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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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.....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2004

Changes for CPT 2004 affect all chapters, and it’s 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....

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....

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....

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....

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....

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....

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....

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....

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....

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?

....

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....

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....

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 terminology’s 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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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.....

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....

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....

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....

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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,....

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....

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.
....

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....

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....

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....

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.....

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.....

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....