Author: Emery, Steven; McDavid, Jan P; Robb, Deborah

Source: Journal of AHIMA

Publication Date: March 2010

Managing compliance can be a challenge for physician practices short on staff and budget.
Reducing risk and capturing benefits begins with a focus on the areas of greatest concern.

The Office of Inspector General (OIG) first issued guidance for physician practices on compliance....

Author: Eminger, Heather; Owens, Jannifer

Source: Journal of AHIMA

Publication Date: April 2014

With the ICD-10-CM/PCS compliance deadline looming, acute care and ambulatory coding staff continue to focus on discovering new mitigation strategies to offset the anticipated loss of productivity that is expected to come with ICD-10 implementation. One strategy, implementing computer-ass....

Author: Empel, Sofia

Source: Journal of AHIMA

Publication Date: October 2014

Picture these scenarios: Jane’s role as health information management (HIM) director recently expanded to include her hospital’s non-clinical information such as human resources, legal, finance, and marketing. According to the senior leadership of John’s health insurance....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2014

On January 1, 2014, the American Medical Association’s Current Procedural Terminology (CPT) was updated with additions, revisions, and deletions. In total, 175 new codes were added, 107 codes were revised, and 47 codes were deleted. In addition, editorial changes and coding guideline addi....

Author: Endicott, Melanie

Source: Journal of AHIMA

Publication Date: January 2010

Wound care diagnoses and procedures can be challenging to code. In order for coders to code them correctly, clinicians must document diagnoses and procedures appropriately and thoroughly. Open communication between coders and clinicians can help facilitate better documentation.

Inpa....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2011

The new ICD-9-CM diagnosis codes go into effect October 1, 2011. This date marks the last regular annual update to the ICD-9-CM code set before the partial code freeze. On October 1, 2012, there will be only limited code updates to ICD-9-CM to capture new technology and new diseases. There wil....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 13, 2015

There are only seven approach values in ICD-10-PCS, so one would think that selecting the correct approach value would be simple, but it’s not! Let’s take a closer look at these seven approaches and then walk through some challenging cases.


Open (0)


....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 08, 2015

Coding productivity is predicted to take a dip during the transition to ICD-10. That dip can be a minor speed bump or a gigantic crater, depending on many factors—which can be mitigated in these last few months leading up to implementation.

Training


The most ef....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 10, 2015

With just four months until the big implementation day, you are probably feeling one of two things… Relief that it’s finally here and you can begin putting into practice everything you’ve learned over the past 5-6 years of preparation, or panic because you still have much more to do to pre....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 01, 2013

There’s a tremendous amount of buzz in the healthcare industry about preparing hospitals and physicians for ICD-10-CM/PCS (ICD-10) implementation. But what should other care settings—such as long term care, home health, and hospice—be doing to prepare?



Identifying S....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 2016

The definitions and clinical criteria of sepsis and septic shock have been revised, per an article published February 23, 2016 in the Journal of the American Medical Association (JAMA). The recommendations from the 19 physician members of the task force that wrote the new definitions were:....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 09, 2015

This is it. The final countdown is on. ICD-10-CM/PCS is just a few short weeks away from finally becoming a reality in the United States. For those of you that have been preparing for years for this day, I bet you are breathing a huge sigh of relief and thinking, “just get it over with alr....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 08, 2015

Journal of AHIMA's monthly online coding column where AHIMA’s coding experts address challenging areas and documentation opportunities for ICD-10-CM/PCS.

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....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 11, 2015

The coding of heart procedures is done very differently in ICD-9-CM versus ICD-10-PCS. In honor of American Heart Month, this month’s Code Cracker explores the guidelines for coding heart procedures.


There are a few specific guidelines associated with procedures don....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: January 14, 2015

The year 2015 is upon us and it’s time to fill in any last-minute gaps in our ICD-10-CM/PCS training. At this point, most coders have been trained in ICD-10 at the basic or intermediate level, and now it’s time to move to a more advanced level of training. Many organizations have stru....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: December 10, 2014

It’s been 24 years since Kevin McCallister was accidentally left at home while the rest of his family went on vacation in the movie Home Alone. Poor little Kevin has to defend his family home when two con men try to rob it on Christmas Eve. Kevin outsmarts the idiotic burglars with bo....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 15, 2013

With the holidays coming up, it’s time to have a little fun with ICD-10-CM codes.  The following tells the story of a Thanksgiving full of mishaps… if your ICD-10-CM skills are up to the challenge.


Josie and Tom had a wonderful Thanksgiving meal with turkey, stuffing, r....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 01, 2013

Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.





Coding supervisors are worried about predicted productivity losses in the transition to ICD-10-CM/P....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: October 09, 2013

Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.




In the hospital inpatient setting, ICD-10-PCS will replace the ICD-9-CM procedure codes (....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 06, 2013

Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.





Work just a few years in the HIM profession and it will soon be clear that change is....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 09, 2014

Clinical documentation improvement (CDI) is front of mind in the health information management (HIM) industry these days. Maybe you’ve seen lots of jobs advertised for CDI specialists lately and have been wondering just what exactly is so hot about this profession. Well, let me tell y....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: December 11, 2013

A recent study published by the US Consumer Product Safety Commission (CPSC) estimates that more than 15,000 injuries attributable to holiday decorating occurred during November and December 2012. These injuries range from falls to burns to lacerations to back strains. As yo....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 10, 2014

When educating physicians about ICD-10-PCS, the most important factor to be pointed out is that ICD-10-PCS will NOT be replacing CPT. Physicians will still need to report their services using CPT/HCPCS codes. However, physicians need to be aware of the nuances associated with ICD-10-P....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 13, 2014

ICD-9-CM includes a supplemental section, E codes, to describe the external causes of injuries and poisonings. These codes are secondary codes for use in any health care setting, which are used to provide data for injury research and evaluation of injury prevention strategies. E codes....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: October 08, 2014

From pink gloves on the football field to pink night lighting on skyscrapers—not to mention the influx of pink clothing everywhere you look—it’s no secret that October is National Breast Cancer Awareness Month. Most people have been touched by breast cancer in some way&md....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 12, 2014

February is American Heart Month, a time when the media is full of information geared toward awareness and prevention of heart disease. According to the Heart Disease and Stroke Statistics—2014 Update report from the American Heart Association:


The total number....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 12, 2014

Ebola Virus


The Ebola virus is front page news everywhere you turn. Tracking of the Ebola outbreak in the United States with coded data is imprecise due to the lack of a specific code for Ebola in ICD-9-CM. This is yet another reason that the ICD-10-CM/PCS code sets....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: January 13, 2016

I am so excited that ICD-10 is finally here—now we can stop wondering when it’s actually going to be implemented and roll up our sleeves to get to work! Now that it’s officially here and everyone is using it, we can really start to dig into the details and take advantage....

Author: Endicott, Melanie

Source: Journal of AHIMA - website

Publication Date: August 26, 2011

The new ICD-9-CM procedure codes go into effect October 1, 2011. This date marks the last regular annual update to the ICD-9-CM code set before the partial code freeze. On October 1, 2012, there will be only limited code updates to ICD-9-CM to capture new technolog....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 10, 2016

In the years leading up to ICD-10-CM/PCS implementation, doomsdayers chanted horror stories of expected productivity losses of up to 50 percent. Now that we are nearly six months post-implementation, I’ve yet to hear about an instance where such a prediction came true.....

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....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 01, 2013

Let’s be honest, there is a lot of angst amongst the physician community concerning the transition to ICD-10. The October 1, 2014 date is quickly approaching and if your practice has not begun preparing for the change, now is the time to get busy! Here are some fun ways....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: January 08, 2014

Now that 2014 is here, it’s time to really get serious about ICD-10-CM/PCS preparation. Coders should already have some basic knowledge of the ICD-10-CM and ICD-10-PCS code sets, and now it’s time to move to a more advanced level of training.


Many organiza....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 11, 2015

Now that ICD-10-CM/PCS has finally been implemented and everyone is using these new code sets, the questions are rolling in. AHIMA’s Engage community is overflowing with questions from coding professionals seeking advice on how to code this or that. Many of the question....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: October 14, 2015

With the arrival of October 1, 2015 came the official rollout of ICD-10-CM/PCS. As such, there are likely more than a few healthcare organizations nationwide frantically working to cope with the new increased specificity that ICD-10 has to offer. Even after months (even....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 12, 2014

I am amazed at how much publicity ICD-10 is getting in the media, and unfortunately it’s not all positive. From Fox News to the Wall Street Journal to You Tube, ICD-10 is a hot topic. Naysayers seem to point out some of the more obscure codes that will likely never be u....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2014

Focus has been on training in ICD-10-CM/PCS for the past few years. With yet another delay, many organizations are slowing down their ICD-10 training and changing their focus back to ICD-9-CM.


The first quarter of 2014 was historic in “coder world” since t....

Author: Endicott, Melanie

Source: Journal of AHIMA - website

Publication Date: August 06, 2014

The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first started rolling out in the late 1990s and early 2000s, the focus was exclusively on acute care Medicare inpatients. The focus was merely on capturin....

Author: Endicott, Melanie

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

Publication Date: July 2016

The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper repo....

Author: Endicott, Melanie

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

Publication Date: May 2014

There are a multitude of CPT codes available to report breast procedures, including incision, excision, introduction, mastectomy, repair, and reconstruction. The correct application of these codes requires an in-depth analysis of the notes associated with codes 19000-19396 and an understa....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2012

Injection and infusion coding is a challenging area, thanks to vast instructional notes, hierarchy rules, and payer-specific policies.


Current Procedural Terminology (CPT) defines the terms “injection” and “infusion” as:


Injection—delivers a dosage in one “shot,” r....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011

ICD-10-CM/PCS will capture a greater level of specificity for nervous system coding. This article highlights some of the new features in coding central and peripheral nervous system cases with ICD-10-CM/PCS.
Nervous System ICD-10-CM Diagnosis Coding

Nervous system diagnosis cod....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2010

Hip fractures are most commonly seen in elderly patients. They are a serious concern for this population because they can lead to a decreased quality of life, extended hospitalizations, or admission to nursing facilities.

Two of the most common causes for fractures are falls and ost....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2012

The increased need for accurate coded data for healthcare delivery, reimbursement, compliance, and regulatory accountability has brought about a corresponding need for data quality monitoring and regular evaluation programs. Maintaining data quality is an ongoing effort that affects many aspec....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2013

Editor’s note: This is the fourth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.


The transition to ICD-10-CM/PCS on October 1, 2014 is much more than just the customary annual update of codes. The ICD-10-CM code set is very similar in struc....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2013

With the oncoming swell of ICD-10-CM/PCS (ICD-10) and computer-assisted coding (CAC), coders may be wondering what the future holds for their career. Some worry that the transition to ICD-10 will be very challenging for long-term coders who have been using ICD-9-CM for several decades. The....

Author: Endicott, Melanie

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

Publication Date: April 2014

There are two major challenges currently plaguing the coder workforce. The first is new graduates are finding it difficult to land jobs due to a lack of experience. Second, healthcare organizations are struggling to recruit experienced coders to fill vacancies.


Recruiting....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 12, 2015

Among the most helpful tools for assisting providers through the transition to ICD-10-CM/PCS are documentation tip sheets detailing the specificity needed to assign accurate codes. Many companies are selling tip sheets, but if you are looking to save a few dollars, here’s a step-by-s....

Author: Endicott, Melanie; Fletcher, Kathi

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2013

A history of attempts to classify mental illness dates back to the 1840 US census, when the government included an entry to record the frequency of “insanity” in a family. This early record was strictly statistical in nature. In 1948—following World War II—the World....

Author: Endicott, Melanie; Gardner, Amy

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2009

The HIM field continues to expand and change, opening up more opportunities for HIM practitioners to move out of the HIM department and into other areas of the hospital. Recent initiatives, such as ICD-10-CM/PCS, MS-DRGs, Hospital-Acquired Conditions, and Present on Admission reporting, have b....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2012

An analysis of the “physician coder” anatomy would reveal a cornucopia of responsibilities nestled under this one succinct title.

They are equal parts clinical documentation improvement specialist, office manager, patient counselor, physician process tracker, coder... the list goes....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: October 2013

Consumers may have been slow to adopt personal health records (PHR) in the past, but experts say this may soon change with the government’s increased focus on consumer engagement.


“The role of the patient is so different now in terms of being an active rather tha....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: January 2016

John Quincy Adams once said, “If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.”


Had HIM been as important in Adams’ time as it is today, the former president would have surely included HIM professionals in the category o....

Author: Eramo, Lisa A

Source: Journal of AHIMA - website

Publication Date: June 2015

Ask any coder about the ICD-10 transition, and he or she will likely tell you that it hasn’t been easy. Coders working in physician practices have had a tough time. Many of these coders have more responsibilities than their inpatient coder counterparts. Physician practice coders may even b....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: February 2015

When Sherry Doggett decided to retire in 2013 after a 30-year career in HIM, the first thing she did was try to figure out how she was going to spend her time. Doggett, who spent her last year of work as the corporate director of transcription at the University of Cincinnati (UC) Academic....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: August 2016

The clues are subtle but critical: Perhaps you get a bill for urgent care services you never received. Or upon reviewing your medical record through a patient portal, you see a diagnosis of back pain and multiple prescriptions for narcotic pain relievers.


Though not definiti....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2016

AHIMA and other key stakeholders continue to drive national and global progress to achieve information systems interoperability in healthcare.


Like a complex puzzle, health information data and system interoperability takes time, effort, and collaboration to solve. And solvin....

Author: Eramo, Lisa A

Source: Journal of AHIMA - website

Publication Date: September 01, 2016

As a health information management (HIM) professional, you know just how difficult it is to explain your profession to others. So many acronyms, so little time. How can you capture all of the nuances of HIM in a way that others will understand while also keeping their attention?
<....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2017

As an independent contractor and data analytics subject matter expert (SME), Lisa Brooks Taylor, RHIA, spends most of her time working with professional associations and large insurers developing machine-computable algorithms to analyze healthcare data. She works closely with data scientis....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: May 2017

Like many new HIM graduates, Makema Hopes, RHIT, began looking for a job immediately after receiving her associate’s degree in 2011. She thought her 80-hour internship at a local hospital prepping and scanning charts would surely help her get her foot in the door with an employer and....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: February 2017

Anxiety—it’s the emotion that looms over most patient financial services (PFS) directors and those working in health information management (HIM) when they discover that their organization’s claims are subject to a Centers for Medicare and Medicaid Services (CMS) Recovery....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2017

Think about what life would be like if we could occasionally hit pause, taking a “time out” of sorts to process information before acting. Unfortunately, we don’t have that luxury—but that doesn’t mean we shouldn’t reflect on the past before moving forwa....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: May 2018

By Lisa A. Eramo, MA


Technology has transformed almost every industry, and health information management (HIM) is no exception. Data used to be handwritten words on a page. Now, with the rise of electronic health records (EHR), dat....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2018

Untitled Document



Attack of the Audits

Mounting Reviews Test HIM Policies and Patience


By Lisa A. Eramo, MA


The recent onslaught of audits in the healthcare industry, and the damage they leave in their wake, likely has many....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: April 2015

Determining what to do with one’s life is a daunting task. Even once you’ve chosen the field of HIM, the sky is the limit in terms of the roles in which you can serve. As HIM evolves commensurate with the electronic health record (EHR), the options only continue to grow—a....

Author: Eramo, Lisa A

Source: Journal of AHIMA - website

Publication Date: February 2015

The technical, legal, and collaborative aspects of information governance had always appealed to Kristi Lundgren, MS, RHIA. Although Lundgren, a former graduate student at the College of St. Scholastica, had studied about the importance of governing data in an electronic environment, she c....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: September 2017

When Carolyn Rubin, CPC, CPC-I, became the director of revenue cycle management at Dallas Nephrology Associates, she had an important task on her to-do list: Relieve the workplace tension that had plagued health information management (HIM) staffers for years. Communication and collaborati....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: June 2013

The clock is ticking, and in only 16 months the healthcare industry will begin to use, process, and exchange ICD-10-CM/PCS (ICD-10) codes. Readiness varies throughout the industry, with some stuttering after the Centers for Medicare and Medicaid Services delayed the ICD-10 implementation d....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2011

Stopping fraud will require health record systems, organizations, and individuals capable of, and committed to, detecting and preventing false claims before they are paid.

Healthcare fraud continues to plague the country, costing the United States billions of dollars per year.
....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: September 2013

The hunger for analyzed healthcare data to improve delivered care and to better meet quality measures is spurring a revolution in healthcare. Providers are demanding better health IT systems that allow HIM and data analytics professionals to sift through large amounts of data and turn it i....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2011

The stage 1 meaningful use criteria do not require that eligible providers (EPs) and eligible hospitals (EHs) create patient portals, but portals may be the best option for meeting certain stage 1 patient access and electronic communication-related provisions. Portals may also be mandatory in....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: September 2012

No information request traffic jams.
No toll road trips to the physical HIM department.
Just an open and instant route to patient health information.
But building and managing a patient portal requires HIM knowledge and expertise.


Patient portals are rapid....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: May 2010

New technologies are enabling patients to capture and transmit health data from their homes. Managing this new data stream takes some planning.

Managing health information that flows into the organization from outside sources has always posed challenges. How will the information be i....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: September 2014

It’s midnight, and your cough has been unrelenting. You power up your laptop and visit one of the many websites that feature online access to physicians 24/7. Within minutes, you’re engaging in a video consultation with a board-certified physician who evaluates you, provides clinical inst....