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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 Clinical Photos in EHRs

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: April 2010



For most organizations, patient-identifiable source data include data from interpretations, summaries, or notes. These data are usually maintained within the originating department, separate from the HIM department and the health record, and sometimes in a different database. Examples incl....

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 CC/MCC Capture Rates as a Key Performance Indicator

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2019


The goal of this Practice Brief is to provide an explanation of the complication/comorbid condition and major complication/comorbid condition (CC/MCC) capture rate, review the calculation, and introduce the uses of this key performance indicator (KPI) by different functions of the mid-revenue c....

Using Ambulatory Data to Shape Planning

Author: Katzenberger, Philip

Source: Journal of AHIMA

Publication Date: November 2002


The information age inundates us with data. The challenge is transforming the data into information that can be used for healthcare planning. In general, obtaining the data is easy but creating information from it begins by asking a few questions:
Who will use this data?
How does t....

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