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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....
Putting an End to Emergency Room Injection/Infusion Coding Confusion
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....
Putting Productivity Plans to Work
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....
Quality Queries for Quality ICD-10-PCS Codes
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....
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....
RAC Forensics 101. Part 1: Medical Record Requests and the Discussion Period
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....
RAC Forensics 101: Part 2: The Results Letter and the Discussion Call
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....
RAC Forensics 101Part 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....
RAC Inpatient Coding Denials: Key Areas of Improper Payment in permanent program
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....
Reading Up on LOINC: What Coders Need to Know
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....
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