Author: Bruce, Tina MHIM, MHI, RHIA, CCS, CDIP

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

Publication Date: November 2018

By Tina Bruce, MHIM, MHI, RHIA, CCS, CDIP


Healthcare practices, clinical documentation improvement specialists, auditors, and coding professionals are on the edge of their seats anxiously awaiting the annual release of coding updates by the....

Author: Johnson, Laurie M.

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

Publication Date: November 2018

By Laurie M. Johnson, MS, RHIA, FAHIMA


Since the implementation of ICD-10-CM/PCS in October 2015, the periodic coding updates have included many changes. For FY 2019, the diagnosis update includes a more manageable number: 279 new codes, 143 revised....

Author: Palkie, Brooke; Kerr, Katie MA, RHIA

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

Publication Date: October 2018

By Katie Kerr, MA, RHIA, and Brooke Palkie, EdD, RHIA


The World Health Organization (WHO) released ICD-11 in June 2018, 18 years after the launch of ICD-10. It has been hailed as a vast improvement and was released in a completely electronic format th....

Author: Thomas, Felicia A; Harding, Wahiyda A

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

Publication Date: October 2018

By Felicia A. Thomas, RHIT, CCS, CPC, CIC, CPC-I, CCDS, and Wahiyda Harding, MSA, RHIA, CCS


To understand the power of coded data, let’s first take a look at its definition. Data analytics is the science of examining raw data with the purpose of drawing conclus....

Author: Bumgarner, Charlotte CDIP, CCS; Latva, Jennifer CCS, COC, CPC, CGSC

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

Publication Date: September 2018

By Charlotte M. Bumgarner, CDIP, CCS, and Jennifer C. Latva, CCS, COC, CPC, CGSC


CODERS OFTEN RELY on a neoplasm’s behavior and location for ICD-10-CM code assignment, rather than first referencing histological type. This oversight can lead....

Author: Hansen, Abby

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

Publication Date: September 2018

By Abby Hansen, MHA, RHIA, CCS, CCS-P


The Centers for Disease Control and Prevention (CDC) reports that suicide rates have increased by more than 30 percent since 1999. In 2014, suicides accounted for 42,773 deaths in the United States; 2015....

Author: Combs, Tammy

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2018

By Tammy Combs, RN, MSN, CDIP, CCS, CCDS


Have you ever wondered what it means to be an effective communicator? In his article “Why Communication Is Today’s Most Important Skill,” Greg Satell discusses Michael Faraday, who helped tr....

Author: DeVoe, Megan

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2018

By Megan DeVoe, CCS


Editor’s Note: This is the final article in a three-part series on how to master the information available on the Centers for Medicare and Medicaid Services website.


Have you ever wondered how a code bec....

Author: Sanvik, Gina

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2018

Untitled Document



CY 2018 OPPS Update


By Gina Sanvik, MS, RHIA


Facilities had the ominous task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule at the beginning of the year to ensure their chargemaste....

Author: Linder, Karen M

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

Publication Date: November 2017

Fiscal year (FY) 2018 ICD-10-CM updates will keep coding professionals busy with approximately 360 new codes, 142 deletions, and 226 code revisions posted by the National Center for Health Statistics (NCHS) on the Centers for Disease Control and Prevention (CDC) website. Due to the numerou....

Author: Ward, Maria

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

Publication Date: November 2017

Every year as the summer months arrive, coding professionals, healthcare providers, documentation improvement specialists, and other healthcare professionals wait expectantly for the release of all the Centers for Medicare and Medicaid Services (CMS) coding updates. This year is no differe....

Author: Land, Daniel

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

Publication Date: October 2017

Coding professionals are the guardians of the patient’s story; they translate the language of medicine into coded data. The accuracy of this translation is essential for many reasons beyond today’s reimbursement. Coded data is used for clinical decision making, healthcare polic....

Author: Davies, Sharon

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

Publication Date: October 2017

One thing is for certain, everyone’s life will end someday. But who wants to broach this uncomfortable subject in a healthcare setting? The patient? The patient’s family? The primary care provider? The hospitalists?


Medicare has recognized the value of this servi....

Author: Comfort, Angie

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

Publication Date: September 2017

The arrival of October 1, 2015 was met with anxiety, alarm, and even terror by many as the healthcare industry braced for what some called “another Y2K-like event”—the ICD-10-CM/PCS implementation. Fast-forward to September 2017, where we have been living in the post-ICD-....

Author: McNicholas, Faith C.

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

Publication Date: July 2017

The Centers for Medicare and Medicaid Services (CMS) created a new place of service (POS) code for use by physicians and other qualified healthcare practitioners (QHPs) who furnish telehealth services from a distant site, effective January 1, 2017.


According to Medicare, ser....

Author: Merriweather, Kay; Slater, Leslie; Bohley, Michele

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

Publication Date: July 2017

“If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming the center of healthcare in th....

Author: Fernandez, Valerie

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

Publication Date: June 2017

A Hierarchical Condition Category (HCC) is defined as a risk adjustment model that is used to calculate risk scores to predict future healthcare costs. The Centers for Medicare and Medicaid Services’ (CMS) CMS-HCC model is used to predict healthcare spending for Medicare Advantage Pl....

Author: DeVoe, Megan

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

Publication Date: June 2017

The Impella® device (2.5 and 5.0) provides percutaneous external ventricular support for high-risk patients who cannot undergo traditional open cardiovascular procedures in the inpatient hospital setting. Like intra-aortic balloon pumps (IABPs) that have been used for decades, these de....

Author: Leonard, Janis

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

Publication Date: May 2017

Prior to the implementation of ICD-10-CM/PCS, Albany Medical Center (Albany), based in Albany, NY, was struggling with attracting qualified coding candidates. Despite recruitment efforts including sign-on bonuses and incentive pay, Albany was unable to maintain staffing levels to meet the....

Author: Ward, Maria

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

Publication Date: May 2017

Coding respiratory cases can sometimes lead to coding professionals getting bogged down in the circle of sequencing instructions, inclusions, and exclusions. This article will help readers gain a better understanding of the differences in the diagnoses that all come with a majority of the....

Author: Bowman, Sue E

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

Publication Date: April 2017

For 2017, there are new CPT category III codes describing procedures involving cardiac contractility modulation systems and implantable counterpulsation ventricular assistance devices. These emerging technologies are currently undergoing clinical trials. These codes are scheduled to sunset....

Author: Reed, Andretta

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

Publication Date: April 2017

This article highlights pneumonia and chronic obstructive pulmonary disease (COPD) code selections and proper sequencing based on healthcare provider documentation, ICD-10-CM Official Guidelines for Coding and Reporting, and ICD-10-CM conventions. As additional coding guidance continues to....

Author: Huey, Kim

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

Publication Date: March 2017

The 2017 update to the CPT code set brings fewer new codes than in previous years but more guideline changes and clarifications, as well as revisions in code description. One Appendix is deleted and a new one is created. There are a total of 149 new CPT codes, 498 revised codes, and 81 del....

Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Nemchik, Scot; Sheridan, Patty Thierry

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

Publication Date: March 2017

To quantify the impact of ICD-10-CM/PCS (ICD-10) on coding productivity, Ciox Health, in partnership with the University of Pittsburgh’s Department of Health Information Management, School of Health and Rehabilitation Sciences, conducted a previous study published in the August 2016....

Author: Gibbs, Sally

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

Publication Date: February 2017

How does a healthcare system with 24 hospitals, 40 physician offices, and 50 free-standing ambulatory surgery centers that spans from the entire state of California to just over the Oregon border continue to keep their coding and billing staff current with the latest coding guidelines and....

Author: Comfort, Angie

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

Publication Date: February 2017

As last year drew to a close, facilities began the looming task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule to ensure their chargemaster and systems were up-to-date with the 2017 changes. The final rule for calendar year (CY) 2017 was released on Novem....

Author: DeVault, Kathryn; Easterling, Sharon; Huey, Kim

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

Publication Date: January 2017

In the current era of healthcare transformation, the continuing importance of documentation and coding cannot be overstated. With the multitude of acronyms being added to the healthcare vocabulary, one may wonder where documentation and coding fits in. It’s important to remember that....

Author: Ward, Maria

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

Publication Date: November 2016

Many changes come with the first update of the new ICD-10 Procedure Coding System (ICD-10-PCS) for fiscal year (FY) 2017. The higher-than-usual volume of changes was to be expected since the update system has been in a holding pattern for several years due to implementation delays. And al....

Author: Rugg, Donna

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

Publication Date: November 2016

The ICD-10 Coordination and Maintenance Committee’s code freeze, first implemented after the October 1, 2011 annual update, has finally thawed. For fiscal year (FY) 2017 the ICD-10-CM classification is back on track with annual code and guideline updates. Due to the thousands of new/....

Author: Land, Daniel

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

Publication Date: October 2016

The complex and sophisticated nature of ICD-10-CM/PCS has increased both the intellectual demands on coding professionals and the importance of an educational approach to the audit process. On October 1, 2016 regular updates to ICD-10 will begin, marked by the introduction of over 5,500 n....

Author: Barta, Ann

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

Publication Date: October 2016

The implementation of ICD-10-PCS has enhanced the skills of coding professionals as it contains many unique features that provide an opportunity to accurately reflect the complexity of the procedures being performed. The assignment of ICD-9-CM procedure codes for spinal fusions often chal....

Author: Clack, Crystal

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

Publication Date: September 2016

Injection and Infusion CPT codes are a topic that many outpatient emergency room (ER) coding professionals would like to fantasize into a state of intergalactic oblivion, but the codes are here to stay. Injection and infusion codes cover only seven pages in the 975-page 2016 CPT coding boo....

Author: Davies, Sharon

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

Publication Date: September 2016

Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the p....

Author: Combs, Tammy

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

Publication Date: July 2016

Illness doesn’t care what country or region a person lives in, and it doesn’t care the race or origin of a person. Since illness is found everywhere around the globe it only stands to reason that providers should also look beyond the boundaries of one country or patient population when re....

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: Maimone, Carol

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

Publication Date: June 2016

Physician queries have historically been an effective communication tool used by health information management (HIM) coding professionals to clarify documentation in the health record for accurate code assignment. The goal for any coding professional is to have all final coded diagnoses an....

Author: DeVault, Kathryn

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

Publication Date: June 2016

The implementation of ICD-10-PCS has created new challenges in coding surgical procedures. While coding professionals have always been expected to read and interpret all surgical documentation, ICD-10-PCS has increased the level of understanding necessary for accurate code assignment.

Author: Kostick, Karen M.

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

Publication Date: May 2016

On October 1, 2015, the ICD-10-CM coding classification was implemented in the United States. This article provides a coding update on how to report injuries resulting from terrorism, which is now classifiable under ICD-10-CM. In the US, ICD-10 (mortality coding) and ICD-10-CM (morbidity c....

Author: Bielby, Judy A

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

Publication Date: May 2016

In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States wo....

Author: Linder, Karen M

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

Publication Date: April 2016

Rochester Regional Health is an integrated health services organization serving the people of western New York and the Finger Lakes region. The system provides care from 150 locations, including five hospitals; more than 100 primary and specialty practices, rehabilitation centers, and ambu....

Author: Hundal, Ripandeep K

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

Publication Date: April 2016

Wounds are injuries that break the skin or other body tissues. They include cuts, scrapes, scratches, and punctured skin. Wounds are typically due to accidental injury but may also result from surgery, stitches, or chronic disease processes.1


Wound care involves evaluation,....

Author: Clack, Crystal

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

Publication Date: March 2016

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) finalized changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) payment system for calendar year (CY) 2016. The OPPS payment rates and policies impact approximately 4,000....

Author: Diop, Karen

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

Publication Date: March 2016

We studied. We practiced. We prepared. We had extensions—first a year, then two. More time to practice. Then, at long last, October 1, 2015 arrived, bringing with it the much-anticipated new code sets ICD-10-CM and ICD-10-PCS. Despite much hand wringing and nay saying, the implementation....

Author: Land, Daniel

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

Publication Date: February 2016

On October 1, 2015 the updates to the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting went into effect. There were no changes to the ICD-10-CM Guidelines at that time. Fifty new ICD-10-PCS codes were added, which brings the total to 71,974 PCS codes for FY 2016. Thir....

Author: Clack, Crystal

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

Publication Date: February 2016

When the first edition of the Current Procedural Terminology (CPT) was released in 1966, there were only 3,554 codes. In 2016, CPT, published by the American Medical Association (AMA), is celebrating its 50th birthday with 10,000 CPT codes. This year’s CPT updates include 140 codes added,....

Author: Hefti, Erik ; Blanco, Javier G

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

Publication Date: January 2016

The “personalized medicine” paradigm is at the forefront of discussions about the future of healthcare, and a wealth of new data concerning how human genetic variation contributes to drug response has the potential to change the practice of medicine. The promise of treating pat....

Author: Clack, Crystal

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

Publication Date: November 2015

Every medical practice should have preventive measures in place to avoid costly coding and billing audits, errors, and subsequent delays in payment. Incorrectly coded claims, missing charges on a patient encounter, and other mistakes can take a substantial bite out of both practice and ph....

Author: Diop, Karen

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

Publication Date: November 2015

Change has become a constant in healthcare. With the introduction of electronic health record (EHR) systems, core measures, the “meaningful use” EHR Incentive Program, value-based purchasing, and the ICD-10-CM/PCS code sets, the healthcare industry has been bombarded by wave after wave in....

Author: Burgess, Sheila

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

Publication Date: October 2015

The dawn of October also welcomes the official go-live date for ICD-10-CM/PCS—meaning there is absolutely no time left to waste in preparing for the additional documentation requirements necessary for successful ICD-10 implementation. Over the past several years, the healthcare industry h....

Author: Harris, Shelly; Kelly, Jeannie

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

Publication Date: October 2015

As the Centers for Medicare and Medicaid Services’ (CMS’) Probe and Educate Initiative draws to a close and the 2016 Outpatient Prospective Payment System (OPPS) proposed rules are released for comment, questions remain for the healthcare industry regarding expectations for selecting pati....

Author: DeVault, Kathryn

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

Publication Date: September 2015

The complexity of ICD-10-PCS, as well as the need for a better understanding of anatomy and physiology and the technique of surgical procedures, has been well documented. The coding of cardiovascular procedures in ICD-10-PCS, in particular, requires focus.


Consider these p....

Author: Kulanko, Jill

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

Publication Date: September 2015

Sepsis is arguably the most challenging condition to code correctly in ICD-9-CM. The condition itself is complex and the definitions regarding sepsis, SIRS, and severe sepsis have evolved over time, keeping coders on their toes. The guidelines are also difficult to understand. Complicatin....

Author: Foley, Margaret M.

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

Publication Date: July 2015

Prior to the October 1, 2015 implementation of ICD-10-CM/PCS, every hospital must examine how the new code set will impact MS-DRG reimbursement. A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimburs....

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....

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....

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: June 2015

All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.

ICD-10-PCS Scope of Work


On October 1, 2015, hospital inpatient pr....

Author: Barta, Ann

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

Publication Date: May 2015

The implications of ICD-10-CM/PCS for healthcare reimbursement is a topic at the top of everyone’s mind in the healthcare industry these days. As healthcare organizations continue to prepare for the transition to ICD-10-CM/PCS on October 1, 2015, an essential and important element of a su....

Author: Drake, Suzanne P

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

Publication Date: May 2015

The organizations health information management professionals serve are reliant on their understanding of outpatient coding and reporting conventions to ensure that the reimbursement received by facilities is accurate and not subject to improper payment audits.


The National....

Author: DeVault, Kathryn

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

Publication Date: April 2015

With just six months until the implementation of ICD-10-CM and ICD-10-PCS, now is the time for HIM professionals to re-evaluate the state of their facility’s implementation plan and make any necessary adjustments to ensure a successful transition. Previous delays may have slowed down....

Author: Stanfill, Mary H

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

Publication Date: April 2015

The call for HIM professionals to develop measures and metrics that guide HIM efforts is not entirely new. Linda Kloss, MA, RHIA, FAHIMA, president of Kloss Strategic Advisors and former chief executive officer at AHIMA, discussed the importance of these measures in a Journal of AHIMA art....

Author: Maimone, Carol

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

Publication Date: March 2015

The Centers for Medicare and Medicaid Services (CMS) released a final rule providing required adjustments to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year (CY) 2015 on October 31, 2014.....

Author: Ward, Maria

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

Publication Date: March 2015

On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Medicare Physician Fee Schedule (PFS) Final Rule. Because of section 101 of the Protecting Access to Medicare Act (PAMA) of 2014, no changes to the fee schedule will occur until April 1, 2015. At t....

Author: Buttner, Patty

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

Publication Date: February 2015

On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....

Author: Haik, William E

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

Publication Date: February 2015

It is a well known fact that ICD-9-CM diagnosis and procedure codes impact hospital reimbursement and compliance. But there is an additional code that often flies under the radar—the discharge status code. Inaccurate discharge status code assignments for Medicare post-acute care transfers....

Author: Reed, Diana

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

Publication Date: January 2015

When it comes to converting superbills and claims from ICD-9-CM to ICD-10-CM, many healthcare providers believe that general equivalence mappings (GEMs) offer a cost effective and simple solution. The ability to purchase relatively cheap automated mappings of specialties’ top codes c....

Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi

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

Publication Date: January 2015

Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of detail....

Author: Stearns, Mike; Fuller, Jan C.

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

Publication Date: November 2014

The International Classification of Diseases (ICD) and SNOMED CT are similar in that both systems have alphanumeric codes associated with clinical concepts. But the systems differ in their purpose and structure, and are best used in different ways in healthcare. For starters, ICD is a cla....

Author: Arends-Marquez, Alexa; Knight, Nicole; Thomas-Flowers, Dwan

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

Publication Date: November 2014

The implications of ICD-10-CM/PCS (ICD-10) for coding operations are a common topic of industry discussion, but the impact of ICD-10 reaches far beyond coding alone. ICD-10 is embedded in the entire revenue cycle for providers. The conversion will impact almost every aspect of operations,....

Author: Franklin, Janet

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

Publication Date: October 2014

There are three age-defined models under commercial risk adjustment. These are the Adult Model (ages 21 and up), the Child Model (ages 2–21), and the Infant Model (ages 0–1). The model applicable to a patient is dependent on their age at the end of the benefit year. If a 20-year-old patie....

Author: Bielby, Judy A

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

Publication Date: October 2014

A poorly managed coding process can thwart the effective use of coded diagnosis and procedure data. Take for example Hospital A, a fictitious hospital that does not effectively manage their coding processes. At this hospital, the coding professionals are concerned primarily with the impact....

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: September 2014

Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....

Author: Franklin, Janet

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

Publication Date: September 2014

Known as the “Three Rs,” three mechanisms were included with the implementation of the Affordable Care Act (ACA) to reduce incentives insurers may have for avoiding the enrollment of high-cost members. The “Three Rs” are risk corridors, reinsurance, and risk adjustment.

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: July 2014

Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....

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....

Author: Rihanek, Theresa

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

Publication Date: June 2014

Traumatic brain injury (TBI) has received considerable attention by the media recently, especially bringing attention to the prevalence of TBI in sports-related activities. According to the Centers for Disease Control and Prevention (CDC), “A TBI is a bump, blow or jolt to the head o....

Author: Barta, Ann

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

Publication Date: June 2014

Editor’s note: This is the third in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.

IN THIS ARTICLE, the Journal of AHIMA continues its three-part Coding Notes series focusing on the nine Medical and Surgical-related sections of ICD-10-PC....

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: Barta, Ann

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

Publication Date: May 2014

Editor’s note: This is the second in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.


In this article, the Journal of AHIMA continues its three part Coding Notes series focusing on the nine Medical and Surgical-related secti....

Author: Barta, Ann

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

Publication Date: April 2014

Editor’s note: This is the first article in a three article series discussing the Medical and Surgical-related sections of ICD-10-PCS.



THERE ARE NINE Medical and Surgical-related sections of ICD-10-PCS. This article, the first in a series of three articles disc....

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: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2014

With only a few weeks left in 2013, the Hospital Outpatient Prospective Payment System (OPPS) final rule for calendar year (CY) 2014 was released on November 27, 2013 and went into effect on January 1, 2014. The final rule is normally provided to the public around the first week of Novemb....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2014

With this article the Journal of AHIMA concludes its 10-part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This installment focuses on three root operations in the Medical and Surgical Section that define other objectives:

• Fusion
• Alteration
• Creation

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: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2014

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


In this article the Journal of AHIMA continues its 10-part Coding Notes series focusing on the 31 root operations in the Medical and Surgical section of ICD-10-PCS.....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2014

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


In this article, the Journal of AHIMA continues the 10-part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This article will describe three....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2014

This article highlights the 2014 ICD-10-CM/PCS updates as approved by the ICD-9-CM Coordination and Maintenance Committee, which includes representatives from the Centers for Medicare and Medicaid Services and the National Center for Health Statistics. As a result of the partial code set....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2013

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


In this article, the Journal of AHIMA continues the 10 part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This article will take a more in de....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2013

When comparing the ICD-9-CM and ICD-10-CM obstetric guidelines, coding professionals should note both revised and completely new guidelines in ICD-10-CM. These guidelines are a result of various new concepts introduced in Chapter 15 of ICD-10-CM, such as the addition of a seventh character....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2013

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


With the upcoming implementation of ICD-10-PCS, there are new definitions and descriptions used to describe the procedures performed. Coding professiona....

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: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2013

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


In the Journal of AHIMA's continuing Coding Notes series focusing on the 31 root operations of ICD-10-PCS, this article will focus on the definitions of four root ope....

Author: Johnston, Gloria

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2013

Although the process of dual coding—assigning both ICD-9-CM and ICD-10-CM/PCS codes at the time of coding—is one way to compare equivalence of the codes, it is too resource-intensive to be practical for every instance where both codes are needed. ICD data mapping can supplement....

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: Scott, Karen S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2013

As the healthcare industry prepares for the transition to ICD-10-CM/PCS, many tools have been developed to assist in mitigating anticipated coding productivity losses. Computer-assisted coding (CAC) is an important tool that healthcare organizations can leverage to help counteract projecte....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2013

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

The implementation of ICD-10-PCS will challenge the skills of coders-it contains many unique features and provides an opportunity to truly reflect the complexity of....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2013

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



One of the keys to understanding ICD-10-PCS is the many new definitions and descriptions used to describe the various components of performed procedures.....

Author: Huey, Kim

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2013

Though it may seem contrary to popular opinion, electronic health record (EHR) products will make providers' coders more necessary and valuable than ever. Physicians who trust only EHR and computer-assisted coding software to choose the codes they bill, without any training or oversight, a....

Author: Scott, Karen S.

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2013

ICD-10-PCS will bring about many changes and challenges for coding professionals. It is important for those involved in coding to start preparing today for the many unique features of the coding system. One of the keys to understanding ICD-10-PCS is the many new definitions and description....

Author: Sheide, Amy; Wilson, Patricia S

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2013

What do coders need to know about Logical Observation Identifiers Names and Codes (LOINC)? A health records coder is unlikely to come across a LOINC code when looking for the correct ICD-9-CM code to reflect the documentation provided. A compliance officer may not see a LOINC code when eva....