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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....

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....

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....

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....

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....

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....

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

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....

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,....

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....

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,....

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....

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....

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....

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....

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-....

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.”

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....

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