have pored over the annual ICD-10-CM/PCS updates to identify the new ICD-10-CM/PCS codes that are effective for use on October 1. With all the code changes with which to become f....

Significance of the Glasgow Coma Scale

Author: Hansen, Abby

Source: AHIMA newsletter article | CodeWrite

Publication Date: September 2017



The Glasgow Coma Scale (GCS) is an assessment used by medical professionals to evaluate the level of a patient’s consciousness. It is a common tool used for patients with brain injuries and strokes, evaluating the degree to which a person’s conscious level is impaired based on....

Taking CDI Into the Physician Office Setting

Author: Huey, Kim

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2017



CDI, referring to clinical documentation improvement, is as familiar to most hospital coding professionals as acronyms like OR, ICU, and ED. But in the physician office, CDI is not well known. However, with implementation of the Merit-based Incentive Payment System (MIPS), CDI will be....

Coding and Quality Measures Brief. Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty Complication Rate

Author: Drake, Suzanne P

Source: CodeWrite | AHIMA newsletter article

Publication Date: June 2017



The Elective Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Complication Rate (THA/TKA) are components of the 2019 Value-Based Purchasing Clinical Care Domain effective for discharges from October 1, 2018, through September 30, 2019, and are used in the Hospital Inpatien....

Coding and Quality Measures Brief. Pediatric Quality Indicator 12: Central Venous Catheter-Related Blood Stream Infection

Author: Koehler, Melissa

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2017



The Agency for Healthcare Research and Quality (AHRQ) has established a set of measures specific to pediatric patients to evaluate the quality of healthcare for this specialized population. Pediatric Quality Indictors (PDIs) are used to measure preventable inpatient hospital instances, as....

Back to Basics: APC Payment Methodology

Author: Tomak, Tracey

Source: CodeWrite | AHIMA newsletter article

Publication Date: April 2017



In August of 2000, the Centers for Medicare and Medicaid Services (CMS) introduced the Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS). The objective of the APC payment system was to control costs and increase efficiencies for outpatient ser....

It's All in the Documentation

Author: Hansen, Abby

Source: CodeWrite | AHIMA newsletter article

Publication Date: February 2017




Over the last several years, it has become common for inpatient coding professionals to take on the role of clinical validation. Documented diagnoses are often ignored based on clinical criteria. For example, the physician documents acute respiratory failure throughout the chart. The....

Hypertension Coding - Crisis Averted

Author: Lojewski, Tedi

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2016



Thanks to the recent publication of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017, the past controversy over the interpretation of the term "With" has been resolved.1 The revision of Section I.A.15, "With," now incorporates what was previously clarified in AHA Coding C....

Hospice Coding Left Out?

Author: Zastoupil, Shawna

Source: AHIMA newsletter article | CodeWrite

Publication Date: October 2016




Like many other healthcare settings, hospices are starting their journey into coding compliance. Before the first Federal Regulation (FY 2013), which addressed diagnosis coding clarification, hospices typically reported one code on their claims. Since that time, the Department of Heal....

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....

AHIMA's Whistleblower Policy

Author: AHIMA

Source: AHIMA newsletter article

Publication Date: June 2016

AHIMA is committed to the highest possible standards of ethical, moral, and legal business conduct. In line with this commitment, we have a whistleblower policy to provide an avenue for volunteers to raise concerns while assuring that they will be protected from reprisals or victimization for whistleblowing.

What Makes a Happy HIM Work Culture?

Author: Dover, Kayce

Source: AHIMA newsletter article

Publication Date: June 2016



"Happy families are all alike," Leo Tolstoy famously wrote. And the same may hold true for HIM departments. So what are the factors that make an HIM department happy? HIM Connections recently conducted a survey of HIM managers and team members to learn about HIM happiness: What works well....

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....

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....

IG: It's a Marathon, not a Sprint

Author: Endicott, Melanie

Source: CodeWrite | AHIMA newsletter article

Publication Date: January 28, 2016





Developing an information governance (IG) program within your organization takes time and planning. Just like marathon runners who follow a training plan that begins with short runs and gradually builds to longer distances, so too should organizations start with small s....

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....

ICD-10 Journeys: a Health System and Coding Company Compare Notes

Author: Muscarella, Maria A.; Peña, Manny

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: March 2015


The transition to ICD-10-CM/PCS has been a roller coaster ride for HIM professionals. The industry has prepared, delayed, prepared, delayed, and prepared again—this time with the expectation that the new coding system will finally go live on October 1, 2015. With its ups and downs, ICD-10 imple....

Coding Mastectomy Procedures

Author: Goswami, Chaitali

Source: CodeWrite | AHIMA newsletter article

Publication Date: September 2014



OBJECTIVE

The purpose of this article is to enable you to understand and correctly implement the coding principles, concepts, and guidelines associated with various mastectomy procedure codes.


SURGICAL INFORMATION

Mastectomy is the surgical procedure in....

External Cause Codes in ICD-10-CM

Author: Fuller, Jan C.

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2014



The increased specificity in ICD-10-CM is reflected in a substantial increase in external cause codes. The traditional “E code” has been replaced with V, W, X and Y codes. While the purpose of the codes remains the same, the ICD-10-CM codes provide a level of detail not possible in ICD-9-....

Addressing PPE Challenges

Author: AHIMA Staff

Source: AHIMA newsletter article

Publication Date: August 2014


While the professional practice experience (PPE) is widely considered to greatly benefit students, there is a need to address a growing number of challenges, including increasing numbers of programs competing for limited PPE placement sites, department and organization mergers, remote staff and....

HIV/AIDS in ICD-10-CM

Author: Parman, Cindy C

Source: CodeWrite | AHIMA newsletter article

Publication Date: May 2014



Human immunodeficiency virus (HIV) attacks the immune system, the body's natural defense system. And of course, without a strong immune system the body has trouble fighting off disease. Both the virus itself and the resulting infection are called HIV. The final stage of HIV infection is a....

Coding Bunionectomy

Author: Kapoor, Alka

Source: CodeWrite | AHIMA newsletter article

Publication Date: March 2014



Bunionectomy is a surgical procedure to excise a bunion. After reading this article you should be able to understand the concepts of assigning the correct CPT code for bunionectomy.



The online Encyclopedia of Surgery defines a bunion as "an enlargement of the joint at....

Help! I am Encoder-Dependent!

Author: Horn, Kelli

Source: CodeWrite | AHIMA newsletter article

Publication Date: March 2014



Many coders in the workforce preparing to take their CCS examination acknowledge that they are dependent on encoders. While this is beneficial in performing daily job duties, it can be a hindrance to successfully passing the examination. The four-hour examination requires that exam-takers....

CAD vs. Angina

Author: Hansen, Abby

Source: CodeWrite | AHIMA newsletter article

Publication Date: December 2013



Unstable angina pectoris is a type of chest pain that happens suddenly and becomes worse over time. It can often be felt in the shoulders, arms, and neck. It is caused by poor blood flow through the blood vessels of the heart muscle and can evolve into a myocardial infarction. Coronary at....

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