Health Information Management Articles by Topic: ICD-9-CM Coding
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APCs Weekly Monitor, Issue 44, November 6, 2009
Q. Several of our facilities that include hospital-based outpatient wound care clinics have...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009
The American Hospital Association’s Coding Clinic for ICD-9-CM is one of the most important...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009
Some of the major code groupings undergoing change this year include more specificity to the...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009
As part of your preparation work for ICD-10, consider ways to offer coders more education on...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009
Inside:
Prepare for ICD-10 with anatomy/physiology education
Determine your coders’ need...
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APCs Weekly Monitor, Issue 43, October 30, 2009
Q. A patient who has undergone a kidney transplant and has plasmapheresis intravenously receives IV...
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JustCoding News: Inpatient, Issue 44, October 28, 2009
Robert S. Gold, MD, examines the concept of acute and chronic pulmonary embolism and thrombosis and...
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JustCoding News: Inpatient, Issue 44, October 28, 2009
Physicians may document appropriate terminology to describe a patient’s condition(s), however...
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APCs Weekly Monitor, Issue 42, October 23, 2009
Q: A patient with multiple wounds at different sites receives active wound management at one wound...
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APCs Weekly Monitor, Issue 42, October 23, 2009
Facilities need to have a clear understanding of when a procedure is diagnostic and when it is...
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APCs Weekly Monitor, Issue 41, October 16, 2009
Q: We don’t have the usual written orders for several tests. However, physicians dictate or...
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APCs Weekly Monitor, Issue 41, October 16, 2009
In FAQ 8736, CMS instructs hospitals how to report units in excess of the medically unlikely edits...
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JustCoding News: Inpatient, Issue 42, October 14, 2009
Physicians may document clinical indicators of significant conditions, but they may not actually...
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JustCoding News: Inpatient, Issue 42, October 14, 2009
A recent JustCoding.com article referenced Coding Clinic advice on coding anemia secondary to...
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APCs Weekly Monitor, Issue 40, October 9, 2009
Q: Patient arrives in ED September 7 at 23:00. ED clinical staff initiate an IV push and hydration...
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APCs Weekly Monitor, Issue 40, October 9, 2009
Coding a screening colonoscopy should be relatively straightforward. However, the interpretation of...
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APCs Weekly Monitor, Issue 39, October 2, 2009
How can your facility ensure compliance with the physician supervision requirements for diagnostic...
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Medical Records Briefing, Issue 10, October 1, 2009
Many hospitals had feared a 1.9% reduction in payment for 2010, but they’ll actually see a...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009
In the September BCCS, we published an article with Coding Clinic advice on coding anemia secondary...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009
Although undercoding is always a concern for facilities, potential upcoding is just as serious a...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009
Coding has continually evolved over the past 10 years, and it will continue to change with the...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009
With audit contractors scrutinizing coding accuracy and an upcoming transition to the ICD-10 coding...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009
Inside:
Use productivity benchmarks to set coding standards
Roller-coaster fall results in...
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Medical Records Briefing, Issue 10, October 1, 2009
This month’s 16-page expanded issue includes our four-page quarterly insert that focuses on...
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CDI Strategies, Issue 20, October 1, 2009
The most recent Coding Clinic, third quarter 2009, contains an entry on glioblastoma with vasogenic...
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JustCoding News: Inpatient, Issue 40, September 30, 2009
In the calm before the ICD-10 storm, CMS added 14 new ICD-9 procedure codes that take effect...
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JustCoding News: Inpatient, Issue 40, September 30, 2009
Reporting complications of surgery is often likened to a tug of war between hospitals and...
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HIM Connection, Issue 39, September 29, 2009
Question: A patient came into the ER with complaints of a headache and facial pain. The ER...
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APCs Weekly Monitor, Issue 38, September 25, 2009
CMS created medically unlikely edits (MUEs) to ensure that providers don’t report excessive...
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HIM Connection, Issue 38, September 22, 2009
Follow these steps when researching an ICD-9-CM coding question.
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APCs Weekly Monitor, Issue 37, September 18, 2009
Q: We understand that we cannot charge for the use of equipment, but can we charge for the soft...
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APCs Weekly Monitor, Issue 37, September 18, 2009
Under the 2009 OPPS final rule, bundling is now subdivided into status indicators Q1, Q2, and Q3.
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JustCoding News: Inpatient, Issue 38, September 16, 2009
The language of the practice of medicine doesn’t always mesh with the language of coding...
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JustCoding News: Inpatient, Issue 38, September 16, 2009
Recovery audit contractors are scrutinizing coding accuracy, and the transition to ICD-10 is only a...
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JustCoding News: Inpatient, Issue 38, September 16, 2009
On September 10, Connolly, the RAC for Region C, approved the following issues for review for...
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HIM Connection, Issue 37, September 15, 2009
QUESTION: A patient undergoes outpatient surgery and is subsequently admitted due to acute blood...
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HIM Connection, Issue 36, September 8, 2009
Q: What does an incidental pregnancy (code V22.2) mean? Is it related at all to an ectopic...
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HIM Connection, Issue 36, September 8, 2009
The following ICD-9-CM codes denote acute respiratory failure (ARF):
518.81, ARF...
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APCs Weekly Monitor, Issue 35, September 5, 2009
Q. A physician orders one dose of a medication to be administered intramuscularly (IM) or...
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APCs Weekly Monitor, Issue 35, September 4, 2009
In its 2010 OPPS proposed rule, CMS acknowledges never having specifically defined...
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CDI Strategies, Issue 18, September 3, 2009
Editor’s note: The following Q&A first appeared in the August 20, 2009, edition of CDI...
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Medical Records Briefing, Issue 9, September 1, 2009
Just because coders have been reporting the present-on-admission (POA) indicator for nearly...
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Medical Records Briefing, Issue 9, September 1, 2009
The final phase of the national Recovery Audit Contractor (RAC) rollout began last month, and...
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Medical Records Briefing, Issue 9, September 1, 2009
This month’s issue covers a wide variety of topics of interest to HIM directors. Our cover...
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Briefings on Coding Compliance Strategies, Issue 9, September 1, 2009
In this issue, we dissect the final 2010 IPPS rule, plus discuss the three new NCDs for never...
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Briefings on Coding Compliance Strategies, Issue 9, September 1, 2009
CMS delayed a payment reduction, but changed MS-DRG weights.
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Briefings on Coding Compliance Strategies, Issue 9, September 1, 2009
Our coding experts provide three questions to ask before reporting anemia secondary to chemotherapy.
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APC Payment Insider, Issue 9, September 1, 2009
ICD-9 code changes increase specificity to provide more information.
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APCs Weekly Monitor, Issue 32, August 21, 2009
Q: How should we code the following scenario: A patient arrives at the catheterization laboratory...
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APCs Weekly Monitor, Issue 31, August 13, 2009
Q: Is there a limit on how frequently patients may receive PET scans, such as 78815 (Tumor...
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APCs Weekly Monitor, Issue 30, August 7, 2009
Q. An APC edit states that 93005 (electrocardiogram, routine EKG with at least 12 leads; tracing...
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APCs Weekly Monitor, Issue 30, August 7, 2009
Coders need to be aware of a new set of E codes that detail injuries sustained by military...
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HIM Connection, Issue 31, August 4, 2009
Though many hospitals had feared a 1.9% reduction in payment for 2010, they will actually see a...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009
A few months ago, I wrote a description of how atrial fibrillation (AF) with rapid ventricular...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009
To help facilities prepare for ICD-10, CMS has pub¬lished two fact sheets that provide general...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009
Inside:
What would you do? Know your ethical obligations
Improve documentation with strong CDI...
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APCs Weekly Monitor, Issue 29, July 31, 2009
Q: What are the guidelines for physician supervision for physical therapy/occupational therapy and...
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APCs Weekly Monitor, Issue 28, July 24, 2009
Q: I work in a hospital outpatient clinic setting. Has CMS issued a deadline for developing...
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APCs Weekly Monitor, Issue 28, July 24, 2009
Providers must ensure the medical necessity of procedures they perform. To reduce revenue loss...
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HIM Connection, Issue 29, July 21, 2009
Certain areas of the patient’s record will most likely provide important clues to the coder...
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APCs Weekly Monitor, Issue 28, July 17, 2009
Q: We know we should append CPT modifier –25 to the visit level when one of our EDs or...
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APCs Weekly Monitor, Issue 28, July 17, 2009
When setting productivity goals, don’t forget to include non-coding responsibilities when...
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APCs Weekly Monitor, Issue 27, July 10, 2009
Q: Which CPT code is appropriate for blood glucose monitoring with a device such as...
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APCs Weekly Monitor, Issue 26, July 3, 2009
Q: My question pertains to CPT code 96376 (therapeutic, prophylactic, or diagnostic injection...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009
Each year, the Cooperating Parties make changes to various ICD-9 code sets. Most recent changes...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009
The job of the recovery audit contractors (RAC) is twofold: Identify overpayments to recoup excess...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009
Despite the fact that ICD-10 implementation is nearly three years away, CMS is ramping up its...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009
The transition to ICD-10 and preparing for recovery audit contractors are two big issues for...
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Medical Records Briefing, Issue 7, July 1, 2009
This month’s expanded issue includes our 4-page quarterly insert about electronic health...
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HIM Connection, Issue 26, June 30, 2009
A change-of-status form will help ensure that a hospital meets all of the criteria for reporting...
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APCs Weekly Monitor, Issue 25, June 26, 2009
Establishing coding productivity standards is a necessary and challenging aspect of managing an...
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APCs Weekly Monitor, Issue 24, June 19, 2009
Q: My question pertains to critical care provided in an ER at a Level 1 Trauma Center. If a patient...
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HIM Connection, Issue 24, June 16, 2009
Q: Where can I find more information about Medicare payments proposed for long-term acute care...
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HIM Connection, Issue 24, June 16, 2009
The new and revised ICD-9 codes that take effect October 1 are now available online. Learn more...
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Briefings on Coding Compliance Strategies, Issue 6, June 1, 2009
Selecting a code for a patient with heart failure used to be fairly straightforward; fewer codes...
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Briefings on Coding Compliance Strategies, Issue 6, June 1, 2009
When CMS released its May 1 proposal, hospitals received a mixed bag of news: There are minimal...
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Briefings on Coding Compliance Strategies, Issue 6, June 1, 2009
Later than usual, CMS finally released the IPPS proposed rule for fiscal year 2010. The biggest...
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HIM Connection, Issue 20, May 19, 2009
Every hospital should develop and maintain its own internal coding manual. It’s an essential...
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HIM Connection, Issue 20, May 19, 2009
Your hospital’s HIM department has more to think about than ever before. President Obama has...
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APCs Weekly Monitor, Issue 19, May 15, 2009
Q: A patient is seen in the ED for laceration repair and then returns for suture or staple removal...
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HIM Connection, Issue 19, May 12, 2009
During the three-year RAC demonstration project, payment for several inpatient debridement...
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HIM Connection, Issue 18, May 5, 2009
On April 28, CMS issued a proposed rule for inpatient rehabilitation facilities (IRF) for FY 2010.
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HIM Connection, Issue 18, May 5, 2009
Q: What code should I report for a cerebral occlusion, thrombotic with cerebral infarction and...
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HIM Connection, Issue 18, May 4, 2009
The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is...
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Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009
A variety of codes apply to certain dis¬eases of the large bowel, so it?s important to understand...
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Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009
Sepsis, septicemia, bacteremia and Systemic Inflamma¬tory Response Syndrome (SIRS) are...
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Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009
Two ICD-9 codes denote debridement in relation to wound care: 86.22, excisional debridement of...
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Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009
Across the country, hospitals are focusing more time and energy on improving quality of care, not...
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HIM Connection, Issue 17, April 28, 2009
On April 13, CMS announced a pilot project to reduce rates of hospital readmissions. The Care...
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HIM Connection, Issue 17, April 28, 2009
In most cases, coders should not assign codes based on documentation that does not come from a...
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APCs Weekly Monitor, Issue 16, April 17, 2009
Everyone knows that an immense amount of teamwork is necessary for a CDI program to truly be...
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APCs Weekly Monitor, Issue 16, April 17, 2009
Christina Benjamin, MA, RHIA, CCS, CCS-P, presents several compliance traps that coders should...
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HIM Connection, Issue 15, April 14, 2009
Q: How should I code Shone’s syndrome with subaortic stenosis and coarctation...
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APCs Weekly Monitor, Issue 14, April 3, 2009
Never assume that sepsis is present on admission (POA). Sepsis or severe sepsis may be present on...
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Briefings on Coding Compliance Strategies, Issue 4, April 1, 2009
We’ve been in the medical record documentation business a long time, and we’ve heard...
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Briefings on Coding Compliance Strategies, Issue 4, April 1, 2009
Coders have a moral and ethical responsibility to judiciously avoid reimbursement fraud and abuse...
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Medical Records Briefing, Issue 4, April 1, 2009
Although coders need not put their nose to the ICD-10 grindstone for another few years, that...
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Medical Records Briefing, Issue 4, April 1, 2009
This month?s issue is full of time-saving tips and guidance related to Joint Commission changes...
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HIM Connection, Issue 12, March 24, 2009
If you haven’t already viewed the handouts from the ICD-9-CM Coordination and Maintenance...
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HIM Connection, Issue 12, March 24, 2009
By Robert S. Gold, MD
Patient falls account for nearly a half-million inpatient days spent in the...
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HIM Connection, Issue 10, March 10, 2009
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I have...
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HIM Connection, Issue 9, March 3, 2009
Q: I report ICD-9 code 876.1 for an infected lumbar wound. However, when I report this code, the...
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Briefings on Coding Compliance Strategies, Issue 3, March 1, 2009
Without complete and ac¬curate code assignment in conjunction with timely cod¬ing and...
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Briefings on Coding Compliance Strategies, Issue 3, March 1, 2009
Hospitals around the country face a new challenge: teaching coders that they can, in certain...
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Briefings on Coding Compliance Strategies, Issue 3, March 1, 2009
At long last, CMS announced an implementation date for ICD-10: 2013. Thought that may seem far...
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Briefings on APCs, Issue 3, March 1, 2009
Start your transition now. The moment HIM departments nationwide have awaited for years has arrived.
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HIM Connection, Issue 6, February 10, 2009
Q: When a patient presents with controlled diabetes that progresses to uncontrolled during a...
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Coding Educator, Issue 2, February 9, 2009
February is Low Vision Awareness Month, so I would like to take the opportunity to share a bit...
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HIM Connection, Issue 5, February 3, 2009
Q: How do you code a full-thickness burn of the colon wall with serosal irritation...
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Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009
Seek clarification regarding etiology by Robert S. Gold, MD Patient falls account for...
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Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009
Revisit definitions, condition code 44, and the connection to inpatient status
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Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009
For more than a year, coders have reported the present-on-admission (POA) indicator for most...
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Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009
Effective January 1, coders can report HCPCS code C9899 when providers implant a prosthetic device...
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HIM Connection, Issue 4, January 27, 2009
Verbal queries have the greatest liability from a legal standpoint and because they are a common...
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HIM Connection, Issue 2, January 13, 2009
CMS revised its July 2008 RAC appeal update to include appeals statistics through August 31, 2008.
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CDI Strategies, Issue 1, January 8, 2009
Question: Part of our clinical support for determining the presence of congestive heart failure...
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Medical Records Briefing, Issue 1, January 1, 2009
We all do a great job in documenting our patients’ history and physical exams. We all...
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Coding Educator, Issue 1, January 1, 2009
Birth defects are the leading cause of death in the first year of life, and approximately one in 33...
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Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009
Editor’s note: Last month in BCCS, we offered an overview of AHIMA’s new query brief...
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Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009
Be aware of new Coding Clinic advice Cardiac resynchronization therapy defibrillator (CRT-D...
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Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009
Get to know your bleeds to ensure proper coding by Robert S. Gold, MD Consider the following...
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HIM Connection, Issue 51, December 30, 2008
Q: I am new to the inpatient coding world and looking for information about when to code oxygen...
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HIM Connection, Issue 49, December 16, 2008
Q: A patient is walking quickly on an icy, unsalted sidewalk so she doesn’t miss her bus. The...
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APCs Weekly Monitor, Issue 50, December 12, 2008
Coder understanding of the origin of secondary diabetes is important to help ensure coding...
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CDI Strategies, Issue 25, December 11, 2008
Where can I find documentation that says that suspected or probable diagnoses have to be in the...
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HIM Connection, Issue 48, December 9, 2008
In Medlearn Matters SE0841, CMS outlines payment implications for each of the present on admission...
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CDI Strategies, Issue 24, December 4, 2008
When a clinical condition suggests a more specific diagnosis, and a physician from a different...
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HIM Connection, Issue 47, December 2, 2008
Q: A physician admits a patient for rejection of a kidney transplant the physician performed four...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Officials answer questions during special ODF By now, one point remains clear: CMS has halted the...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Coders and CDI specialists now have concrete guidance regarding when, how, and to whom they should...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Since October 1, 2007, providers have been adapting to a revised hospital inpatient reimbursement...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
CMS discusses RAC expansion, ICD-10, and never events CMS hosted a Hospital & Hospital Quality...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Hospitals have been waiting for finalized wage indexes and standardized payment rates since CMS...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
As of October 1, coders began reporting new codes for secondary diabetes. To maintain coding...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
by Robert S. Gold, MD Applying the present-on-admission (POA) indicator to pressure ulcers is no...
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HIM Connection, Issue 45, November 18, 2008
Q: What present on admission (POA) indicator should we assign when a patient presents to the...
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CDI Strategies, Issue 23, November 13, 2008
What present on admission (POA) indicator should we assign when a patient presents to the hospital...
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Medical Records Briefing, Issue 12, November 7, 2008
Scenario 1
A patient does not properly insulate her hands (i.e., wear gloves) while shoveling her...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Gastrointestinal (GI) bleed and its manifestations can be confusing without some insight into...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
The ICD-9-CM Manual provides many helpful tools you can use to your advantage. For example, despite...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Most surgeons find carcinoid tumors incidentally, either during the postmortem exam when a patient...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Just because a physician documents a condition during the postoperative period doesn’t mean...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Forty percent of Medicare admission denials relate to improper one-day stays. If this statistic...
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Coding Educator, Issue 11, November 1, 2008
November, which is National Epilepsy Awareness month, is a great time to find out more about...
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Coding Educator, Issue 10, October 1, 2008
Every year, when the month of October arrives, my thoughts return to a time years ago when a young...
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Briefings on APCs, Issue 9, September 1, 2008
Encoders are among the most valuable coding resources on the market, but software is just one tool...
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HIPAA Weekly Advisor, Issue 35, September 1, 2008
On August 22, HHS announced a proposed regulation to replace the ICD-9 code sets now used to report...
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Coding Educator, Issue 9, September 1, 2008
September is National Sickle Cell Awareness Month and this is the perfect opportunity to address...
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Briefings on APCs, Issue 8, August 1, 2008
The National Center for Health Statistics (NCHS) released its annual ICD-9-CM code changes May 30...
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APCs Weekly Monitor, Issue 22, May 30, 2008
Part 2 of a 2-part series. See the May 23, 2008 APCs Weekly Monitor for the CMS stance on...
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APCs Weekly Monitor, Issue 21, May 23, 2008
Do CMS and the Office of Inspector General (OIG) consider the intentional unbundling of codes to be...