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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....

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 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 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 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....

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