1544 results.
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DRG Grouping and ICD-10-CM/PCS
Author: Foley, Margaret M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2015
Prior to the October 1, 2015 implementation of ICD-10-CM/PCS, every hospital must examine how the new code set will impact MS-DRG reimbursement. A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimburs....
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....
Linking the Right Info and the Right Person … at the Right Time
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: July 2015
With its roots in DRGs, the prospective payment system, and value-based purchasing, clinical documentation improvement (CDI) can seem like a practical administrative task. The process of ensuring accurate clinical documentation is—like so many HIM functions—often done in the ba....
Natural Language Processing: a Promising ICD-10 Transition Solution
Author: Bailey-Woods, Linda
Source: CodeWrite | AHIMA newsletter article
Publication Date: July 2015
The ICD-10 deadline and the need to satisfy meaningful use (MU) requirements are giving HIM leaders reason to investigate and implement automation and technology solutions such as natural language processing (NLP). NLP is promoted to increase effectiveness of their clinical documentation i....
CodeWrite (July 2015)
Author: AHIMA Staff
Source: AHIMA newsletter
Publication Date: July 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Results from the Veterans Health Administration ICD-10-CM/PCS Coding Pilot Study
Author: Weems, Shelley; Fenton, Susan H.
Source: Perspectives in Health Information Management
Publication Date: July 2015
Abstract
The Veterans Health Administration (VHA) of the US Department of Veterans Affairs has been preparing for the October 1, 2015, conversion to the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) for....
AHIMA Comments on March 2015 ICD-10-CM code proposals
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: June 11, 2015
AHIMA letter to Donna Pickett, MPH, RHIA, Medical Classification Administrator, National Center for Health Statistics
Injection and Infusion Coding Offers High Stakes: Outpatient Coders Must Play Their Cards Right
Author: Flewelling, Charles
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2015
With the consistently rising value of highly skilled outpatient coders, numerous HIM departments are moving to a staffing model that employs coding professionals who are well versed in coding both inpatient and outpatient encounters. Coders in the profession today should possess a mastery....
How Deep Do You Dig into ICD-10-PCS Coding?
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2015
All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.
ICD-10-PCS Scope of Work
On October 1, 2015, hospital inpatient pr....
Electronic Documentation Templates Support ICD-10-CM/PCS Implementation (2015 update)
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2015
Editor’s Note: This Practice Brief supersedes the October 2012 Practice Brief “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation.”
Improving patient care continues to take center stage in the healthcare industry, as demonstrated by an increa....
Rules of the Road Differ for Inpatient and Outpatient Coding
Author: Quick, Tara; Hickman, Stephani
Source: Journal of AHIMA
Publication Date: June 2015
As facilities approach the final laps in the race towards implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), they should heed the yellow caution flag warning of basic challenges with the vast differences between inpatient and....
CodeWrite Community Newsletter (June 2015)
Author: AHIMA
Source: AHIMA newsletter
Publication Date: June 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Tackling the ICD-10-PCS Approaches
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 13, 2015
There are only seven approach values in ICD-10-PCS, so one would think that selecting the correct approach value would be simple, but it’s not! Let’s take a closer look at these seven approaches and then walk through some challenging cases.
Open (0)
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A Relook at POA Indicators
Author: Martin, Ginny
Source: CodeWrite | AHIMA newsletter article
Publication Date: May 2015
Accurate assignment of the present on admission (POA) indicator has new significance with the inception of value-based purchasing (VBP). Coding and the supporting medical record documentation are being used to identify the hospital-acquired conditions and patient safety indicators on whic....
Malignancy: Aftercare or Follow-Up?
Author: Parman, Cindy C
Source: CodeWrite | AHIMA newsletter article
Publication Date: May 2015
Physician documentation has always supported accurate diagnosis code reporting, but never more so than with the transition to ICD-10-CM codes. Specific terminology and the use of key words and phrases is essential, especially with terms such as "aftercare" and "follow-up," which phy....
ICD-10 Gap Analysis Points to Revenue Neutral Transition
Author: Barta, Ann
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2015
The implications of ICD-10-CM/PCS for healthcare reimbursement is a topic at the top of everyone’s mind in the healthcare industry these days. As healthcare organizations continue to prepare for the transition to ICD-10-CM/PCS on October 1, 2015, an essential and important element of a su....
CodeWrite Community Newsletter (May 2015)
Author: AHIMA
Source: AHIMA newsletter
Publication Date: May 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
AHIMA Comments on Proposed Procedure Code Modifications Presented at the ICD-10 Coordination and Maintenance Committee Meeting Held March 2015
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: April 15, 2015
Notes from the ICD-9-CM Coordination and Maintenance Committee meeting, cosponsored by the National
Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS),
held on March 5, 2013 in Baltimore, MD.
Must-Do ICD-10 Prep Checklist for Physicians
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: April 08, 2015
Journal of AHIMA's monthly online coding column where AHIMA’s coding experts address challenging areas and documentation opportunities for ICD-10-CM/PCS.
Documentation Issues in ICD-10-CM/PCS
Author: Rhinehart, Ebenetta M
Source: CodeWrite | AHIMA newsletter article
Publication Date: April 2015
Clinical documentation specialists (CDS’s) are experiencing an increased emphasis on the work they do because of the increased specificity required for ICD-10-CM and ICD-10-PCS coding. Currently, unanswered queries are a nuisance and may result in an inaccurate diagnosis-related group&nbs....
CodeWrite Community Newsletter (April 2015)
Author: AHIMA
Source: AHIMA newsletter
Publication Date: April 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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....
Coding Saint Patrick's Day
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: March 11, 2015
Saint Patrick’s Day is both a cultural and religious celebration that includes displays of the color green, eating and drinking, and parades. One of the greatest places to celebrate this day, outside of Ireland, is the city of Chicago, where the people go all out for Saint Patrick’s D....
So What Exactly is Clinical Documentation Improvement?
Author: McDonald, Lori
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2015
There is a lot of talk in health information management these days about clinical documentation improvement (CDI). You may have questions, or you may be hearing questions around you. This short article answers three basic questions about CDI.
What is CDI?
2015 ICD-10-CM Coding Guideline Changes
Author: DeVault, Kathryn
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2015
Although they were minimal, the 2015 ICD-10-CM Coding Guidelines contained some updates that should be reviewed, as they provide additional clarification for coding in ICD-10-CM. A complete set of the 2015 guidelines can be found on the CMS website. Several of the guideline changes and upd....
CodeWrite Community Newsletter (March 2015)
Author: AHIMA
Source: AHIMA newsletter
Publication Date: March 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
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.....
ICD-10-CM Coding Guidance for Long-Term Care Facilities
Author: Liebner, Carole S; Lowery, Amanda L; Maccariella-Hafey, Patricia C; Usher, Joan L; Ward, Maria; Young, Carol
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: March 2015
Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident's clinical conditions.
ICD-10-CM facilitates the collection and....
Building a Remote CDI Workforce
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: February 2015
The HIM Problem
To improve the efficiency and productivity of its clinical documentation improvement (CDI) program, Baystate Health decided to train CDI specialists to work from home.
The HIM Problem Solvers
Walter Houlihan MBA, RHIA, FAHIMA, direc....
Coding Heart Procedures in ICD-9-CM and ICD-10-PCS
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: February 11, 2015
The coding of heart procedures is done very differently in ICD-9-CM versus ICD-10-PCS. In honor of American Heart Month, this month’s Code Cracker explores the guidelines for coding heart procedures.
There are a few specific guidelines associated with procedures don....
Anemia, Malignancy And Antineoplastic Treatment In ICD-10-CM
Author: Parman, Cindy C
Source: CodeWrite | AHIMA newsletter article
Publication Date: February 2015
Anemia is a condition that develops when the blood lacks sufficient healthy red blood cells or hemoglobin to carry oxygen to body tissues. According to WebMD, anemia is the most common blood condition in the United States, affecting 3.5 million Americans.1 Severe or long-lasting anemia ca....
CPT Updates for CY 2015
Author: Buttner, Patty
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2015
On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....
CodeWrite Community Newsletter (February 2015)
Author: AHIMA
Source: AHIMA newsletter
Publication Date: February 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments
Author: Mills, Ronald E; Butler, Rhonda R.; Averill, Richard F.; McCullough, Elizabeth C; Fuller, Richard L; Bao, Mona Z
Source: Journal of AHIMA - website
Publication Date: February 2015
On October 1, 2015, ICD-9-CM is scheduled
to be replaced by the International Classification
of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) for reporting
diagnosis data across all sites of service and the
International Classification of Diseases, Tenth
Hospital Discharge Status Codes: Risks and Rewards
Author: Haik, William E
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: February 2015
It is a well known fact that ICD-9-CM diagnosis and procedure codes impact hospital reimbursement and compliance. But there is an additional code that often flies under the radar—the discharge status code. Inaccurate discharge status code assignments for Medicare post-acute care transfers....
Understanding The History Component of The E/M Code - Part 2
Author: Maccariella-Hafey, Patricia C
Source: CodeWrite | AHIMA newsletter article
Publication Date: January 2015
This is the second of a two-part series on the history component of the CPT Evaluation and Management code. The first part was published in the December 2014 issue of CodeWrite.
Levels of Evaluation and Management (E/M) services are based on four types of history (Problem F....
Seven Lessons Learned in 2014 to Improve ICD-10 Training in 2015
Author: Haugen, Mary Beth
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: January 2015
A new year often inspires us to reflect on past experiences. This is certainly true when preparing coders for ICD-10. Ask yourself these questions: In terms of coder training, what worked well for your organization and your team in 2014? What aspects of coder training can be improved or en....
Evaluation of PHI Hunter in Natural Language Processing Research
Author: Redd, Andrew; Pickard, Steve; Meystre, Stephane; Scehnet, Jeffrey; Bolton, Dan; Heavirland, Julia; Weaver, Allison Lynn ; Hope, Carol; Garvin, Jennifer Hornung
Source: Perspectives in Health Information Management
Publication Date: January 2015
Abstract
Objectives: We introduce and evaluate a new, easily accessible tool using a common statistical analysis and business analytics software suite, SAS, which can be programmed to remove specific protected health information (PHI) from a text document. Removal of PHI is import....
Top Ten Challenges of Passing the CCS Examination (And How to Overcome Them)
Author: Horn, Kelli
Source: Journal of AHIMA
Publication Date: January 2015
Hundreds of coders and students desire to take the next step in their career by obtaining the Certified Coding Specialist (CCS) credential. This examination represents high-level achievement and proficiency in inpatient and outpatient coding and associated concepts. Benefits of certificat....
GEMs: Buyers Beware. Crosswalk and Translation Tools Can Bring Unexpected Risks
Author: Reed, Diana
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2015
When it comes to converting superbills and claims from ICD-9-CM to ICD-10-CM, many healthcare providers believe that general equivalence mappings (GEMs) offer a cost effective and simple solution. The ability to purchase relatively cheap automated mappings of specialties’ top codes c....
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....
CodeWrite Community Newsletter (January 2015)
Author: AHIMA
Source: AHIMA newsletter
Publication Date: January 2015
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Foot in the Door: How Post-Graduate Apprenticeship Programs Can Help Organizations Prepare for ICD-10
Author: Dover, Kayce; Phillips, Chloe
Source: Journal of AHIMA
Publication Date: January 2015
It’s a constant dilemma—new health information management (HIM) graduates struggle to find jobs because they lack experience, yet it’s difficult to get that coveted experience without having a job. Even despite an increasing demand for coders, many new graduates cannot find employers will....
Cut Through the ICD-10 Noise with Documentation Guidelines
Author: Elion, Jon
Source: Journal of AHIMA - website
Publication Date: January 2015
Physicians have been bombarded with opinions, information and misinformation about ICD-10-CM/PS. This makes it challenging for them to cut through the politics and posturing and focus exclusively on practical and pragmatic approaches to deal with the new coding system. Discussions are ofte....
Year in Review: Highlights from 2014
Author: Sheber, Sarah
Source: Journal of AHIMA - website
Publication Date: December 2014
The Journal of AHIMA’s ongoing web series “HIM Frontlines,” explores pressing obstacles that health information management (HIM) professionals encounter in a rapidly changing healthcare environment. Major federal initiativs such as the “meaningful use” EHR Incentive Program, HITECH-HIPAA,....
Staying "Home Alone" Can Result in a Multitude of Injuries
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: December 10, 2014
It’s been 24 years since Kevin McCallister was accidentally left at home while the rest of his family went on vacation in the movie Home Alone. Poor little Kevin has to defend his family home when two con men try to rob it on Christmas Eve. Kevin outsmarts the idiotic burglars with bo....
Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS (2014 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: December 2014
Editor's note: This practice brief has been updated. See the latest version here.
CDI Tips Developed to Maximize ICD-10-CM/PCS
Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi
Source: Journal of AHIMA - website
Publication Date: December 2014
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 det....
Understanding the History Component of the E/M Code (Part 1)
Author: Maccariella-Hafey, Patricia C
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2014
This is the first of a two-part series on the history component of the CPT Evaluation and Management code.
As discussed in the October 2014 CodeWrite article "Introduction to Evaluation and Management Services," evaluation and management (E/M) services are cognitive services....
Are Parkinson's Disease and Parkinsonism the Same Thing?
Author: Bielby, Judy A
Source: CodeWrite | AHIMA newsletter article
Publication Date: December 2014
OBJECTIVE
The objective of this article is to examine the difference between the terms "Parkinson’s disease" and "Parkinsonism."
CLINICAL INFORMATION
Parkinson’s disease is a motor system disorder. In Parkinson’s disease, brain cells that....
ICD-10 and Documentation
Author: U.S. Centers for Medicare & Medicaid Services
Source: ICD-TEN Top Emerging News | AHIMA newsletter article
Publication Date: December 2014
This December, the Centers for Medicare & Medicaid Services (CMS) is working with AHIMA to highlight the importance of documentation in ICD-10. Earlier this month, CMS and AHIMA collaborated to offer a webinar on ICD-10 and documentation, and we wanted to continue the discussion in this mon....
CodeWrite Community Newsletter December 2014
Author: AHIMA
Source: AHIMA newsletter
Publication Date: December 2014
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Coding for ICD-10-CM: More of the Basics
Author: Bowman, Sue E; Leon-Chisen, Nelly
Source: U.S. Centers for Medicare & Medicaid Services
Publication Date: December 02, 2014
The objective of this video is to enhance viewers’ understanding of the characteristics and unique features of ICD-10-CM, as well as similarities and differences between ICD-9-CM and ICD-10-CM.
Grow-Your-Own Program Bridges Gap for Graduates to Full Time Coding Positions
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: November 2014
The HIM Problem
North Shore-LIJ Health System, a group of 17 hospitals in New York City, Long Island and Westchester County, NY, had been facing a coder shortage and wasn’t happy with the contract coders they were working with.
The HIM Problem Solver
AHIMA Comments on Proposed Procedure Code Modifications Presented at the ICD-10 Coordination and Maintenance Committee Meeting Held September 2014
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: November 20, 2014
Comments on the proposed procedure code revisions recommended for implementation
AHIMA Comments on Proposed Diagnosis Code Modifications Presented at the ICD-10 Coordination and Maintenance Committee Meeting Held September 2014
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: November 20, 2014
Comments on the proposed diagnosis code revisions recommended for implementation
Coding Injuries in ICD-10-CM (update)
Author: Zeisset, Ann M.
Source: Journal of AHIMA
Publication Date: November 2014
ICD-10-CM provides greater specificity in coding injuries than ICD-9-CM. While many of the coding guidelines for injuries remain the same as ICD-9-CM, ICD-10-CM does include some new features, such as seventh characters.
Chapter 19 Overview
Chapter 19 is titled "In....
Coding Ebola Virus and Enterovirus D68
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: November 12, 2014
Ebola Virus
The Ebola virus is front page news everywhere you turn. Tracking of the Ebola outbreak in the United States with coded data is imprecise due to the lack of a specific code for Ebola in ICD-9-CM. This is yet another reason that the ICD-10-CM/PCS code sets....
Cost of Converting Small Physician Practices to ICD-10 Much Lower than Reported
Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.
Source: Journal of AHIMA - website
Publication Date: November 2014
The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....
Setting the Facts Straight About ICD-10: What Physicians Need to Know About the Transition
Author: AHIMA
Source: AHIMA Advocacy and Policy
Publication Date: November 2014
While many organizations see the benefits of using ICD-10, including the ability to capture more detailed
information, others have concerns, including the costs of implementation. Despite the significant
amount of information that has been published about ICD-10 during the last 10 years, many
misconceptions persist today. The information below covers basic facts about the ICD-10
transition that are of particular interest to the physician community.
ICD-10's Impact Reaches Far Beyond Coding: Examining the New Code Sets' Revenue Cycle Implications
Author: Arends-Marquez, Alexa; Knight, Nicole; Thomas-Flowers, Dwan
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: November 2014
The implications of ICD-10-CM/PCS (ICD-10) for coding operations are a common topic of industry discussion, but the impact of ICD-10 reaches far beyond coding alone. ICD-10 is embedded in the entire revenue cycle for providers. The conversion will impact almost every aspect of operations,....
ICD-10-CM Coding Challenges in a Physician Setting: Rash
Author: McNicholas, Faith C.
Source: CodeWrite | AHIMA newsletter article
Publication Date: November 2014
Coding in a physician practice can be a challenge. Those who work in this setting will likely agree there are many times coders end up coding an encounter based on the signs and symptoms or just the clinical findings as documented in the patient medical record. Either way, it is important....
Be e-Prepared: Tips for Tackling Ever-changing Electronic Audits, e-Discovery, and e-Measures
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: November 2014
Don’t let the quiet before the storm fool you. Regulators might be hushed now, but compliance activity is expected to keep health information management (HIM) professionals on their toes throughout 2015. As electronic health record (EHR) implementation becomes more pervasive, so too does....
CodeWrite Community Newsletter November 2014
Author: AHIMA
Source: AHIMA newsletter
Publication Date: November 2014
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
New Changes De-Spookify Modifier -59
Author: Wilson, Donna D
Source: Journal of AHIMA - website
Publication Date: October 30, 2014
The proper application of modifier -59 (Distinct Procedural Service) has mystified many a coder. The Centers for Medicare and Medicaid Services (CMS) has recently indicated that modifier -59 is the most commonly used and abused of all the modifiers—mainly due to the fact that it is used to....
Taking the Grow-Your-Own-Coder Movement to High School
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: October 2014
The HIM Problem
Rural hospitals in Kansas are trying to cut the cost of outsourcing coding by starting the credentialing process in local high schools.
The HIM Problem Solver
Sherry Farrell, MBA, RHIT, HIM coordinator at Seward County Community College/....
ICD-10 Form Letter and Vendor Readiness Questionnaire
Author: AHIMA
Source: AHIMA
Publication Date: October 15, 2014
A MS Word version of this document is available for customizing.
ICD-10-CM Will Improve the Tracking of Breast Cancer
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: October 08, 2014
From pink gloves on the football field to pink night lighting on skyscrapers—not to mention the influx of pink clothing everywhere you look—it’s no secret that October is National Breast Cancer Awareness Month. Most people have been touched by breast cancer in some way&md....
Introduction to Evaluation and Management Services
Author: Huey, Kim
Source: CodeWrite | AHIMA newsletter article
Publication Date: October 2014
Evaluation and management (E/M) are cognitive services in which a physician or other qualified healthcare professional diagnoses and treats illness or injury. Almost all specialties will perform evaluation and management services. Even physicians who generate the bulk of their revenue in....
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....
CodeWrite Community Newsletter October 2014
Author: AHIMA
Source: AHIMA newsletter
Publication Date: October 2014
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Reliable Coded Data Require a Reliable Coding Process Framework
Author: Bielby, Judy A
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: October 2014
A poorly managed coding process can thwart the effective use of coded diagnosis and procedure data. Take for example Hospital A, a fictitious hospital that does not effectively manage their coding processes. At this hospital, the coding professionals are concerned primarily with the impact....
How Physicians See ICD-10, and Its Effect on Their Practice
Author: AHIMA Staff
Source: Journal of AHIMA - website
Publication Date: September 28, 2014
The United States is one of the last countries to switch from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, 10th Revision, Clinical Modification, Procedure Coding System (ICD-10-CM/PCS). The com....
What Physicians Need to Know About ICD-10-PCS
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: September 10, 2014
When educating physicians about ICD-10-PCS, the most important factor to be pointed out is that ICD-10-PCS will NOT be replacing CPT. Physicians will still need to report their services using CPT/HCPCS codes. However, physicians need to be aware of the nuances associated with ICD-10-P....
Coding Mastectomy Procedures
Author: Goswami, Chaitali
Source: CodeWrite | AHIMA newsletter article
Publication Date: September 2014
OBJECTIVE
The purpose of this article is to enable you to understand and correctly implement the coding principles, concepts, and guidelines associated with various mastectomy procedure codes.
SURGICAL INFORMATION
Mastectomy is the surgical procedure in....
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....
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.
CodeWrite Community Newsletter September 2014
Author: AHIMA
Source: AHIMA newsletter
Publication Date: September 2014
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
Coping with Government Audits
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: August 2014
The HIM Problem: Medicare Auditor Scrutiny of Inpatient Claims
This spring, the Centers for Medicare and Medicaid Services (CMS) issued its “two midnight rule” which was intended to define and clarify what Medicare considers to be criteria justifying an inpatient st....
Transitioning From E Codes in ICD-9-CM to V, W, X, Y Codes in ICD-10-CM
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 13, 2014
ICD-9-CM includes a supplemental section, E codes, to describe the external causes of injuries and poisonings. These codes are secondary codes for use in any health care setting, which are used to provide data for injury research and evaluation of injury prevention strategies. E codes....
Evolving and Adapting: The Changing Role of the CDI Professional
Author: Endicott, Melanie
Source: Journal of AHIMA - website
Publication Date: August 06, 2014
The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first started rolling out in the late 1990s and early 2000s, the focus was exclusively on acute care Medicare inpatients. The focus was merely on capturin....
External Cause Codes in ICD-10-CM
Author: Fuller, Jan C.
Source: CodeWrite | AHIMA newsletter article
Publication Date: August 2014
The increased specificity in ICD-10-CM is reflected in a substantial increase in external cause codes. The traditional “E code” has been replaced with V, W, X and Y codes. While the purpose of the codes remains the same, the ICD-10-CM codes provide a level of detail not possible in ICD-9-....
3 Myths of ICD-10-CM/PCS: Addressing Why it is Not Feasible to use SNOMED CT in Place of ICD-10 or Wait for ICD-11—and Other Misperceptions
Author: Bowman, Sue E
Source: Journal of AHIMA
Publication Date: August 2014
As the US healthcare industry experiences yet another delay in ICD-10-CM/PCS implementation, misunderstandings surrounding the ICD-10-CM/PCS transition continue to perpetuate. This article addresses a few of the most common misperceptions—myths that need to be exposed with fact-based....
CodeWrite Community Newsletter August 2014
Author: AHIMA
Source: AHIMA newsletter
Publication Date: August 2014
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
CDI and Coding Make a Winning Team
Author: Endicott, Melanie
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 09, 2014
Clinical documentation improvement (CDI) is front of mind in the health information management (HIM) industry these days. Maybe you’ve seen lots of jobs advertised for CDI specialists lately and have been wondering just what exactly is so hot about this profession. Well, let me tell y....
Projected Impact of the ICD-10-CM/PCS Conversion on Longitudinal Data and the Joint Commission Core Measures
Author: Fenton, Susan H.; Benigni, Mary Sue
Source: Perspectives in Health Information Management
Publication Date: July 2014
Abstract
The transition from ICD-9-CM to ICD-10-CM/PCS is expected to result in longitudinal data discontinuities, as occurred with cause-of-death in 1999. The General Equivalence Maps (GEMs), while useful for suggesting potential maps do not provide guidance regarding the frequen....
Improving and Measuring Inpatient Documentation of Medical Care within the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index
Author: Rosenbaum, Benjamin P; Lorenz, Robert R; Luther, Ralph B; Knowles-Ward, Lisa; Kelly, Dianne L; Weil, Robert J
Source: Perspectives in Health Information Management
Publication Date: July 2014
Abstract
Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related....
Preparing for ICD-10- CM/PCS Implementation: Impact on Productivity and Quality
Author: Stanfill, Mary H; Hsieh, Kang Lin; Beal, Kathleen; Fenton, Susan H.
Source: Perspectives in Health Information Management
Publication Date: July 2014
Abstract
Coding productivity is expected to drop significantly during the lead-up to and in the initial stages of ICD-10-CM/PCS implementation, now expected to be delayed until October 1, 2015. This study examined the differences in coding productivity between ICD-9-CM and ICD-10-....
Document Like This, Not That: CDI Insights from the Physician and CDI Specialist Perspective
Author: Lo, Wil
Source: Journal of AHIMA
Publication Date: July 2014
Many HIM professionals, especially clinical documentation improvement (CDI) program participants, wonder why it can be so difficult for physicians to provide timely, reliable, precise, consistent, clear, and complete documentation in patients’ charts. It seems logical that time spent on p....
Reinventing CDI: Organizations Relaunching And Reworking Data Integrity Efforts, And Coding Roles, With Clinical Documentation Improvement Programs
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: July 2014
It’s a particularly busy night in the local hospital’s emergency department, which is running—as usual—slightly short-staffed. The on-call attending physician goes from room to room treating and diagnosing patients with typical emergency department maladies: influenza, fractured ankle, in....
CDI's Promise and Possibilities
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: July 2014
“The first job of a leader—at work or at home—is to inspire trust. It’s to bring out the best in people by entrusting them with meaningful stewardships, and to create an environment in which high-trust interaction inspires creativity and possibility.”
Top Ten ICD-10-CM/PCS Questions
Author: AHIMA
Source: AHIMA
Publication Date: July 2014
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....
Improve Data and Outcomes with CDI
Author: Kennedy, Angela
Source: Journal of AHIMA
Publication Date: July 2014
ICD-10-CM/PCS will require significantly more clinical detail than ICD-9-CM, making clinical documentation improvement (CDI) efforts paramount for healthcare providers across the continuum of care. While CDI programs aim to substantiate claims and improve revenue streams, CDI itself shoul....
Use Data Mining Findings as a Tool to Support CDI Education
Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2014
Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....
Clinical Documentation Improvement Eases the Transition to ICD-10
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2014
Reactions within the healthcare community to the ICD-10-CM/PCS implementation delay are varied. Many clinical documentation improvement (CDI) specialists are already well into ICD-10-CM/PCS code set education and may see the delay as a frustrating set back, while others view it as an oppor....
Selecting the Ideal CDI Physician Advisor
Author: Huff, Garry L.; Fee, James P; Clesi, Wendy; Perry, Joni; Rajappan, Melissa
Source: Journal of AHIMA
Publication Date: July 2014
Physicians are increasingly being utilized as advisors in various aspects of healthcare delivery. These include utilization review, quality resource management, and clinical documentation improvement. An effective strategy must be used to develop a physician advisor program in the area of....
Document Like This, Not That: Coders' Perspective
Author: Lo, Wil
Source: Journal of AHIMA - website
Publication Date: July 2014
A companion piece to Lo’s article in the July 2014 issue of Journal of AHIMA discusses documentation issues from the coders’ perspective. Coders face a formidable task, navigating charts and linking documentation with coding guidelines and conventions.
CodeWrite Community Newsletter July 2014
Author: AHIMA
Source: AHIMA newsletter
Publication Date: July 2014
Monthly newsletter containing practical news for coding, reimbursement, and healthcare compliance
AHIMA Comments on CMS' Proposed Changes to the Medicare Hospital Inpatient Prospective Payments Systems (IPPS) and Fiscal Year 2015 Rates
Author: Gordon, Lynne Thomas
Source: AHIMA testimony and comments
Publication Date: June 27, 2014
AHIMA responds to
the Centers for Medicare & Medicaid Services’ (CMS) proposed changes to the Medicare Hospital
Inpatient Prospective Payment Systems (IPPS) and fiscal year 2015 Rates.
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