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Quest for Quality and Comparability in the National Healthcare Database: Announcing A Payer’s Guide to Health Care Data Quality and Integrity

Author: AHIMA Coding Policy and Strategy Committee

Source: Journal of AHIMA - Coding Notes

Publication Date: September 1996


As the computer-based patient record slowly becomes a reality, the need has never been greater for a national cooperative effort to recognize and apply uniform terminology and coding guidelines for both the clinical community and fiscal intermediaries. AHIMA’s Coding Policy and Strategy Commit....

New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization

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....

ICD-10's Impact Reaches Far Beyond Coding: Examining the New Code Sets' Revenue Cycle Implications

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,....

Clinical Documentation Improvement in the Outpatient Setting

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....

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....

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Measurement and Monitoring, Extracorporeal Assistance and Performance, and Extracorporeal Therapies

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....

2014 ICD-10-CM/PCS Updates

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....

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....

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Osteopathic, Other Procedures, and Chiropractic

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....

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-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....

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....

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....

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....

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....

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
....

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....

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.
....

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....

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....

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....

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....

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....

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