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2002 DRG Updates Already in Effect
Author: Uppena, Mary
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2001
The 2002 diagnosis related group (DRG) updates went into effect October 1, 2001. With the implementation of these changes to the hospital inpatient DRGs portion of the prospective payment system (PPS), there will be 499 DRGs in 25 Major Diagnostic Categories (MDCs).
Changes t....
2005 ICD-9-CM Codes and DRG Changes
Author: Willard, Dianne; Worthington, Debbie; Ashley, Patti
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2004
ICD-9-CM coding and DRG changes for fiscal year 2005 include 150 new diagnosis codes, 21 new V codes, 54 new procedure codes, 25 invalid diagnosis codes, and 3 new DRGs. The changes were released in the August 11 Federal Register and went into effect October 1, 2004, for discharges occurring o....
2006 CPT Coding Update
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2006
A number of changes to CPT codes take effect January 1, 2006. These changes affect category I, II, and III codes, with a total of 277 additions, 110 deletions, and 71 code revisions.
Evaluation and Management
Within the evaluation and management (E/M) section, the codes for fol....
2007 CPT Coding Update
Author: Wiedemann, Lou Ann; Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2007
A number of changes to the current CPT codes took effect on January 1, 2007. These changes affect categories I, II, and III codes, with a total of 258 additions, 308 deletions, and 79 revisions. A summary of all additions, deletions, and revisions can be found in appendix B of the 2007 C....
2008 CPT Coding Update
Author: Jorwic, Therese M
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2008
The new CPT codes took effect January 1, 2008. Changes include 244 additions, 314 revisions, and 50 deletions. A comprehensive list of changes can be found in appendix B of the CPT book. Highlights of the changes by section are outlined here.
Evaluation and Management
A revised....
2009 CPT Coding Update
Author: Majerowicz, Anita
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2009
Changes to CPT codes for 2009 include 293 additions, 133 revisions, and 92 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2009 CPT code manual. The changes took effect January 1.
E/M Codes
Nu....
2010 CPT Coding Update
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2010
Changes to CPT codes for 2010 include 219 additions, 141 revisions, and 63 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2010 CPT coding book. The changes took effect January 1.
Resequencing
The most n....
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....
2017 CPT Coding Update
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....
2019 ICD-10-PCS Coding Updates
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....
ABCs of HHS-HCCs: Taking a Closer Look at the Commercial Risk Adjustment
Author: Franklin, Janet
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: October 2014
There are three age-defined models under commercial risk adjustment. These are the Adult Model (ages 21 and up), the Child Model (ages 2–21), and the Infant Model (ages 0–1). The model applicable to a patient is dependent on their age at the end of the benefit year. If a 20-year-old patie....
ABCs of Medicare Advantage
Author: Hernandez, Jeannette
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2008
Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.
By June 2....
ACA Risk Adjustment Models Emerge in Commercial Care
Author: Franklin, Janet
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2014
Known as the “Three Rs,” three mechanisms were included with the implementation of the Affordable Care Act (ACA) to reduce incentives insurers may have for avoiding the enrollment of high-cost members. The “Three Rs” are risk corridors, reinsurance, and risk adjustment.
A Dive into Section I.A.19: Code Assignment and Clinical Criteria
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....
Advances in Burn Reconstruction Complicate Coding: Get Familiar with Terminology, Techniques for Accurate Coding
Author: Erhardt, Walter L.; Medal, Diana
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2003
Recent advances in the science of wound healing are making an impact on the treatment of burns. This is particularly evident not only in the way burn wounds are being managed initially, but also in how these wounds are being reconstructed. While these scientific advances make this field an exc....
Analysis of POA and Hospital- Acquired Conditions Data, Part 1
Author: Schraffenberger, Lou Ann
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2008
On October 1, 2007, hospitals began reporting secondary diagnoses that were present on admission (POA). The POA indicator can be reported as Y, present on admission; N, not present on admission; U, unknown; or W, clinically undetermined.
Beginning October 1 of this year, N and U indi....
Analysis of POA and Hospital-Acquired Conditions Data: Part 2
Author: Schraffenberger, Lou Ann
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2008
Last October hospitals began reporting secondary diagnoses that were present on admission (POA). These indicators are reported as Y, present on admission; N, not present on admission; U, unknown; or W, clinically undetermined. Beginning October 1 of this year, N and U indicators will affect Me....
Another Look at Home Care PPS
Author: Youmans, Karen; Scichilone, Rita A; Dougherty, Michelle
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2001
In the October 2000 Journal of AHIMA, we outlined the new home health care prospective payment system (PPS).1 Coding professionals working with home health providers have learned new terms and additional guidelines for reporting. However, confusion remains concerning code assignments, because s....
Anthrax: What Every Coder Should Know
Author: Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2002
The inhalation anthrax identified by a Florida physician in October 2001, during the recent series of bioterrorist attacks, was the first case of reported inhalation anthrax in the United States in more than 25 years.1 With the threat of anthrax as a biological weapon, correct coding could be....
Applying Facility E/M Codes in the Hospital Emergency Department
Author: Peters, Robert; Wiedemann, Lou Ann
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2007
Evaluation and management (E/M) codes were added to the CPT codebook in 1992 to classify physician services. Use of these codes increased when they became integral to physician practice reimbursement. E/M codes became a tool for practices to trend individual physician profiles and reimbursemen....
Are You Ready for POA Reporting?
Author: Bowman, Sue E
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2007
Reporting option “U” should not be routinely assigned and should be used in very limited circumstances. Coding professionals should query the provider when the documentation is unclear.
Medical record documentation from any provider involved in the care and treatment of the patient may be u....
Assigning E Codes: Two New Sections Go into Effect October 1
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2009
Two new E code sections go into effect October 1—E000, External Cause Status, and E001–E030, Activity. The sections will facilitate prevention strategies developed by epidemiologists and injury prevention specialists and bring ICD-9-CM E codes more in line with ICD-10-CM external c....
Assigning Secondary Codes from the History and Physical
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2006
To code or not to code can be one of the toughest questions a coder faces on a day-to-day basis. Assigning the appropriate secondary diagnoses can be a challenge. This article describes appropriate coding of secondary diagnoses by reviewing documentation of a history and physical.
Un....
Auditing ICD-10 Through the Lens of Education
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....
Back to the Basics of Spine Surgery: Anatomy, Terminology Knowledge Can Improve Coding
Author: Kuehn, Lynn
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2012
The human spine is a complex unit that combines the structures of both the nervous and musculoskeletal systems. Understanding the anatomy, terms and definitions, and procedure concepts associated with spinal surgery can make for a considerably smoother coding process.
Anatomy of the Spine....
Back to the Basics on ICD-10-PCS Spinal Fusion Coding - Retired
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....
Best Practices for Coding Productivity: Assessing Productivity in ICD-9 to Prepare for ICD-10
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2012
As organizations begin to prepare for ICD-10 implementation, the question of coder productivity is usually close to the top of everyone's list. Addressing productivity in ICD-9-CM will provide a baseline of information crucial for the transition to ICD-10-CM/PCS.
The AHIMA e-HIM Cod....
Beyond Coding to Content Analysis
Author: Richmond, Rosalind; Chapman, Claudia; Cook, Jane; Levy, Brian
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2005
The health information technology (HIT) field can provide HIM professionals with many career opportunities at software and content companies. HIT roles require highly developed content analysis skills, including abstracting, coding, documentation compliance, and utilization review. The availab....
Brief History of ICD-10-PCS
Author: Mullin, Robert L.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 1999
The International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) was developed as a replacement for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) volume 3, Procedures. This version of ICD, in use since J....
Brushing Up On ICD-10-PCS
Author: Bowman, Sue E
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: October 2007
Although the US continues to wait for an implementation date for ICD-10-CM and ICD-10-PCS, HIM professionals should maintain a basic familiarity with these new coding systems. This article provides an overview of ICD-10-PCS.
The Structure of ICD-10-PCS
ICD-10-PCS....
Building Clarity on the Two-Midnight Rule
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....
Building the Coding Career Ladder
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....
Calendar Year 2015 OPPS Update
Author: Maimone, Carol
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2015
The Centers for Medicare and Medicaid Services (CMS) released a final rule providing required adjustments to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year (CY) 2015 on October 31, 2014.....
Calendar Year 2016 OPPS Rule Update
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....
Call for Additional Coding Metrics
Author: Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2015
The call for HIM professionals to develop measures and metrics that guide HIM efforts is not entirely new. Linda Kloss, MA, RHIA, FAHIMA, president of Kloss Strategic Advisors and former chief executive officer at AHIMA, discussed the importance of these measures in a Journal of AHIMA art....
Can Natural Language Processing Aid Outpatient Coders?
Author: Warner, Homer R. Jr.
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2000
As HIM vendors strive to perfect automated coding, one supporting technology has reached an exciting stage of development. Natural language processing (NLP) is a major challenge for the computer industry because of the complexity and variability of human speech. NLP differs from simple word s....
Casting Conundrum: Correct Coding for Casts, Splints, and Strapping
Author: Nelson, Tanai S; Benjamin, Christina
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2009
Correctly coding casts, splints, and strapping can be confusing. Much of the confusion is related to what type of materials are classified as casts, splints, or strapping; whether the CPT application codes or the HCPCS level II codes should be assigned; and whether the work performed is includ....
CDI in the Outpatient Setting: Finding the 'Hidden Gems' of Opportunity for Improvement
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....
CDI Opportunities for HIM Professionals
Author: Endicott, Melanie; Gardner, Amy
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2009
The HIM field continues to expand and change, opening up more opportunities for HIM practitioners to move out of the HIM department and into other areas of the hospital. Recent initiatives, such as ICD-10-CM/PCS, MS-DRGs, Hospital-Acquired Conditions, and Present on Admission reporting, have b....
CDI Tips Developed to Maximize ICD-10-CM/PCS
Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2015
Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of detail....
Cervical Dysplasia and CIN: What's the Difference?
Author: Herr, Victoria A.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2005
In fiscal year 2005, new ICD-9-CM codes were created for reporting cervical dysplasias and abnormal Pap smears. From a clinical perspective, the new codes and instructional notes align ICD-9-CM with current terminology used in diagnosing and reporting cellular abnormalities of the cervix. From....
Change at Hand: How PDAs Can Transform Coding, Billing
Author: Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2002
Have you ever had a physician ask if you can put the encounter form on her hand-held computer? Or maybe the physicians in your medical group have been offered free personal digital assistants (PDAs) if they use a certain application and they want you to find out if these devices can expedite c....
Changes Abundant for CPT 2004
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2004
Changes for CPT 2004 affect all chapters, and its important to stay up to speed. This article presents a summary of CPT changes for 2004. Because a number of the procedures may be unfamiliar to some coding professionals, AHIMA has provided online links to descriptive articles on these s....
Characteristics and Challenges of Long-term Acute Care Hospitals
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2006
Governed by somewhat different rules than other acute care providers, long-term acute care (LTAC) hospitals represent a special segment of the provider market. This article reviews the definition of a LTAC hospital and discusses some of the special challenges facing HIM practitioners and codin....
Charging vs. Coding: Untangling the Relationship for ICD-10
Author: Pilato, Jeff
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2013
While the transition to ICD-10-CM/PCS has the potential to put revenue at risk, adding staff to the revenue cycle is rarely an option in today’s cost-cutting environment. There are no extra hands to review charges, double-check bills, or safeguard claims. To mitigate risk, preventive....
Choosing Modalities for Carotid Stenosis
Author: Wiley, Sean
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2003
One of the leading causes of stroke and transient ischemic attack (TIA) is carotid artery disease (CAD). With technology changing at such a rapid rate, it is difficult for physicians to decide on the gold standard of care when it comes to visualizing carotid stenosis. This article will explain....
Clarification of Clinical Data Sets, Vocabularies, Terminologies, and Classification
Author: AHIMA Coding Policy and Strategy Committee
Source: Journal of AHIMA - Coding Notes
Publication Date: February 1999
[Please note: the content in this article is out of date. It is being updated by AHIMA's Clinical Terminology and Classification Practice Council]
Clinical data set, vocabulary, terminology, and classification system. We frequently hear, see, and speak these terms, but what....
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....
Clarifying Selected CPT Modifiers
Author: Scichilone, Rita A
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2000
Coding for professional services is complicated enough when coding professionals are charged with assisting the physician to select the best five-digit number for the services rendered. It becomes even more complex when circumstances of the case require the CPT code to be modified. Add....
Clarifying the Infusion and Injection Quandary
Author: Johnson, Laurie M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2007
Coding infusions and injections has been a source of confusion and frustration since the Centers for Medicare and Medicaid Services (CMS) introduced C codes in 2006. However, in calendar year 2007, CMS made an about face and eliminated the C codes, reverting back to the published 2007 CPT....
Classification of Coagulopathy
Author: Grebner, Leah A.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2005
The term coagulopathy can be confusing for coding professionals because it may refer to a myriad of conditions that are classified differently in ICD-9-CM. Take for example a patient who has bleeding somewhere (e.g., hematuria or epistaxis). The physician lists “coumadin coagulopathy&rd....
Classifying and Reclassifying Hyperplasia of the Prostate
Author: Grocela, Joseph; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2004
Fewer than five years ago, ICD-9-CM contained just one code for classifying hyperplasia of the prostate. Today, there are nine ICD-9-CM codes in category 600, Hyperplasia of prostate. What is hyperplasia, and why have so many changes been made to this code category in recent years?
....
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....
Closer Look at Cardiac Function and Resynchronization
Author: Bryant, Gloryanne H.; Gold, Robert S.
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2002
by Gloryanne Bryant, RHIT, CCS, and Robert Gold, MD
Coding cardiac conditions and treatments can be difficult for coders, due both to the intricacies of the muscle and its workings and the lack of specificity and documentation in the medical record. This article reviews common cardiac....
Closer Look: the SNOMED Clinical Terms to ICD-9-CM Mapping
Author: Imel, Margo
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2002
In the July/August 2001 Journal of AHIMA, SNOMED Takes the Next Step describes the terminologys structure, use in electronic patient records, the evolutions from SNOMED® RT and an overview of the mappings of SNOMED® CT. This article is an update on SNOMED, with a clo....
Coder and the Cancer Registrar: Defining the Differences in Roles and Coding
Author: Fritz, April
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2005
To the average coder, the hospital’s cancer registrar is the person who comes and gets charts, keeps them for a while, and then returns them to the HIM department. But little is known about what goes on at that other desk. This article outlines a cancer registrar’s duties and the d....
Coders Can Benefit from Bare Bones Podiatry Lesson
Author: Jones, Lolita M.
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2003
Podiatry is the specialty that manages diseases and problems of the feet. Many coding specialists find it difficult to assign CPT codes to podiatry cases. Because so many podiatry procedures are currently performed in the outpatient setting, it is common for coding specialists to be faced with....
Codes and Treatments for Drug and Alcohol Conditions
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2006
In 2003 61 percent of adults drank alcohol, according to the National Center for Health Statistics.1 Illicit drug use for that same year is reported at 8 percent, with 6 percent using marijuana.2 With those statistics, it’s a safe bet that coding professionals will encounter records repo....
Codes for Chronic Kidney Disease: Help in Distinguishing between Renal Failure and Renal Insufficiency
Author: Gold, Robert S.; Bowman, Sue E
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2006
Coders assign codes to disease processes for many reasons, including capturing diseases treated at facilities, accurate representation of illness severity, and specificity of causes of symptoms and justification for treatment. To this end, we have been perplexed by terminology used by physicia....
Coding and HIM in Home Care: Up to the Challenge
Author: Blevins, Ida K.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2004
Home care coding has always been a challenge given the fact that codes are assigned upon admission or on the “front end” of care provision. The luxury of having a complete medical record filled with physician documentation to support diagnoses (e.g., in acute-care facilities) is a....
Coding Breast Procedures with CPT
Author: Endicott, Melanie
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: May 2014
There are a multitude of CPT codes available to report breast procedures, including incision, excision, introduction, mastectomy, repair, and reconstruction. The correct application of these codes requires an in-depth analysis of the notes associated with codes 19000-19396 and an understa....
Coding Cardiovascular Catheterization: Accuracy Requires a Multidisciplinary Effort
Author: Lenahan, Monica
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2009
Cardiac catheterization procedures involve the insertion of a catheter into a chamber or vessel of the heart for investigational and interventional purposes. A small puncture is made most commonly in the femoral artery in the groin region. A guidewire is then inserted into the incision and thr....
Coding Chronic Kidney Disease
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2007
by June Bronnert, RHIA, CCS, CCS-P
Chronic kidney disease (CKD) affects 20 million Americans, or one in every nine adults, and another 20 million Americans are at risk of developing CKD, according to the National Kidney Foundation. With this prevalence, it is important for coding professio....
Coding Complex Bariatric Surgery
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2005
Bariatric, or weight-loss, surgery is a rapidly evolving specialty. From jejunocolic and jejuno-ileal bypass procedures, through the days of minimally invasive procedures such as gastric balloons and endoscopic-banded gastroplasty, to today’s procedures that involve both gastroplasty and....
Coding Connections in Revenue Cycle Management
Author: Cummins, Ruth; Waddell, Julie
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2005
Recently, there has been a significant amount of talk in the healthcare industry about revenue cycle improvement. So what is all of the excitement about? It is about the bottom line. Specifically, how we can improve our bottom line through more effective and efficient revenue cycle management.....
Coding Consultation E/M Services Correctly
Author: Peter, Karla R.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: November 2006
Incorrect coding of consultative services can cost the healthcare industry and organizations dearly. In March the Office of Inspector General (OIG) announced that approximately 75 percent of evaluation and management (E/M) services billed in 2001 as consultative and allowed by Medicare did n....
Coding Debridement Procedures
Author: McCullough, Dan
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2008
Coding debridement procedures can be difficult-even for the most experienced coding professional. Recent studies have documented inappropriate coding of debridement procedures that have resulted in millions of dollars in overpayments.
This article offers guidance on the app....
Coding Dementia
Author: Laakso, Roz
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2004
Dementia is defined as “a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living.”1 Alzheimer’s disease is an age-related, irreversible brain disorder that occurs gradually and results in me....
Coding Diabetes Mellitus in ICD-10-CM: Improved Coding for Diabetes Mellitus Complements Present Medical Science
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2012
Results of a recent coding and clinical documentation pilot study indicate that the ICD-10-CM coding classification changes made for diabetes mellitus have significantly improved coding for this disease. The results of the study noted that although a few ICD-10-CM "unspecified" diabetes codes....
Coding Discussions about the Elephant in the Room
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....
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....
Coding for APCs: Case Studies
Author: Scichilone, Rita A
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2000
When APC implementation begins on August 1, HIM professionals can expect increased complexity when coding outpatient encounters. Examining case studies in selected areas subject to APC payment may help coding professionals better understand the APC reporting process. Although coding guidelines....
Coding for External Causes of Morbidity in ICD-10-CM
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2011
The ICD-10-CM external causes of morbidity tabular list includes significant enhancements to the ICD-9-CM supplementary classification of external causes of injury and poisonings (E800–E999). The ICD-10-CM list features category restructuring, reorganization, and major code expansion.
Coding for Mammography Services
Author: Buck, Stacie L
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2007
You’re diligently auditing outpatient diagnostic services when you find an order in the medical record for a screening mammogram. However, a diagnostic mammogram was performed, not a screening mammogram.
The business office and the patient request that you change the diagno....
Coding for Medication Therapy Management Services
Author: Vogenberg, F. Randy; Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2006
Different practical issues surround the implementation of medication therapy management (MTM) services and subsequent payment in community pharmacy, long-term or home care, and institutional practice settings. This article delves into the new codes for MTM services, why they were issued, and t....
Coding for Telemedicine is Now a Reality
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....
Coding for Vascular Access Devices: New CPT Subsection Sheds Light on Procedures, Devices
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2004
The coding of vascular access procedures has been problematic for some time. New codes were added to CPT as new techniques developed, but the organization of the subsection was vague and the coding of some types of devices unclear. With CPT 2004, an entire new subsection, Central Venous Acces....
Coding Guidelines for Pain
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2007
New codes for generalized pain, central pain syndrome, and postoperative pain were approved for ICD-9-CM in FY 2007 and went into effect October 1, 2006. Previously codes for pain were found in the body system chapters and the symptom chapters. A new category was created in the nervous sys....
Coding Hip Fractures
Author: Endicott, Melanie
Source: Journal of AHIMA - Coding Notes
Publication Date: June 2010
Hip fractures are most commonly seen in elderly patients. They are a serious concern for this population because they can lead to a decreased quality of life, extended hospitalizations, or admission to nursing facilities.
Two of the most common causes for fractures are falls and ost....
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....
Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Obstetrics, Placement, And Administration
Author: Barta, Ann
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2014
Editor’s note: This is the first article in a three article series discussing the Medical and Surgical-related sections of ICD-10-PCS.
THERE ARE NINE Medical and Surgical-related sections of ICD-10-PCS. This article, the first in a series of three articles disc....
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....
Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2014
Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.
This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....
Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2014
Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.
This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....
Coding in Critical Access Hospitals
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2009
National health policy has been increasingly responsive to the healthcare needs of rural residents and providers. Rural America has a large percentage of the nation’s Medicare population, and this percentage continues to grow as residents born in the Baby Boomer generation begin to retir....
Coding Injuries in ICD-10-CM
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2011
Note: This article has been updated. The updated version is available here.
Coding in Long-Term Care Hospitals: How Medicare Distinguishes LTCHs from Other Providers
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2008
The term “long-term care hospital” (LTCH) can leave some in a quandary—do these facilities provide acute care or long-term care? Many people associate them with skilled nursing facilities.
However, LTCHs are not synonymous with skilled nursing facilities; each has....
Coding in the Ambulatory Surgery Center
Author: Peterson, Cindi
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2006
There are more than 4,200 ambulatory surgery centers (ASCs) nationwide, performing more than 8 million surgical procedures annually.1 With the increased volume of outpatient procedures, there is no shortage of opportunities for coding professionals.
ASC coding can prove demanding, how....
Coding in the Coming Decade: Three Initiatives That Will Drive the Profession’s Evolution
Author: Buck, Stacie L
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2008
The saying “The only thing that is constant is change” certainly describes the HIM profession and the role of coding professionals.
Over the last three decades the coding professional’s role has evolved dramatically, and it will continue to do so in the decades to c....
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....
Coding on the Home Front
Author: Zeisset, Ann M.
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2002
Recently, a group of coders participated in a survey about their day-to-day experiences as remote, or at-home coders. The survey asked a series of questions related to the positives and negatives of coding at home versus coding in the more traditional office setting. Below is a summary of the....
Coding Open Fractures in ICD-10-CM
Author: Comfort, Angie
Source: Journal of AHIMA - Coding Notes
Publication Date: September 2012
Fractures are a common medical malady, and coders encounter them often. But the differences between coding fractures in ICD-9-CM and ICD-10-CM are vast.
Upon implementation of ICD-10-CM the code system currently in place for fractures within ICD-9-CM will cease to exist, and a new,....
Coding Peripheral Angioplasties
Author: Hull, Susan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2006
Like other interventional procedures, peripheral angioplasties involve complex combination coding. Surgical and radiological supervision and interpretation codes must be assigned for each procedure. In some instances multiples of both code types are assigned. This article discusses the various....
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.
....
Coding Preventive Care Services
Author: Wilkinson, Dianne
Source: Journal of AHIMA - Coding Notes
Publication Date: March 2008
According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....
Coding Radiology Services
Author: Walk, Gerri
Source: Journal of AHIMA - Coding Notes
Publication Date: January 2009
Because coding and radiology departments often share accountability for the quality of outpatient radiology coding, it is important that coding professionals share coding issues and charge capture expectations with radiology staff. This article outlines methods to improve the quality of coded....
Coding Root Operations with ICD-10-PCS: Understanding Bypass, Inspection, and Map
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2013
Editor's note: This is the seventh in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.
In this article, the Journal of AHIMA continues the 10 part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This article will take a more in de....
Coding Root Operations with ICD-10-PCS: Understanding Change, Replacement, and Revision
Author: Barta, Ann
Source: Journal of AHIMA - Coding Notes
Publication Date: February 2014
Editor’s note: This is the ninth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.
In this article the Journal of AHIMA continues its 10-part Coding Notes series focusing on the 31 root operations in the Medical and Surgical section of ICD-10-PCS.....
Coding Root Operations with ICD-10-PCS: Understanding Detachment, Destruction, and Extraction
Author: Barta, Ann
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2013
Editor's note: This is the second in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.
One of the keys to understanding ICD-10-PCS is the many new definitions and descriptions used to describe the various components of performed procedures.....
Coding Root Operations with ICD-10-PCS: Understanding Division, Release, Control, and Repair
Author: Endicott, Melanie
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2013
Editor’s note: This is the fourth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.
The transition to ICD-10-CM/PCS on October 1, 2014 is much more than just the customary annual update of codes. The ICD-10-CM code set is very similar in struc....
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