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....