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....

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: Dunn, Rose T

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2001

This is the last in a series of three "Coding Notes" articles addressing productivity measurement and incentive plans for coding professionals. The April Journal of AHIMA (vol. 72, no. 4) article discussed the general principles of developing facility-specific productivity m....

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: 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....

Author: Easterling, Sharon

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2011

Thirteen months after the Recovery Audit Contractor (RAC) process was implemented nationwide, healthcare organizations are still learning how to best manage the audit process. The initial reviews were automated, but since that time RACs have also begun complex coding reviews and medical necess....

Author: Easterling, Sharon

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2011

Healthcare organizations are still struggling to manage the Recovery Audit Contractor (RAC) process implemented last year. This article is the second in a series that discusses the provider portal, the discussion period, and the review results letter. Part 1, published in the January issue, di....

Part 3: Denials Management

Author: Easterling, Sharon

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2011

The denials management process is the final step in the RAC process and can be the most time-consuming portion, depending on the circumstances of each case. Providers may appeal a RAC decision either through the discussion period or the formal Medicare Appeals Process.

Becoming know....

Author: Wilson, Donna D

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2012

The Recovery Audit Contractor (RAC) demonstration program found that "most of the overpayment amounts collected by the RACs (about 85 percent) were from inpatient hospital providers," and "almost half of the improper payments were the result of incorrect coding."1 Things have changed with....

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....