Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

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

Publication Date: July 2014

Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

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: Stearns, Mike; Fuller, Jan C.

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

Publication Date: November 2014

The International Classification of Diseases (ICD) and SNOMED CT are similar in that both systems have alphanumeric codes associated with clinical concepts. But the systems differ in their purpose and structure, and are best used in different ways in healthcare. For starters, ICD is a cla....

Author: Arner, Kathy

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

Publication Date: February 2007

Coding for facility and professional services on the same encounter can be confusing. This article outlines the differences in guidelines between the two coding types.

The Setting Factor


Over and over, coding professionals have been tol....

Author: Brouch, Kathy L.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2003

For more information on physician queries, see the "Developing a Physician Query Process" practice brief in the October 2001 Journal of AHIMA and in the FORE Library: HIM Body of Knowledge in the Communities of Practice at www.ahima.org.
Is obtaining an answer to a coding question a daunting t....

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: 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,....