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CY 2013 OPPS Update

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013



As 2012 drew to a close, US healthcare facilities began the daunting task of reviewing the Centers for Medicare and Medicaid Services’ (CMS) hospital outpatient prospective payment system (OPPS) update to ensure their chargemaster and systems were up-to-date with the 2013 changes. Th....

CPT Code Updates for 2013

Author: Miller, Jackie

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013



The CPT code set has undergone extensive revisions for 2013, with codes, guidelines, and modifiers being revamped and updated. HIM coding professionals should download and review the CPT 2013 errata on the AMA website before starting to use the new codes. This download can be accessed at w....

EHRs Offer Coders Opportunities, Challenges

Author: Batres, Janie

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2012


With emerging technologies like electronic health record systems (EHRs) and computer-assisted coding (CAC) gaining traction in the healthcare industry, coding professionals are being presented with more challenges and opportunities than ever before. The shift from paper-based records to electr....

Coding Open Fractures in ICD-10-CM

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2012


Fractures are a common medical malady, and coders encounter them often. But the differences between coding fractures in ICD-9-CM and ICD-10-CM are vast.

Upon implementation of ICD-10-CM the code system currently in place for fractures within ICD-9-CM will cease to exist, and a new,....

ICD-10-CM Update 2012

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2012


This article highlights the 2012 ICD-10-CM update as approved by the ICD-9-CM Coordination and Maintenance Committee. The 2012 ICD-10-CM update includes the addition of new codes that already exist in ICD-9-CM, implemented in the FY 2012 ICD-9-CM update or recently incorporated into ICD-10 th....

Communication with a Side of Encouragement, Please: Effective Communication Strategies for a Smooth CDI Program implementation Transition

Author: Flood, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2012


Clinical documentation improvement (CDI) programs are spreading rapidly across the United States-and for good reason. They help facilities improve the level of documentation that goes into the patient medical record, leading to fewer errors and an overall improvement for continuity of care. Bu....

Coding Diabetes Mellitus in ICD-10-CM: Improved Coding for Diabetes Mellitus Complements Present Medical Science

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2012


Results of a recent coding and clinical documentation pilot study indicate that the ICD-10-CM coding classification changes made for diabetes mellitus have significantly improved coding for this disease. The results of the study noted that although a few ICD-10-CM "unspecified" diabetes codes....

Ensuring Remote Coding Compliance

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012


More and more HIM department managers are turning to remote coding. However, before implementing this staffing model, managers must answer several questions regarding the privacy and security of patient information, including:
What are the compliance risks?
How will privacy and secu....

FY 2012 ICD-10-PCS Updates

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012


Limited updates were made to ICD-10-PCS for fiscal year 2012 as set forth under the partial code freeze established by the ICD-9-CM Coordination and Maintenance Committee.1 The freeze is intended to aid the transition to the new code set by limiting updates for 2012 and 2013 to essential chan....

CPT Code Updates for 2012

Author: O’Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012


The 2012 updates to the CPT code set include 278 new codes, 139 code revisions, and 98 code deletions. This brings the total number of CPT codes to 9,641.

All major sections of the CPT code set, as well as the introduction and appendix A, have undergone changes. Beginning with the i....

CY 2012 OPPS Update

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012


The final rule for calendar year 2012 Hospital Outpatient Prospective Payment System (OPPS) was released on November 30, 2011. The rule went into effect for outpatient hospital-based services January 1, 2012.

This article outlines the updates in the final rule.
Financial Impact....

The Respiratory System and ICD-10-CM/PCS

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2012


The transition to ICD-10-CM/PCS will provide coding professionals with the opportunity to enhance and improve their coding skills. However, it will also require coders brush up on their anatomy and physiology knowledge. This is the perfect time to gain a better understanding of the differences....

FY 2012 Changes to the Hospital IPPS

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2011


The final rule for the FY 2012 Hospital Inpatient Prospective Payment System was released August 1, 2011. Changes in the rule went into effect with October 1, 2011, inpatient discharges.
MS-DRG Documentation and Coding Adjustment

The Centers for Medicare and Medicaid Services....

Coding Neoplasms in ICD-10-CM

Author: Bielby, Judy A

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2011


ICD-10-CM codes provide greater detail than ICD-9-CM codes for reporting neoplasms. In many instances, ICD-10-CM neoplasm codes can provide information on whether a neoplasm occurred in a right-sided or left-sided body part. ICD-10-CM also provides codes for reporting neoplasm sites with great....

New ICD-9-CM Diagnosis Codes for FY 2012

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....

Preparing for the CAC Transition

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2011


One of the biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the "use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare p....

Three-Day Window Updates

Author: Garrett, Gail S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011


The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 was signed into law on June 25, 2010. One of its provisions revised the three-day payment policy, or the so-called "three-day DRG window."

This article highlights the changes to the three-da....

Staying Alert on Sleep Medicine Coding

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2011


The field of sleep medicine is rapidly expanding, and its coding and reimbursement are attracting more attention from federal and state governments, public health organizations, scientists, payers, auditors, the transportation industry, and healthcare consumers. Emerging topics in the area of....

The Circulatory System and ICD-10-CM/PCS

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2011


Many coding professionals will need to learn new terminology and brush up on their anatomy and physiology (A&P) knowledge to prepare for the ICD-10-CM/PCS transition. Although it is still too early for intense training on the new code sets, now is the time for coding professionals to gain....

CY 2011 Changes to the Hospital OPPS

Author: Karban, Karen M

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2011


The final rule for the calendar year 2011 Hospital Outpatient Prospective Payment System (OPPS) was released November 24, 2010. Changes in the rule went into effect with January 1, 2011, outpatient hospital-based services.

The changes to OPPS continue to reflect packaging adjustments....

CPT Update 2011

Author: Smith, Gail I.; Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2011


Each year CPT adds codes to reflect new procedures and surgical techniques. For example, new codes were added in the surgical section to identify procedures performed using balloon catheters.

In addition, CPT continues to make editorial changes and add coding guidelines within the t....

Overview of the ESRD PPS

Author: Nelson, Tanai S

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010


In August the Centers for Medicare and Medicaid Services established a new prospective payment system (PPS) for end-stage renal disease (ESRD) facilities. The ESRD PPS will provide a single payment to ESRD facilities for renal dialysis services and other items and services related to home dial....

FY 2011 Changes to the Hospital IPPS

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010


The final rule for the FY 2011 Hospital Inpatient Prospective Payment System was released July 30, 2010. Changes in the rule went into effect with October 1, 2010, inpatient discharges.

The changes to MS-DRGs and the complication and comorbidity (CC) and major complication and comorb....

Strategies for Remote Coding Success: Remote Coding Program Helps Norman Regional Retain Quality Coders

Author: Miller, Amy; Ridpath, Debra

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2010


Remote coding is helping organizations attract and retain experienced coding professionals at a time when highly skilled coding professionals are in short supply. Successfully implementing a remote coding program requires that facilities have their entire clinical documentation online and qual....

Establishing a CDI Program: How One Organization Leveraged Nursing and Coding Skills to Improve Clinical Data

Author: Lopez, Barbara A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010


Establishing a clinical documentation improvement (CDI) program is an organization-wide, transformational process that affects a hospital’s culture, reaching across all disciplines and touching every colleague and the way they perform their jobs. Many factors can lead healthcare organizations....

Coding Hip Fractures

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....

Obstetric Coding in ICD-10-CM/PCS

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2010


ICD-10-CM/PCS will capture a greater level of specificity for obstetric coding. This article highlights some of the new features in coding obstetric cases with ICD-10-CM/PCS.
OB Diagnoses Coding with ICD-10-CM

Obstetric cases require diagnosis codes from chapter 15 of ICD-10-CM,....

ICD-10-PCS Root Operation Groups, Part 2

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2010


Root Operations that Take Out Solids, Fluids, Gases from a Body Part, Involve Cutting or Separation Only, and Put In OR put Back or Move Some OR All of a Body Part

The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically coded and repor....

ICD-10-PCS Root Operation Groups

Author: Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2010

Root Operations that Take Out Some or All of a Body Part

The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically reported in the hospital inpatient setting. As with all codes in ICD-10-PCS, the medical and surgical procedure codes contain....

2010 CPT Coding Update

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2010


Changes to CPT codes for 2010 include 219 additions, 141 revisions, and 63 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2010 CPT coding book. The changes took effect January 1.
Resequencing

The most n....

ICD-10-PCS Root Operation Guidelines

Author: Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2010


ICD-10-PCS has a completely different structure than ICD-9-CM. Each ICD-10-PCS code consists of individual values rather than lists of fixed codes and text descriptions, with each value containing a unique definition. The objective of the procedure is identified in the third character, the roo....

FY 2010 Changes to the Hospital IPPS

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2009


The final rule for the FY 2010 Hospital Inpatient Prospective Payment System was released on July 31, 2009. Changes in the rule went into effect with inpatient discharges of October 1, 2009, and are reflected in Grouper Version 27.0.

The changes to MS-DRGs and the complication and co....

Coding in Critical Access Hospitals

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2009


National health policy has been increasingly responsive to the healthcare needs of rural residents and providers. Rural America has a large percentage of the nation’s Medicare population, and this percentage continues to grow as residents born in the Baby Boomer generation begin to retir....

New Guidance for Home Health Coding

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2009


Sweeping PPS changes for home health went into effect January 2008, making much of the prior coding guidance issued by the Centers for Medicare and Medicaid Services (CMS) incompatible with changes in the revised data collection set. Home health coding professionals anxiously awaited further i....

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....

ICD-10-CM Official Coding Guidelines

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


One of the keys to a successful transition to ICD-10-CM/PCS is a thorough understanding of the ICD-10-CM Official Coding Guidelines, which were posted to the National Center for Health Statistics Web site in January 2009. Similar to the ICD-9-CM coding guidelines, the ICD-10-CM guidelines are....

ICD-10 Reimbursement Mappings: New Mappings from CMS Help Organizations in the Transition to ICD-10

Author: Butler, Rhonda R.; Mills, Ronald E

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2009


Starting October 1, 2013, healthcare claims will be submitted to payers using ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. Some payers such as the Centers for Medicare and Medicaid Services (CMS) are converting their reimbursement systems to use ICD-10 codes directly. However, som....

Key Issues in the 2009 OPPS Final Rule

Author: Clark, Andrea

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2009


The final rule for the 2009 Outpatient Prospective Payment System (OPPS) includes multiple revisions that hospitals must address in their practices, policies, and operations. Hospitals should develop strategies for analyzing the financial impact and operational challenges by reviewing the foll....

2009 CPT Coding Update

Author: Majerowicz, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2009


Changes to CPT codes for 2009 include 293 additions, 133 revisions, and 92 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2009 CPT code manual. The changes took effect January 1.

E/M Codes


Nu....

Coding Radiology Services

Author: Walk, Gerri

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2009


Because coding and radiology departments often share accountability for the quality of outpatient radiology coding, it is important that coding professionals share coding issues and charge capture expectations with radiology staff. This article outlines methods to improve the quality of coded....

FY 2009 Hospital IPPS Final Rule

Author: Schwab, Linda

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008


The final rule for the FY 2009 hospital inpatient prospective payment system (IPPS) went into effect October 1, 2008. Although there are relatively few changes to MS-DRGs and the complication and comorbidity (CC) and major CC (MCC) lists, the final rule signals that the Centers for Medicare an....

ABCs of Medicare Advantage

Author: Hernandez, Jeannette

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008


Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.

By June 2....

Clarifying Patient Status Code

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2008


The patient status code reflects the level of care a patient was discharged or transferred to when leaving an acute care hospital as an inpatient or outpatient (i.e., emergency department or emergency room). A recent Centers for Medicare and Medicaid Services MLN Matters publication provides a....

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