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Clinical Documentation Improvement
Author: AHIMA; Combs, Tammy; Ericson, Cheryl E
Source: _None
Publication Date: January 2022
Physician Coding Toolkit
Author: AHIMA Work Group
Source: AHIMA toolkit
Publication Date: March 2021
This provider practice coding toolkit provides multiple tools and resources to help providers successfully navigate
through the many changes in today’s healthcare environment.
Coding Checkup: Determining the New Normal for Coding Accuracy in a Post-ICD-10 World
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: June 2017
In many ways ICD-10 coding professionals share a lot in common with college students preparing to spend a semester abroad. Both spend invaluable hours in a classroom learning the nuances and permutations of a new language, as well as months of practicing their new skills in workshops with....
Ins and Outs of HCCs
Author: Fernandez, Valerie
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: June 2017
A Hierarchical Condition Category (HCC) is defined as a risk adjustment model that is used to calculate risk scores to predict future healthcare costs. The Centers for Medicare and Medicaid Services’ (CMS) CMS-HCC model is used to predict healthcare spending for Medicare Advantage Pl....
CodeWrite (May 2017)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: May 2017
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities
Author: Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M.
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: May 2017
In order to effectively discuss clinical documentation improvement (CDI) opportunities in physician practices, it is important to first understand the drivers and goals of a physician practice CDI program. Historically, diagnosis codes have had little impact in regard to physician practice paym....
Understanding Respiratory Diagnoses
Author: Ward, Maria
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: May 2017
Coding respiratory cases can sometimes lead to coding professionals getting bogged down in the circle of sequencing instructions, inclusions, and exclusions. This article will help readers gain a better understanding of the differences in the diagnoses that all come with a majority of the....
AHIMA Query Toolkit - Retired
Author: AHIMA
Source: AHIMA toolkit
Publication Date: April 2017
AHIMA Comments on ICD-10-PCS Proposals Presented at March 2017 ICD-10 Coordination and Maintenance Committee meeting
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: April 06, 2017
AHIMA Comments on October 2017 ICD-10-CM Proposals Presented at March 2017 ICD-10 Coordination and Maintenance Committee meeting
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: April 06, 2017
Back to Basics: APC Payment Methodology
Author: Tomak, Tracey
Source: CodeWrite | AHIMA newsletter article
Publication Date: April 2017
In August of 2000, the Centers for Medicare and Medicaid Services (CMS) introduced the Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS). The objective of the APC payment system was to control costs and increase efficiencies for outpatient ser....
How a Code is Born (and How You Can Be Involved)
Author: Martin, Ginny
Source: AHIMA newsletter article | CodeWrite
Publication Date: April 2017
If you were asked to assign a code for a diagnosis or procedure, you probably wouldn’t have a problem doing that. Our coding classes explained how to assign an ICD-10-CM code by first looking up the correct term in the Alphabetic Index, verifying the code in the Tabular List, and fol....
CodeWrite (April 2017)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: April 2017
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Coding and Quality Measures Brief. OP-8: MRI Lumbar Spine for Low Back Pain
Author: Handlon, Lauree
Source: CodeWrite | AHIMA newsletter article
Publication Date: April 2017
In this edition of the "Coding and Quality Measures Brief," we will examine the technical specifications and the coding opportunities specific to outpatient measure eight (OP-8) for MRI lumbar spine for low back pain.
The Centers for Medicare & Medicaid Services (CMS) has....
New CPT Codes Describe Emerging Technologies in the Treatment of Heart Failure
Author: Bowman, Sue E
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2017
For 2017, there are new CPT category III codes describing procedures involving cardiac contractility modulation systems and implantable counterpulsation ventricular assistance devices. These emerging technologies are currently undergoing clinical trials. These codes are scheduled to sunset....
Pneumonia and COPD Reporting in the Inpatient Setting
Author: Reed, Andretta
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: April 2017
This article highlights pneumonia and chronic obstructive pulmonary disease (COPD) code selections and proper sequencing based on healthcare provider documentation, ICD-10-CM Official Guidelines for Coding and Reporting, and ICD-10-CM conventions. As additional coding guidance continues to....
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....
New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization
Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Nemchik, Scot; Sheridan, Patty Thierry
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2017
To quantify the impact of ICD-10-CM/PCS (ICD-10) on coding productivity, Ciox Health, in partnership with the University of Pittsburgh’s Department of Health Information Management, School of Health and Rehabilitation Sciences, conducted a previous study published in the August 2016....
CodeWrite (March 2017)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: March 2017
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Skilled Nursing Facility (SNF/NF) Clinical Documentation Improvement (CDI) Tip Sheets
Author: AHIMA Long Term Care CDI Workgroup
Source: AHIMA Task Force
Publication Date: February 2017
These tips focus on the language and/or wording that will garner greater details and specificity of the coded data for a given
diagnosis, condition, and disease. In addition to the focus on coded data, these tips also include information to reflect quality care, frequency of documentation requirements, and documentation sources. These tips are meant to provide guidance in recognizing gaps in the clinical documentation.
Evolution of Coding Information/Resources to an Organization-wide Portal Site
Author: Gibbs, Sally
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2017
How does a healthcare system with 24 hospitals, 40 physician offices, and 50 free-standing ambulatory surgery centers that spans from the entire state of California to just over the Oregon border continue to keep their coding and billing staff current with the latest coding guidelines and....
CY 2017 OPPS Update
Author: Comfort, Angie
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2017
As last year drew to a close, facilities began the looming task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule to ensure their chargemaster and systems were up-to-date with the 2017 changes. The final rule for calendar year (CY) 2017 was released on Novem....
CodeWrite (February 2017)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: February 2017
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Use of Automated SNOMED CT Clinical Coding in Clinical Decision Support Systems for Preventive Care
Author: Al-Hablani, Bader
Source: Perspectives in Health Information Management
Publication Date: January 2017
Abstract
Objective: The objective of this study is to discuss and analyze the use of automated SNOMED CT clinical coding in clinical decision support systems (CDSSs) for preventive care. The central question that this study seeks to answer is whether the utilization of SNOMED CT i....
Changing the Way We Code Moderate (Conscious) Sedation
Author: Foley, Dianna
Source: AHIMA newsletter article | CodeWrite
Publication Date: January 2017
The 2017 Current Procedural Terminology (CPT®) coding will involve a change regarding moderate (conscious) sedation. Under conscious sedation, patients can purposefully respond to verbal commands. Airway or cardiovascular support is not required, and the patient's own breathing is sufficie....
Coding and Quality Measures Brief. Patient Safety Indicator 11: Postoperative Respiratory Failure Rate
Author: Drake, Suzanne P
Source: AHIMA newsletter article | CodeWrite
Publication Date: January 2017
This "Coding and Quality Measures Brief" will examine the technical specifications and the coding opportunities specific to the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 11 (PSI 11) for Postoperative Respiratory Failure Rate.
This information....
CodeWrite (January 2017)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: January 2017
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Role of Coding and Documentation in the Quality Payment Program
Author: DeVault, Kathryn; Easterling, Sharon; Huey, Kim
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2017
In the current era of healthcare transformation, the continuing importance of documentation and coding cannot be overstated. With the multitude of acronyms being added to the healthcare vocabulary, one may wonder where documentation and coding fits in. It’s important to remember that....
Provider’s Condensed Resource for Revenue Cycle, Coding Tools, and More
Author: Clack, Crystal; Freeman, Rae; Lewis, Laquette
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: January 2017
A cyclone of regulatory requirements for providers has officially touched down in the United States. The Affordable Care Act (ACA), Medicare Access and CHIP Reauthorization Act (MACRA), patient-centered medical home (PCMH), and value-based purchasing (VBP) initiatives are contributing to dramat....
Heart of the Matter: ICD-10-PCS Cardiac Coding
Author: Land, Daniel
Source: Journal of AHIMA
Publication Date: January 2017
A robust knowledge of anatomy and cardiac surgery techniques, a comprehensive understanding of coding guidelines, and an eye for precision are key components of correct ICD-10-PCS cardiac coding.
This article will review ICD-10-PCS Official Guidelines for Coding and Reportin....
Investigative Approach: How Clinical Documentation Teams Improve Communication, Documentation Outcomes and Patient Care
Author: Robinson, Steven
Source: Journal of AHIMA - website
Publication Date: December 29, 2016
Clinical documentation programs’ success is a result of the healthcare team keeping a constant vigil on communication while operationalizing outcomes and instilling provider support. Patient care is largely dependent on accurate communication among the healthcare provider team. In a....
Clinical Validation: the Next Level of CDI (December 2016 update)
Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne
Source: AHIMA practice brief
Publication Date: December 2016
One of the more challenging tasks for both coding and clinical documentation improvement (CDI) professionals is clinical validation. This is a relatively new responsibility that has evolved as CDI programs mature and CDI and coding professionals advance their knowledge and collaboration on clin....
CodeWrite (December 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: December 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Coding and Quality Measures Brief: Pressure Ulcer Rate
Author: Drake, Suzanne P
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2016
The "Coding and Quality Measures Brief" is a new CodeWrite series that explores individual quality metric technical specifications and identifies the coding opportunities in the acute care inpatient setting for reporting the measure.
Inclusion or exclusion to a me....
ICD-10-CM Checkpoint: Application of 7th Characters
Author: Buttner, Patty
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2016
Case scenario: A patient fell at home, sustaining a displaced fracture of the base of the neck of the left femur. The treatment for the fracture was a total hip replacement in an acute inpatient hospital. She is now being transferred to a skilled nursing facility (SNF) for rehabilitation.....
Hypertension Coding - Crisis Averted
Author: Lojewski, Tedi
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2016
Thanks to the recent publication of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017, the past controversy over the interpretation of the term "With" has been resolved.1 The revision of Section I.A.15, "With," now incorporates what was previously clarified in AHA Coding C....
Importance of Interdisciplinary Teams
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: November 23, 2016
Have you ever spent hours working on a project, only to find out at a random meeting that another team has been working on the same project? This type of scenario can be frustrating to both teams and lead to distrust in the work process—not to mention wasted time that could have been spent....
AHIMA Comments on ICD-10-CM proposals for October 2017 implementation presented at the September 2016 ICD-10 Coordination and Maintenance Committee meeting
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: November 2016
Letter to Donna Pickett, MPH, RHIA, ICD-10 Coordination and Maintenance Committee, National Center for Health Statistics
AHIMA Comments on ICD-10-PCS proposals presented at the September 2016 ICD-10 Coordination and Maintenance Committee meeting
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: November 2016
Letter to Patricia Brooks, RHIA, Centers for Medicare and Medicaid Services, CMM, HAPG, Division of Acute Care
Coding Viral Sepsis
Author: Sanvik, Gina
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: November 10, 2016
How to code viral sepsis has been a topic of discussion on AHIMA’s Engage Coding, Classification and Reimbursement community, and has be the subject of several inquiries to AHIMA’s Code-CheckTM coding question service.
The viral sepsis coding confusion may com....
ICD-10-PCS: An Applied Approach
Author: Kuehn, Lynn; Jorwic, Therese M
Source: AHIMA book
Publication Date: 2016
This comprehensive text, which uses the 2017 code set, is devoted to learning and mastering the process of building codes in ICD-10-PCS. All current coding professionals and students in academic programs must become and remain proficient in using this system for inpatient procedures.
FY 2017 Updates to ICD-10-PCS
Author: Ward, Maria
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: November 2016
Many changes come with the first update of the new ICD-10 Procedure Coding System (ICD-10-PCS) for fiscal year (FY) 2017. The higher-than-usual volume of changes was to be expected since the update system has been in a holding pattern for several years due to implementation delays. And al....
FY 2017 Updates to ICD-10-CM
Author: Rugg, Donna
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: November 2016
The ICD-10 Coordination and Maintenance Committee’s code freeze, first implemented after the October 1, 2011 annual update, has finally thawed. For fiscal year (FY) 2017 the ICD-10-CM classification is back on track with annual code and guideline updates. Due to the thousands of new/....
Coding Skin and Soft Tissue Lesion Excision in CPT
Author: Jones, Lolita M.
Source: CodeWrite | AHIMA newsletter article
Publication Date: November 2016
Coding the excision of skin and soft tissue lesions, either benign or malignant, can be difficult because of the numerous Current Procedural Terminology (CPT)® coding guidelines. This article will explain how these guidelines can be applied in a consistent and logical manner to ensure that....
CodeWrite (November 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: November 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Ongoing Challenges of ICD-10-CM Coding in the Post-Acute Care Setting: Coding Sequelae of Cerebral Vascular Disease
Author: LePage, Staci
Source: CodeWrite | AHIMA newsletter article
Publication Date: November 2016
The objective of this article is to examine the ICD-10-CM coding issues involved with the coding of sequelae of cerebral vascular disease.
Developing a Plan to Master Physician Engagement
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: October 27, 2016
Mastering physician engagement can be a challenging process, but it is within reach when you develop a plan of action and have a little patience. During AHIMA’s 2016 CDI Summit: Advancing the Documentation Journey, held August 1-2 in Washington, DC, Dr. John Showalter, MD, MSIS, University....
AHIMA Comments on ICD-10-CM proposals presented at the September 2016 ICD-10 Coordination and Maintenance (C&M) Committee
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: October 03, 2016
Comment letter to Donna Pickett, ICD-10 Coordination and Maintenance Committee, National Center for Health Statistics
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....
CodeWrite (October 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: October 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Tying Together CDI, ICD-10, and Healthcare Data Analytics: How CDI Programs and ICD-10 Are Impacting Data Analytics—and The Benefits Healthcare Organizations Are Seeing
Author: Bradley, Paul
Source: Journal of AHIMA
Publication Date: October 2016
A year in and ICD-10 is almost approaching the point of old news.
Of course—I’m kidding! Nothing could be further from the truth. From a data analytics perspective, the impact of ICD-10 is only beginning to be realized and understood.
For one, this first year....
Coding High-Risk Pregnancy: What’s New for 2017?
Author: Sanvik, Gina
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: September 14, 2016
With the release of the FY 2017 updates to the ICD-10-CM Official Coding Guidelines, there’s a lot for coding professionals to review. This post will take a closer look at one of the updates in Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A). The guideline for “P....
Managing the Present on Admission Reporting Process (2016 update)
Author: Campbell, Angela; D'Amato, Cheryl; Rugg, Donna
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2016
Editor’s Note: This Practice Brief is an update of the March 2010 version, which replaced the November 2007 Practice Brief “Planning for Present on Admission.”
Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to report patient primary and....
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....
Do You Want Fries With That? Decoding All the 'Extras' in Physician Visits
Author: Davies, Sharon
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2016
Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the p....
Don't Leave Money on the Table: Mastering MACRA, PQRS, and Value-Based Purchasing: How Quality Coding Impacts Quality Reporting
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: September 2016
Whenever there’s a flashy new piece of consumer technology, there are always holdouts who insist on sticking with the old, more comfortable way of doing things. Consider a grammarian who rejects online dictionaries for a cumbersome hard-bound book. Or the road tripper who prefers their an....
Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement
Author: Whittle, Kelly
Source: Journal of AHIMA
Publication Date: September 2016
It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....
New "MOON" — Observation Status Notification
Author: Wilson, Donna D
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2016
"Why do I owe so much money for my last hospital stay? I have Medicare; doesn't that cover everything?" Maybe you have heard this question before—possibly from your own grandparents. The Centers for Medicare and Medicaid Services (CMS) hears regularly from Medicare beneficiaries whos....
What's Up With Sepsis ... Again: The Role of Coding Professionals and CDI
Author: Easterling, Sharon
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2016
Coding professionals, along with clinical documentation improvement (CDI) professionals, have a tremendous role in reviewing documentation and clinical indicators in the assignment of sepsis, severe sepsis, and shock. Both types of professionals support the physician in addressing diagnose....
CodeWrite (September 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: September 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Modifier 25 — Defending a "Significant, Separately Identifiable Service"
Author: Morrow, Karna W
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2016
Think about the last time you attached modifier 25 to an Evaluation and Management (E/M) code. What were the circumstances? It was a new patient. The procedure or service was not planned. The provider documented each of the key components in addition to documenting the procedure. The payor....
AHIMA Comments on 2017 Hospital Outpatient Prospective Payment System Proposed Rule
Author: AHIMA Advocacy and Policy Team; Gordon, Lynne Thomas
Source: AHIMA testimony and comments
Publication Date: August 31, 2016
Comment letter to Andrew Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services
Reviewing for Inpatient Quality
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 25, 2016
The Hospital Value-Based Purchasing (HVBP) Program has heightened hospital awareness of quality outcomes. Under this program, payments made under the Inpatient Prospective Payment System (IPPS) are based on the quality of care that was provided. Quality of care is recognized through the cl....
DSM-5 vs. ICD-10-CM
Author: Foley, Dianna
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 10, 2016
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) both present ways to classify diseases. In the case of DSM-5, it is strictly for mental dis....
Improving Coding and Documentation Quality Through Real-Time Collaboration: Nurses and Coding Professionals Team Up to Tackle Documentation Issues
Author: Horn, Kelli; Younger, Adrienne; Snow, Trevor
Source: Journal of AHIMA
Publication Date: August 2016
While working through the recent implementation of ICD-10, leaders at Ardent Health Services began to focus on the re-bill process and what it would look like in the months following use of the new code set. Re-billing means submitting a corrected bill to the payer after it has been rejec....
ICD-10 Coding Productivity Study Highlights Emerging Standards
Author: Watzlaf, Valerie J.M.; Nemchik, Scot; Hoerner, Mike; Sheridan, Patty Thierry
Source: Journal of AHIMA
Publication Date: August 2016
The implementation of ICD-10 has been compared to Y2K, with industry analysts noting that October 1, 2015 came and went with little fanfare. This commentary speaks volumes to the significant preparation that occurred in the months and years leading up to ICD-10. If you were in the trenches....
Look Back on the ICD-10 Transition: Crisis Averted or Imaginary?
Author: Bowman, Sue E
Source: Journal of AHIMA
Publication Date: August 2016
The transition to ICD-10-CM/PCS (ICD-10) was an update to the antiquated 30-year-old ICD-9-CM coding system that was made to reflect changes in the practice of medicine that have occurred over the past three decades. It is a next-generation coding system that modernizes and expands the ca....
What's Up With Sepsis...Again
Author: Easterling, Sharon
Source: CodeWrite | AHIMA newsletter article
Publication Date: August 2016
BACKGROUND
Much discussion among medical, coding, and clinical documentation professionals has followed the recent release of the Sepsis-3 (Sep-3) definition, "Life-threatening organ dysfunction caused by a dysregulated host response to infection," published in JAMA: The Jour....
CodeWrite (August 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: August 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Ins and Outs of Perineal Laceration Repairs in ICD-10-PCS
Author: DeVault, Kathryn
Source: CodeWrite | AHIMA newsletter article
Publication Date: August 2016
For coding professionals who code obstetrics (OB) cases, both ICD-10-CM and ICD-10-PCS have presented some challenges. This article will focus on perineal laceration repairs. Recent advice in Coding Clinic has raised questions about coding these procedures in ICD-10-PCS.
The....
HIM's Role in Value-Based Reimbursement: Three Leaders Weigh In on Impact
Author: Czahor, Amy; Evans, Ginna; Friedman, Beth; Head, Erin
Source: Journal of AHIMA - website
Publication Date: August 01, 2016
The healthcare industry’s move from paper to electronic health records (EHRs) has spanned two decades. The implementation of ICD-10 took four years. Now the shift from fee-for-service to value-based reimbursement is upon us. Like most large healthcare initiatives, full realization of....
Managing a Part-Time Remote CDI Team
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: July 29, 2016
As clinical documentation improvement (CDI) programs become more popular, providers are still struggling with implementing CDI programs for several different reasons, including: geographical location; a shortage of outpatient coders and CDI specialists; or even the lack of physi....
Seventh Character Application for Injuries in the Principal Diagnosis and the Impact to Data Quality
Author: Wall, Kathleen E.
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 25, 2016
By now, we’ve all had practice assigning 7th characters for injuries. And, by now, we all know that in theory the guidance seems very clear—but the application of this new concept is not clear at all. Why is there so much confusion and why does it matter? What are the short- and long-term....
ICD-TEN: Top Emerging News (July 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: July 2016
emerging news, educational opportunities, practical information on coding with the new ICD-10-CM/PCS, preparatory steps for implementation
Developing Productivity Standards through Analytics [sponsored article]
Author: Pitsikoulis, John; Doty, Laura
Source: Journal of AHIMA - website
Publication Date: July 15, 2016
“Productivity” is defined as the effectiveness of productive effort, measured in terms of the rate of output per unit of input, easily defined and applicable in many manufacturing scenarios. For the line worker in a manufacturing plant, output is basically the number of widgets or com....
Get Ready: Code Downpour On Its Way
Author: Sanvik, Gina
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 13, 2016
Although many HIM professionals and coding professionals were just starting to get comfortable with ICD-10-CM/PCS, it is time to prepare for the thousands of new ICD-10 changes coming soon.
The upcoming ICD-10 updates for the Fiscal Year (FY) 2017 will also represe....
Clinical Documentation Improvement Toolkit (2016 version)
Author: Arrowood, Danita; Bailey-Woods, Linda; Barnette, Erin; Combs, Tammy; Endicott, Melanie; Miller, Jennifer
Source: AHIMA toolkit
Publication Date: July 2016
This toolkit provides many of the necessary tools and documents needed for implementing and/or maintaining a robust CDI program.
SNOMED CT to ICD-10-CM Map
Author: National Library of Medicine
Source: Government (U.S.)
Publication Date: July 2016
The purpose of the SNOMED CT to ICD-10-CM map is to support semi-automated generation of ICD-10-CM codes from clinical data encoded in SNOMED CT for reimbursement and statistical purposes.
CodeWrite (July 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: July 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Disease Groupings: What are They, How are They Used, and How Do They Compare Internationally?
Author: Lucyk, Kelsey; Lu, Mingshan; Sajobi, Tolulope; Quan, Hude
Source: Perspectives in Health Information Management
Publication Date: July 2016
Abstract
The purpose of this article is to review diagnosis-related group (DRG) systems by introducing the concept of disease groupings, describing the country-specific DRGs based on the International Classification of Diseases (ICD), and comparing country-specific disease classif....
Mapping Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): Lessons Learned from Applying the National Library of Medicine’s Mappings
Author: Nandigam, Hari; Topaz, Maxim
Source: Perspectives in Health Information Management
Publication Date: July 2016
Abstract
The Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) are two commonly used standardized health terminologies in the United States. In fall 2015, healt....
Querying Through the Chaos: How to Get Docs' Attention Amidst the Digital Healthcare Haze
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: July 2016
It wasn’t that long ago that online dating—and resultant marriages—carried a stigma. There was a sharp divide between the people who believed in meeting their loves the old fashioned way, and those who felt that online dating was a natural extension of their already Internet-centric profe....
Transitioning from Coding to CDI Offers New Career Opportunities
Author: Endicott, Melanie
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2016
The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper repo....
Clinical Documentation for Value-based Reimbursement: Why It Takes a Village to Ensure Success
Author: Fee, James P; Clesi, Wendy
Source: Journal of AHIMA
Publication Date: July 2016
Like it or not, the transition to value-based healthcare is well underway. In January 2015, the Department of Health and Human Services (HHS) announced its Better, Smarter, Healthier campaign with clear goals and a timeline for shifting Medicare reimbursement from volume to value. Through....
Clinical Validation: The Next Level of CDI
Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2016
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
CDI is about Relationships
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: July 2016
“Alone we can do so little; together we can do so much,” said Helen Keller. This quote was part of Keller’s vaudeville circuit speech, but the sentiment holds true for those of us in the spotlight of HIM.
Our goal is to tell the patient’s story accurat....
Biopsies and the Assignment of ICD-10-PCS 7th Character X
Author: Maccariella-Hafey, Patricia C
Source: CodeWrite | AHIMA newsletter article
Publication Date: July 2016
The objective of this article is to examine when it is appropriate to assign the 7th character of "X-Diagnostic" in ICD-10-PCS coding for tissues taken for biopsy.
Importance of Technology in CDI
Author: Ericson, Cheryl E; Wieczorek, Michelle M.
Source: CodeWrite | AHIMA newsletter article
Publication Date: July 2016
The fact that more than 80 percent of organizations staff clinical documentation improvement (CDI) professionals, despite it being a supplemental business function, is an indication of the undeniable benefits of CDI programs. Organizations have been slow, however, to invest in technology d....
AHIMA Comments on CMS' Proposed Changes to the Medicare Hospital Inpatient Prospective Payments Systems (IPPS) and Fiscal Year 2017 Rates
Author: AHIMA Advocacy and Policy Team; Gordon, Lynne Thomas
Source: AHIMA testimony and comments
Publication Date: June 15, 2016
Comment letter to Andrew Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services
AHIMA Special E-Alert (June 13, 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: June 13, 2016
ICD10's effect on productivity: survey results released
Differentiating Fracture Coding with Osteoporosis Present
Author: Sanvik, Gina
Source: Journal of AHIMA - website
Publication Date: June 08, 2016
While working on the team for AHIMA’s Code-CheckTM Coding Question Service, I’ve noticed several questions related to providing clarification in ICD-10-CM for a fracture in a patient with known osteoporosis.
ICD-10-CM expands the code selection to more than 150 pa....
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....
Coding Audits Evolve with ICD-10: Industry Experts Define New Benchmarks and Best Practices
Author: Boomershine, Julie
Source: Journal of AHIMA
Publication Date: June 2016
From privacy and security risk assessments to perennial health plan record reviews, HIM departments are inundated with audits. The move to ICD-10-CM/PCS adds another layer of audit complexity and requirements as hospital and health systems step up their coding quality review processes, pr....
Unlocking the Benefits of ICD-10 through Data Analytics
Author: Ewing, Crystal
Source: Journal of AHIMA
Publication Date: June 2016
The reality of the ICD-10-CM/PCS implementation and the fact that it was, by all measures, a success, is the payoff of years of hard work. It’s the product of lessons learned from the implementation of 5010 and the outcome of diligence on the part of healthcare professionals, providers, a....
Semantic Content in EHR Systems
Author: Bhattacharyya, S. B; Warner, Diana
Source: Journal of AHIMA
Publication Date: June 2016
An electronic health record (EHR) can greatly help the timely delivery of efficient healthcare if the information it contains is adequate, accurate, and accessible in a timely manner. An EHR is a longitudinal record of an individual’s health journey made up of electronic documents from va....
Dissecting the Operative Report for Accurate ICD-10-PCS Code Assignment
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2016
The implementation of ICD-10-PCS has created new challenges in coding surgical procedures. While coding professionals have always been expected to read and interpret all surgical documentation, ICD-10-PCS has increased the level of understanding necessary for accurate code assignment.
Guidelines for Achieving a Compliant ICD-10-PCS Query
Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2016
Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.
The complex and highly specific nature of ICD-10-PCS has changed....
CPT Codes for Percutaneous Biliary Procedures
Author: Buttner, Patty
Source: CodeWrite | AHIMA newsletter article
Publication Date: June 2016
This year has brought many new additions to Current Procedural Terminology (CPT®) coding. This article discusses several new codes related to percutaneous biliary procedures. A new range of 14 codes for percutaneous biliary procedures has been introduced in the Digestive System subse....
Building on the ICD-10-PCS Puzzle
Author: Scott, Nena
Source: CodeWrite | AHIMA newsletter article
Publication Date: June 2016
ICD-10-PCS presents many major challenges, with many obstacles. This procedural system is like putting a puzzle together. Finding the pieces to the puzzle requires the coding professional to read the entire operative report and, if applicable, the entire pathology report.
As....
CodeWrite (June 2016)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: June 2016
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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