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Coding Preventive Care Services

Author: Wilkinson, Dianne

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2008


According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....

2008 CPT Coding Update

Author: Jorwic, Therese M

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2008


The new CPT codes took effect January 1, 2008. Changes include 244 additions, 314 revisions, and 50 deletions. A comprehensive list of changes can be found in appendix B of the CPT book. Highlights of the changes by section are outlined here.
Evaluation and Management

A revised....

Coding Debridement Procedures

Author: McCullough, Dan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2008


Coding debridement procedures can be difficult-even for the most experienced coding professional. Recent studies have documented inappropriate coding of debridement procedures that have resulted in millions of dollars in overpayments.

This article offers guidance on the app....

Home Health PPS Update

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2008


The long-anticipated update to the Home Health Prospective Payment System (PPS), released in the August 29, 2007, Federal Register, goes into effect January 1, 2008. The final rule encompasses a wide range of changes for home health agencies.
An Overview of the Final Rule
....

Ensuring Proper Wound Care Service Coding: OIG Highlights Need for Organizations to Assess Wound Care Coding Practices

Author: Bryant, Gloryanne H.

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

Publication Date: November 2007



This year the Office of Inspector General (OIG) issued two reports relating to wound care services and Medicare payments. As the OIG has included wound care services as part of its 2007 work plan, coding and HIM professionals should review each report and re-assess their organization̵....

Final Rule for FY 2008 IPPS: MS-DRGs and POA Top List in a Year of Major Change

Author: D'Amato, Cheryl; Garrett, Gail S.; Johnson, Laurie M.

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

Publication Date: November 2007



The final rule for the fiscal year 2008 inpatient prospective payment system (IPPS) went into effect October 1, 2007. The rule includes ICD-9-CM code changes, implementation of the new Medicare severity-adjusted (MS) DRG system, and a number of quality-related changes that affect how Medic....

Getting Quality Clinical and Coded Data: How UMHS's CDIP Improved Clinical Coded Data and Clinical Staff Relationships

Author: Blackford, Gwendolyn; Whitehouse, Rosanne

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

Publication Date: October 2007


Obtaining codeable clinical documentation at the point of care in a large teaching facility can be challenging. However, the HIM department at the University of Michigan Health System (UMHS) in Ann Arbor, MI, took on the task, implementing a clinical documentation improvement program (CDI....

IRF PPS Coding Challenges

Author: Trela, Patricia

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

Publication Date: May 2007


Inpatient rehabilitation facility (IRF) coding can be a challenge due to the Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS), which was implemented in 2002 to cover patients paid under Medicare Part A. IRF PPS requires completion of the IRF-Patient Assessment In....

FY 2007 IPPS Overview: Comprehensive Changes in Effect for Inpatient Prospective Payment System

Author: Johnson, Laurie M.; Garrett, Gail S.

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

Publication Date: November 2006


The Inpatient Prospective Payment System (IPPS) final rule for fiscal year 2007 will prove challenging for inpatient providers. The rule (published in the August 18 Federal Register and available at www.access.gpo.gov/su_docs/fedreg/a060818c.html) includes some of the most comprehensive changes....

Coding Pregnancy

Author: Bronnert, June

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

Publication Date: October 2006


While science and research have shed light on the various stages of fetal development, the process is still fascinating. This article details each month of a fetus’s development and reviews common delivery complications and where related information may be documented in the record.
....

Codes for Chronic Kidney Disease: Help in Distinguishing between Renal Failure and Renal Insufficiency

Author: Gold, Robert S.; Bowman, Sue E

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

Publication Date: January 2006


Coders assign codes to disease processes for many reasons, including capturing diseases treated at facilities, accurate representation of illness severity, and specificity of causes of symptoms and justification for treatment. To this end, we have been perplexed by terminology used by physicia....

2006 CPT Coding Update

Author: Hull, Susan

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

Publication Date: January 2006


A number of changes to CPT codes take effect January 1, 2006. These changes affect category I, II, and III codes, with a total of 277 additions, 110 deletions, and 71 code revisions.
Evaluation and Management

Within the evaluation and management (E/M) section, the codes for fol....

DRG Changes for FY 2006

Author: Leary, Renee; D'Amato, Cheryl

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2005


The final Medicare DRG changes for fiscal year (FY) 2006, which were published in the August 12, 2005, Federal Register, include 16 new DRGs, the deletion of 10 existing DRGs, and numerous changes to DRG assignments of current diagnosis and procedure codes. These DRG changes, along with other....

Coding Complex Bariatric Surgery

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2005


Bariatric, or weight-loss, surgery is a rapidly evolving specialty. From jejunocolic and jejuno-ileal bypass procedures, through the days of minimally invasive procedures such as gastric balloons and endoscopic-banded gastroplasty, to today’s procedures that involve both gastroplasty and....

Coding Ethically

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2005


With the many reimbursement issues and regulatory requirements surrounding coding, it is sometimes necessary for coders to refamiliarize themselves with what it means to code ethically. AHIMA’s Coding Policy and Strategy Committee developed the Standards of Ethical Coding, which were app....

Reporting Codes Accurately

Author: Giannangelo, Kathy

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2005


Coding professionals routinely review records and, when appropriate, query physicians to clarify a condition. Once the specifics are known, ICD-9-CM is used to determine the appropriate codes to record a patient’s diagnosis and report the healthcare claim. Coding professionals know that....

Problem List Coding in e-HIM

Author: Fraser, Greg

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2005


In 1968 Larry Weed, MD, introduced the idea that a complete and accurate problem list is an essential component of the medical record.1 The problem-oriented medical record (POMR), in which all data contained in the medical record can be linked to a list of problems, has been almost universally....

Trouble with DRGs: Part 2

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2005


Last issue’s article presented some ways that DRG criteria redefine well-established clinical entities such as respiratory failure and sepsis. This article will discuss two other incompatibilities between DRG criteria and clinical practice: the clinical distinctions required by the DRG s....

Trouble with DRGs

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2005


A major frustration among coding professionals, particularly in the inpatient setting, is the difficulty in translating physician documentation into diagnostic related group (DRG) data. Some hospitals have attempted to improve their coding effectiveness by establishing time-consuming physician....

Keeping up to Date: 2005 CPT Surgery Changes

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2005


CPT changes for 2005 affect all portions of the manual, although there are very few changes in the pathology and laboratory section. This article will focus on the changes for the surgery section. The January and February 2005 issues of CodeWrite (available through the Coding Community of Prac....

Coding Dementia

Author: Laakso, Roz

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2004


Dementia is defined as “a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living.”1 Alzheimer’s disease is an age-related, irreversible brain disorder that occurs gradually and results in me....

Changes Abundant for CPT 2004

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004


Changes for CPT 2004 affect all chapters, and it’s important to stay up to speed. This article presents a summary of CPT changes for 2004. Because a number of the procedures may be unfamiliar to some coding professionals, AHIMA has provided online links to descriptive articles on these s....

Understanding Diabetes Mellitus

Author: Huff, Garry L.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2003


Diabetes mellitus represents a group of disorders that are characterized by hyperglycemia. The clinical and ICD-9-CM classification of diabetes mellitus have evolved as understanding of insulin physiology has expanded. This article will explain diabetes mellitus and its ICD-9-CM classification....

Choosing Modalities for Carotid Stenosis

Author: Wiley, Sean

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003


One of the leading causes of stroke and transient ischemic attack (TIA) is carotid artery disease (CAD). With technology changing at such a rapid rate, it is difficult for physicians to decide on the gold standard of care when it comes to visualizing carotid stenosis. This article will explain....

CPT Category III Codes Cover New, Emerging Technologies: New Codes Developed to Address Issues in Light of HIPAA

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003


In 1998, the American Medical Association (AMA) initiated the CPT-5 Project. This project was a broad-based and comprehensive effort to make needed and practical enhancements to the CPT code set that would address challenges presented by emerging user needs and HIPAA. One of the initiatives tha....

Internal Radiation Brings Hope to Prostate Cancer Patients: With Brachytherapy Treatment Come New HCPCS Codes

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


In 2003, the American Cancer Society estimates that 220, 900 men will be diagnosed with prostate cancer in the US, making it the second leading cause of cancer deaths in men.1 Today in the US, patients with prostate cancer have access to less invasive surgical cancer treatment plans. This arti....

Advances in Burn Reconstruction Complicate Coding: Get Familiar with Terminology, Techniques for Accurate Coding

Author: Erhardt, Walter L.; Medal, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


Recent advances in the science of wound healing are making an impact on the treatment of burns. This is particularly evident not only in the way burn wounds are being managed initially, but also in how these wounds are being reconstructed. While these scientific advances make this field an exc....

Sepsis, Related Terms Cause Confusion for Coders: Set the Record Straight About Sepsis, SIRS, Septic Shock

Author: Prophet-Bowman, Sue

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2003


Sepsis, severe sepsis, SIRS, and septic shock have long been a source of confusion for coders. New ICD-9-CM codes established recently for Systemic Inflammatory Response Syndrome (SIRS), and additional proposed code revisions have added to the confusion regarding the differentiation among these....

Fracture Treatment Poses Coding Challenge: Multiple Treatment Options Require Special Attention

Author: Hutchinson, Mark R.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2003


There are 206 bones in the human body and each is susceptible to fracture. The choices in fracture management are complex and based on a number of issues including fracture type, fracture pattern, specific bone, age of fracture, age of patient, associated injuries, and physician preference. Co....

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