Health Information Management Articles by Topic: ICD-9-CM Coding
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CDI Strategies, Issue 2, January 22, 2015
Editor’s Note: James S. Kennedy, MD, CCS, CDIP,director of CDIMD Physician Champions offers...
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CDI Strategies, Issue 19, September 11, 2014
Q: We’re having a lot of discussions with physicians right now and need to get some clarity...
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CDI Strategies, Issue 15, July 17, 2014
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase...
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CDI Strategies, Issue 13, June 19, 2014
Over-identifying sepsis and failing to code sepsis when it is present are just two of the problems...
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Briefings on APCs, Issue 3, March 1, 2014
Coders are aware that ICD-10-CM will allow much more specificity than ICD-9-CM, and that is...
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Briefings on APCs, Issue 3, March 1, 2014
How does CPT® define “final examination” for code 99238 (hospital discharge day...
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Briefings on APCs, Issue 3, March 1, 2014
In this month's issue, we review latest 2014 CPT® Manual changes, examine how MUEs are...
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Briefings on Coding Compliance Strategies, Issue 2, January 29, 2014
The UHDDS defines principal diagnosis as the condition established after study to be chiefly...
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APCs Insider, Issue 3, January 17, 2014
Currently in ICD-9-CM, a myocardial infarction is considered to be acute when stated as such or...
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APCs Insider, Issue 52, December 20, 2013
As 2013 nears an end, many providers are likely approaching 2014 with trepidation as ICD-10...
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CDI Strategies, Issue 24, November 21, 2013
"[Recovery Auditors] are doing a really good job at identifying the patients who don't have...
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HIM-HIPAA Insider, Issue 45, November 18, 2013
CMS recently released five online resources to aid providers in their ICD-10 implementation...
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CDI Strategies, Issue 20, September 26, 2013
In two recent findings from the Office of the Inspector General (OIG), improper documentation may...
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CDI Strategies, Issue 17, August 15, 2013
HCPro is seeking Coding Education Specialists to serve as instructors for ICD-10-related boot...
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CDI Strategies, Issue 17, August 15, 2013
A recent study conducted by the AHIMA Foundation in collaboration with the Cleveland Clinic...
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HIM-HIPAA Insider, Issue 28, July 29, 2013
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X-NONE
X-NONE...
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CDI Strategies, Issue 15, July 18, 2013
Sepsis. Ureosepsis. Severe Sepsis. Systemic inflammatory response syndrome (SIRS). Bacteremia...
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HIM-HIPAA Insider, Issue 23, June 24, 2013
Normal
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X-NONE
X-NONE...
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APCs Insider, Issue 25, June 21, 2013
Don't burn your ICD-9-CM Manual October 1, 2014. Not everyone is going to transition to...
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APCs Insider, Issue 24, June 14, 2013
CMS released three FAQs about ICD-10 billing, including how to bill encounters that cross the...
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APCs Insider, Issue 22, May 31, 2013
General equivalence mappings (GEMs) are reference maps between ICD-9-CM and ICD-10-CM codes. They...
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HIM-HIPAA Insider, Issue 10, March 25, 2013
When it comes to coding for infectious and parasitic diseases, the translation from ICD-9-CM to...
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APCs Insider, Issue 2, January 11, 2013
Determining the appropriate order to translate diagnoses into ICD-9 codes on the claim form can be...
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CDI Strategies, Issue 1, January 3, 2013
Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the...
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CDI Strategies, Issue 1, January 3, 2013
Depending on how they are sequenced, CC and MCC conditions can have a direct effect on MS-DRG...
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APCs Insider, Issue 51, December 21, 2012
Dual coding is one way to prepare for the transition to ICD-10. The idea is to have coders using...
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APCs Insider, Issue 48, December 7, 2012
Glomerular filtration rate (GFR) measures the creatinine level of the blood and how well the...
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ICD-10 Trainer, Issue 23, November 16, 2012
Do you know what you don’t know about ICD-10? Do you know where your knowledge gaps are...
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CDI Strategies, Issue 23, November 8, 2012
ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that...
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APCs Insider, Issue 43, November 2, 2012
Patients with chronic kidney disease (CKD) may also suffer from a sudden loss of the ability of the...
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JustCoding News: Inpatient, Issue 43, October 24, 2012
In ICD-9-CM, coders report specific codes to indicate a surgeon used robotic assistance. Lori-Lynne...
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JustCoding News: Outpatient, Issue 42, October 17, 2012
QUESTION: I work for a gastrointestinal (GI) practice and I have a question regarding the correct...
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JustCoding News: Inpatient, Issue 41, October 10, 2012
Provider documentation of inpatient wound care services may be confusing at best and completely...
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JustCoding News: Inpatient, Issue 41, October 10, 2012
Q: I have a question about coding transplant complications. My understanding is if the complication...
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JustCoding News: Inpatient, Issue 39, September 26, 2012
Q: I have a question about coding bipolar disorder. When can I report ICD-9-CM code 296.89 (other...
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JustCoding News: Inpatient, Issue 37, September 12, 2012
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy...
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HIM-HIPAA Insider, Issue 10, September 10, 2012
Timing and dating all entries in the medical record can be difficult if the medical record is still...
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HIM-HIPAA Insider, Issue 10, September 10, 2012
Q. How do a cervical/vaginal laceration complication/repair and a routine episiotomy performed for...
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HIM-HIPAA Insider, Issue 9, August 31, 2012
A quick glance at ICD-9-CM and ICD-10-CM stroke and coma codes reveals many similarities and some...
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CDI Strategies, Issue 18, August 30, 2012
Q: I was interested in further discussion about cystic fibrosis coding. I am conducting an audit on...
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JustCoding News: Inpatient, Issue 35, August 29, 2012
Neoplasm coding in ICD-10-CM is similar to the current ICD-9-CM coding. Most benign and all...
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JustCoding News: Inpatient, Issue 35, August 29, 2012
ICD-9-CM and ICD-10-CM stroke and coma codes reveal many similarities and some important...
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JustCoding News: Inpatient, Issue 35, August 29, 2012
Retain. Train. Assess. Investigate. Analyze. HIM professionals have undoubtedly come across action...
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HIM-HIPAA Insider, Issue 7, August 20, 2012
Clear and consistent documentation makes a coder’s job much easier, and it improves data...
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JustCoding News: Outpatient, Issue 34, August 8, 2012
QUESTION: A patient complained of intractable pain from compression fracture (sustained the day...
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HIM-HIPAA Insider, Issue 5, August 6, 2012
Inpatient facilities received mixed news on proposed changes to the list of complications and...
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HIM-HIPAA Insider, Issue 5, August 6, 2012
Should coders or coding managers be involved in an EHR rollout? The answer to this question is...
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JustCoding News: Inpatient, Issue 31, August 1, 2012
Although ICD-10 includes more codes than ICD-9-CM, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, and...
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JustCoding News: Inpatient, Issue 31, August 1, 2012
QUESTION: I'd like to address our coders' questions on how to code poisoning due to bath salts...
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HIM-HIPAA Insider, Issue 4, July 30, 2012
QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on...
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ICD-10 Trainer, Issue 15, July 27, 2012
Epilepsy affects nearly 3 million Americans and 50 million people worldwide, so you may see some of...
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JustCoding News: Outpatient, Issue 30, July 25, 2012
Many coders can quickly quote the code for diabetes mellitus in ICD-9-CM (code 250.00) when the...
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JustCoding News: Outpatient, Issue 30, July 25, 2012
As you get the opportunity to investigate the complete pregnancy chapter in ICD-10-CM, you will...
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JustCoding News: Outpatient, Issue 30, July 25, 2012
Cross-training coders has definitive short-term advantages, such as enhancing staff coverage during...
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JustCoding News: Outpatient, Issue 30, July 25, 2012
QUESTION: How is the coding for asthma going to be different in ICD-10-CM?
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HIM-HIPAA Insider, Issue 3, July 23, 2012
Let's get to the heart of the matter. ICD-10-CM coronary artery disease (CAD) and myocardial...
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CDI Strategies, Issue 15, July 19, 2012
Q: We recently had a case where a patient with severe chronic obstructive pulmonary disease...
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JustCoding News: Inpatient, Issue 29, July 18, 2012
New clinical guidelines for malnutrition could help alleviate compliance challenges associated with...
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JustCoding News: Inpatient, Issue 29, July 18, 2012
The digestion process is complex and there’s a lot that can go wrong. Thankfully, Robert S...
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JustCoding News: Inpatient, Issue 29, July 18, 2012
In late May, CMS released nationwide a new short-term (ST) acute care Program for Evaluating...
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JustCoding News: Inpatient, Issue 29, July 18, 2012
QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on...
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HIM-HIPAA Insider, Issue 2, July 16, 2012
Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless a patient is...
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JustCoding News: Outpatient, Issue 28, July 11, 2012
Pain is an expected component of injuries, illnesses, and surgical procedures. In some instances...
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HIM-HIPAA Insider, Issue 1, July 9, 2012
Q: Which code should I report for atypical small acinar proliferation of the prostate? Is ICD-9-CM...
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CDI Strategies, Issue 14, July 5, 2012
By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, CCDS
Broaden the scope of your CDI...
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HIM-HIPAA Insider, Issue 27, July 3, 2012
Q: A patient is admitted January 3 and undergoes spinal surgery that day. No laboratory specimens...
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APCs Insider, Issue 25, June 29, 2012
According to the ICD-9-CM Official Guidelines for Coding and Reporting, coders should report V...
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ICD-10 Trainer, Issue 13, June 29, 2012
Until HHS issues a clear and direct statement on a final ICD-10-CM/PCS implementation date, some...
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ICD-10 Trainer, Issue 13, June 29, 2012
When a physician performs a procedure designed to put in a device without doing anything else to a...
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JustCoding News: Outpatient, Issue 26, June 27, 2012
Chronic kidney disease (CKD) is the permanent alteration in the kidney’s ability to perform...
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JustCoding News: Outpatient, Issue 26, June 27, 2012
QUESTION: The vendor for our cochlear implants has stated it’s standard to provide our...
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HIM-HIPAA Insider, Issue 26, June 26, 2012
Let's get to the heart of the matter. ICD-10-CM coronary artery disease (CAD) and myocardial...
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JustCoding News: Inpatient, Issue 25, June 20, 2012
Why do coders need to know about Value Based Purchasing, the Readmissions Reduction Program...
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JustCoding News: Inpatient, Issue 25, June 20, 2012
Choosing a principal diagnosis can be tricky for coders. Luckily, Gloryanne Bryant, BS, RHIA, RHIT...
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JustCoding News: Inpatient, Issue 25, June 20, 2012
Medical necessity denials traditionally focus on high-dollar MS-DRGs, such as those for hip and...
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JustCoding News: Inpatient, Issue 25, June 20, 2012
Medicare Fee-For-Service (FFS) will accept only ASC X12 Version 5010 or NCPDP Telecom D.0...
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JustCoding News: Inpatient, Issue 25, June 20, 2012
QUESTION: A patient was exposed to shingles, for which a coder reported ICD-9-CM code V01.79...
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HIM-HIPAA Insider, Issue 25, June 19, 2012
Starting in July, hospitals can risk their reimbursement under the Medicaid program for conditions...
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JustCoding News: Outpatient, Issue 24, June 13, 2012
The Rh factor of positive and negative can lead to problems between a mother and the developing...
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HIM-HIPAA Insider, Issue 24, June 12, 2012
Q: Our question pertains to the following scenario: The studies section of a history and physical...
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HIM-HIPAA Insider, Issue 24, June 12, 2012
Medicare Quarterly Provider Compliance Newsletter, October 2011, Vol. 2, Issue 1, reminds coders to...
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HIM-HIPAA Insider, Issue 23, June 5, 2012
Q: The patient scenario involves a healing traumatic finger amputation with concern but no...
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HIM-HIPAA Insider, Issue 23, June 5, 2012
Coders should review documentation thoroughly, query when necessary, and consider the following tip...
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JustCoding News: Outpatient, Issue 22, May 30, 2012
Facilities can't bill for skin substitutes unless they also bill for a skin substitute application...
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JustCoding News: Outpatient, Issue 22, May 30, 2012
The guiding principle is the definitive methodology used for all risk adjustment medical record...
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HIM-HIPAA Insider, Issue 22, May 29, 2012
Q: Should I report ICD-9-CM code 701.1 (keratoderma, acquired) or 706.8 (other specified diseases...
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JustCoding News: Inpatient, Issue 21, May 23, 2012
Depending on the demographics of the region a hospital serves, its coders could determine code...
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HIM-HIPAA Insider, Issue 21, May 22, 2012
Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient...
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ICD-10 Trainer, Issue 10, May 18, 2012
Coders often report signs and symptoms when physicians document them in the patient’s medical...
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ICD-10 Trainer, Issue 10, May 18, 2012
Certain conditions have both an underlying etiology and multiple body system manifestations due to...
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ICD-10 Trainer, Issue 10, May 18, 2012
Home repair and improvement can be hazardous to your health. Just ask the residents of Calamity...
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JustCoding News: Inpatient, Issue 19, May 9, 2012
Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year...
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JustCoding News: Inpatient, Issue 19, May 9, 2012
QUESTION: A physician documents in an operative report debridement of a necrotic muscle (not due to...
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JustCoding News: Outpatient, Issue 16, April 18, 2012
QUESTION: I would like to know the correct codes to use when a patient comes into the ER after...
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HIM-HIPAA Insider, Issue 16, April 17, 2012
After HHS proposed a year-long delay of ICD-10-CM/PCS, questions emerged regarding the current...
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CDI Strategies, Issue 8, April 12, 2012
A Maryland hospital allegedly added malnutrition as a secondary diagnosis, employing tactics that...
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JustCoding News: Inpatient, Issue 15, April 11, 2012
New on JustCoding Platinum!
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JustCoding News: Inpatient, Issue 15, April 11, 2012
During the last year, the buzz from the health information management (HIM) and coding community...
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JustCoding News: Inpatient, Issue 15, April 11, 2012
If you're going to spend time and resources to conduct a coding audit, you certainly want to ensure...
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JustCoding News: Inpatient, Issue 15, April 11, 2012
CMS has posted a summary report from the discussion of procedure codes at the ICD-9-CM Coordination...
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JustCoding News: Inpatient, Issue 15, April 11, 2012
QUESTION: For a healing traumatic finger amputation with concern but no diagnosis of infection at...
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HIM-HIPAA Insider, Issue 14, April 3, 2012
Coding isn't just about reading documentation and selecting codes based on certain words. It's...
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CDI Strategies, Issue 7, March 29, 2012
The ICD-9-CM Coordination and Maintenance (C&M) Committee discussed a few changes to the...
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JustCoding News: Inpatient, Issue 13, March 28, 2012
Coders are constantly analyzing documentation for clues and details that may indicate the need for...
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JustCoding News: Inpatient, Issue 13, March 28, 2012
These days, documentation improvement and compliance are at the forefront of coders' minds. In some...
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JustCoding News: Inpatient, Issue 13, March 28, 2012
How does medical necessity get “overlooked” on the physician side as well as the...
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JustCoding News: Inpatient, Issue 13, March 28, 2012
CMS released in February a fact sheet, “Global Surgery,” which contains information...
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JustCoding News: Outpatient, Issue 12, March 21, 2012
Knowing spinal anatomy provides the foundation necessary to assign codes both before and after the...
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HIM-HIPAA Insider, Issue 12, March 20, 2012
CMS expects to release a new ICD-10-CM/PCS implementation date sometime in April. That date will be...
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HIM-HIPAA Insider, Issue 12, March 20, 2012
Q: A physician admitted a patient with pneumonia, which was the first diagnosis. The second...
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APCs Insider, Issue 11, March 16, 2012
Coders need to understand the intimate details of the upper and lower respiratory systems to report...
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JustCoding News: Inpatient, Issue 11, March 14, 2012
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it onto the...
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JustCoding News: Inpatient, Issue 11, March 14, 2012
When a provider notes a diagnosis on the hospital-acquired condition (HAC) list, coders must be...
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JustCoding News: Inpatient, Issue 11, March 14, 2012
What should inpatient coders remember about the three-day payment window requirements? Although it...
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JustCoding News: Inpatient, Issue 11, March 14, 2012
QUESTION: Recently, reviewers have denied diagnostic code 584.9 (acute renal failure [ARF]) based...
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HIM-HIPAA Insider, Issue 11, March 13, 2012
ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that...
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JustCoding News: Inpatient, Issue 9, February 29, 2012
Coders who keep in mind the injuries that define multiple significant trauma are more likely to...
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JustCoding News: Inpatient, Issue 9, February 29, 2012
Robert S. Gold, MD, discusses updates to the code definitions and exclusions for various lung...
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JustCoding News: Inpatient, Issue 9, February 29, 2012
Even if you didn’t make a personal New Year's resolution, you should make a professional one...
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JustCoding News: Inpatient, Issue 9, February 29, 2012
Trailblazer Health Enterprises, LLC, the Medicare administrative contractor (MAC) for Jurisdiction...
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JustCoding News: Outpatient, Issue 6, February 8, 2012
With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in...
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JustCoding News: Inpatient, Issue 5, February 1, 2012
A coder can be misled when coding directly from an encoder, and heavy dependence on one can...
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JustCoding News: Inpatient, Issue 5, February 1, 2012
QUESTION: A physician admits a 30-year-old male with lower abdominal pain. A CT scan showed...
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CDI Strategies, Issue 2, January 19, 2012
Q:I have a question regarding sequencing. I would usually have sequenced 428.21 (heart failure) as...
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JustCoding News: Inpatient, Issue 3, January 18, 2012
Computer-assisted coding (CAC) is a hot topic these days. Many industry experts claim that CAC is...
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JustCoding News: Inpatient, Issue 3, January 18, 2012
The goals of coding should always be ensuring data accuracy and capturing a patient's true clinical...
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JustCoding News: Inpatient, Issue 1, January 4, 2012
Medicare Advantage plans rely on the Hierarchical Condition Categories (HCC) system for...
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CDI Strategies, Issue 27, December 22, 2011
Most of the cases that HIM professionals code are straightforward; some are more difficult, and a...
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CDI Strategies, Issue 27, December 22, 2011
The American Hospital Association (AHA) has not made any formal decisions regarding when it will...
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CDI Strategies, Issue 27, December 22, 2011
Q:Does documentation such as “suggestive of” or “suspicious of” qualify as...
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HIM-HIPAA Insider, Issue 51, December 20, 2011
Training coordinators must find ways of integrating remote staff members into the training...
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JustCoding News: Inpatient, Issue 49, December 7, 2011
Clinical documentation plays a vital role in all coding. It is especially important, however, when...
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JustCoding News: Inpatient, Issue 49, December 7, 2011
As the weather cools, the heat is on coders to properly report the high number of pneumonia cases...
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JustCoding News: Inpatient, Issue 49, December 7, 2011
Coders should not underestimate the vital role they play in their organization’s efforts to...
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CDI Strategies, Issue 25, December 1, 2011
Invest in computer-assisted coding (CAC) now because of its potential positive impact on...
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JustCoding News: Outpatient, Issue 46, November 16, 2011
Coders shouldn’t fear the upcoming transition to ICD-10-CM. It’s not as scary or as...
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HIM-HIPAA Insider, Issue 46, November 15, 2011
Becoming inundated with coding information is easy in this fast-paced world of interconnectedness...
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HIM-HIPAA Insider, Issue 45, November 8, 2011
Q: One of our podiatrists documents “surgical debridement of devitalized tissue with...
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HIM-HIPAA Insider, Issue 45, November 8, 2011
As the weather cools, the heat is on coders to properly report the high number of pneumonia cases...
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APCs Insider, Issue 44, October 28, 2011
As part of the final regular update to ICD-9-CM before the transition to ICD-10-CM October 1, 2013...
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CDI Strategies, Issue 23, October 27, 2011
The Department of Health and Human Services and the Department of Defense accused Baltimore-based...
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HIM-HIPAA Insider, Issue 43, October 25, 2011
Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM (Northern California Revenue...
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HIM-HIPAA Insider, Issue 43, October 25, 2011
Variety is often the spice of life, and this year's 168 new ICD-9-CM diagnosis codes seem to...
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HIM-HIPAA Insider, Issue 42, October 18, 2011
Hospitals reported syncope and collapse (MS-DRG 312) as the top MS-DRG with respect to financial...
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HIM-HIPAA Insider, Issue 42, October 18, 2011
In the November issue of MRB, you’ll find articles on the following topics!
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HIM-HIPAA Insider, Issue 41, October 11, 2011
Q: A physician documents emaciation without noting malnutrition. ICD-9-CM indexes emaciation to...
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HIM-HIPAA Insider, Issue 40, October 4, 2011
The Revenue Cycle Institute has released a new white paper, “Principal Diagnosis Selection...
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HIM-HIPAA Insider, Issue 40, October 4, 2011
It shouldn't come as a surprise that RACs use the Common Working File (CWF) to ensure that...
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APCs Insider, Issue 40, September 30, 2011
The CDC significantly expanded code series 173.x (other malignant neoplasms of the skin) by adding...
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CDI Strategies, Issue 20, September 29, 2011
Documentation improvement staff often struggle with principal diagnosis selection. A clear...
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CDI Strategies, Issue 20, September 29, 2011
Q: How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes...
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HIM-HIPAA Insider, Issue 39, September 27, 2011
Q: Should I report ICD-9-CM code V71.5 (observation following alleged rape or seduction) after an...
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HIM-HIPAA Insider, Issue 39, September 27, 2011
The Program for Evaluating Payment Patterns Electronic Report (PEPPER), distributed either...
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HIM-HIPAA Insider, Issue 38, September 20, 2011
The FY 2012 IPPS final rule is out, and hospitals that are bracing for changes effective October 1...
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HIM-HIPAA Insider, Issue 38, September 20, 2011
In the October issue of MRB, you’ll find articles on the following topics!
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HIM-HIPAA Insider, Issue 36, September 6, 2011
According to a survey on coder productivity published in the May edition of MRB, 83% of those with...
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HIM-HIPAA Insider, Issue 35, August 30, 2011
Q: Some of our physicians are uncomfortable making addendums to the discharge summary to include...
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HIM-HIPAA Insider, Issue 34, August 23, 2011
Q: I am auditing records that include diagnosis code V66.7 (palliative care) for patients...
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HIM-HIPAA Insider, Issue 33, August 16, 2011
In ICD-10-CM, the diabetes mellitus codes are combination codes that include the type of...
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HIM-HIPAA Insider, Issue 33, August 16, 2011
It started with two courageous coders who knew the query process at Johns Hopkins Bayview Medical...
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HIM-HIPAA Insider, Issue 33, August 16, 2011
In the September issue of MRB, you’ll find articles on the following topics!
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HIM-HIPAA Insider, Issue 32, August 9, 2011
CMS released its final rule for the FY 2012 Inpatient Prospective Payment System integral to...
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HIM-HIPAA Insider, Issue 32, August 9, 2011
Q: A patient has chronic lower back pain from spinal stenosis. Should I code chronic lower back...
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CDI Strategies, Issue 16, August 4, 2011
CMS released the Inpatient Prospective Payment System (IPPS) Final Rule, Monday, Aug. 1, reducing a...
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HIM-HIPAA Insider, Issue 31, August 2, 2011
Coding and sequencing HIV can be challenging for coders, so it's no surprise that CMS identified it...
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HIM-HIPAA Insider, Issue 31, August 2, 2011
When it comes to ICD-10 education, a day late may mean you're more than a few dollars short. The...
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APCs Insider, Issue 30, July 29, 2011
Q: What’s the newest timeline for the transition to ICD-10-CM? We know the important role...
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HIM-HIPAA Insider, Issue 30, July 26, 2011
There’s no time like the present to conduct a coding and documentation assessment in...
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HIM-HIPAA Insider, Issue 30, July 26, 2011
Coding productivity will decrease at least initially with the switch to ICD-10-CM/PCS. Coders will...
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HIM-HIPAA Insider, Issue 30, July 26, 2011
Medical Records Briefing is conducting a benchmarking survey on ICD-10-CM/PCS implementation...
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HIM-HIPAA Insider, Issue 30, July 26, 2011
ICD-10. The biggest change to happen in health information management in more than 20 years is on...
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HIM-HIPAA Insider, Issue 29, July 19, 2011
The descriptions of diagnosis codes in ICD-10-CM may be very different than what coders have become...
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HIM-HIPAA Insider, Issue 29, July 19, 2011
In the August issue of MRB, you’ll find articles on the following articles and more.
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APCs Insider, Issue 28, July 15, 2011
A pathologic fracture is a broken bone caused by disease. ICD-10-CM expands code selection for this...
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HIM-HIPAA Insider, Issue 28, July 12, 2011
Q: Many of our orthopedic surgeons are documenting open reduction internal fixation (ORIF...
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HIM-HIPAA Insider, Issue 27, July 5, 2011
CMS released two special edition MLN articles last week. One article, SE1121, highlights some of...
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HIM-HIPAA Insider, Issue 26, June 28, 2011
Q: Some of our physicians have started documenting “aspiration without pneumonia.” When...
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CDI Strategies, Issue 13, June 23, 2011
While the bulk of discussion regarding how to ethically and responsibly submit queries to...
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HIM-HIPAA Insider, Issue 25, June 21, 2011
Q: How should I report patellofemoral chondrosis?
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HIM-HIPAA Insider, Issue 25, June 21, 2011
Not sure where to focus your RAC preparations these days? Look no further than the Program for...
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HIM-HIPAA Insider, Issue 25, June 21, 2011
In the July issue of MRB, you’ll find articles on the following articles and more!
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HIM-HIPAA Insider, Issue 24, June 14, 2011
CMS has released its fiscal year (FY) 2012 IPPS proposed rule, and coders need to note various...
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HIM-HIPAA Insider, Issue 22, May 31, 2011
CMS published the 2012 Inpatient Prospective Payment System (IPPS) proposed rule May 5 in the...
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HIM-HIPAA Insider, Issue 22, May 31, 2011
If you haven't already heard, HAC data is now publicly available on CMS' website, and as of April...
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HIM-HIPAA Insider, Issue 21, May 24, 2011
Q: In what instances would a dual system be necessary after ICD-10 takes effect?
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CDI Strategies, Issue 10, May 12, 2011
Hospitals can start experimenting with how new ICD-10-CM/PCS codes will translate to MS-DRGs since...
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HIM-HIPAA Insider, Issue 19, May 10, 2011
Inpatient coders may lack familiarity with the ¬inpatient-only procedure list because CMS...
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HIM-HIPAA Insider, Issue 18, May 3, 2011
Exactly how will ICD-10 affect MS-DRG assignment? As coders began learning the intricacies of...
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HIM-HIPAA Insider, Issue 17, April 26, 2011
The Centers for Medicare & Medicaid Services (CMS) plans limited changes to complications and...
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HIM-HIPAA Insider, Issue 16, April 19, 2011
The Association of Clinical Documentation Improvement Specialists (ACDIS) submitted comments March...
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HIM-HIPAA Insider, Issue 16, April 19, 2011
Q: The following procedures are performed in the radiology department: 51.01 (percutaneous...
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HIM-HIPAA Insider, Issue 16, April 19, 2011
In the May issue of MRB, you’ll find articles on the following topics and more!
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HIM-HIPAA Insider, Issue 15, April 12, 2011
Q: May I report Lewy body dementia (LBD) for a patient who has Parkinson’s disease with...
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HIM-HIPAA Insider, Issue 14, April 5, 2011
Q: I have been trying to determine whether a skin graft includes debridement. Based on what I have...
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HIM-HIPAA Insider, Issue 14, April 5, 2011
Physician queries are a predictable part of any coder's job. Coders may pose hundreds—even...
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HIM-HIPAA Insider, Issue 13, March 29, 2011
Be sure to take a look at Coding Clinic, 3rd and 4th quarters 2010, if you haven't already...
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HIM-HIPAA Insider, Issue 12, March 22, 2011
If you haven't already considered adopting computer-assisted coding (CAC) software, there's no time...
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HIM-HIPAA Insider, Issue 11, March 15, 2011
In the April issue of MRB, you’ll find articles on the following topics and more!
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HIM-HIPAA Insider, Issue 10, March 8, 2011
You’re coding a record, and the documentation of a patient’s stage III pressure ulcer...
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HIM-HIPAA Insider, Issue 8, February 22, 2011
Q. A patient presents for a follow-up visit after undergoing surgery for insertion of a rod. The...
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HIM-HIPAA Insider, Issue 7, February 15, 2011
A patient’s medical record could include a laundry list of diagnoses, but not all of these...
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HIM-HIPAA Insider, Issue 7, February 15, 2011
MRB recently conducted its 2010 coder productivity benchmarking report. (Stay tuned for the...
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HIM-HIPAA Insider, Issue 6, February 8, 2011
During the January 12 Hospital & Hospital Quality Open Door Forum, CMS representatives...
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HIM-HIPAA Insider, Issue 6, February 8, 2011
Q: What code should I report for a distortion product otoacoustic emissions (DPOAE) hearing test...
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Briefings on Coding Compliance Strategies, Issue 2, February 1, 2011
Learn about reporting secondary diagnoses, assigning the POA indicator, ICD-10 procedure...
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HIM-HIPAA Insider, Issue 5, February 1, 2011
The last thing you need is more to do, but when it comes to preparing your HIM department for EHR...
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HIM-HIPAA Insider, Issue 4, January 25, 2011
With an ever-growing list of RAC-targeted MS-DRGs and a host of coding compliance traps that...
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HIM-HIPAA Insider, Issue 4, January 25, 2011
HCPro is conducting in-depth research into coder productivity, and we value your input. The survey...
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HIM-HIPAA Insider, Issue 3, January 18, 2011
HCPro is conducting in-depth research into coder productivity, and we value your input. The survey...
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HIM-HIPAA Insider, Issue 2, January 11, 2011
HCPro is conducting in-depth research into coder productivity, and we value your input. The survey...
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HIM-HIPAA Insider, Issue 1, January 4, 2011
Briefings on Coding Compliance Strategies recently asked advisory board members about the best...
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HIM-HIPAA Insider, Issue 1, January 4, 2011
HCPro is conducting in-depth research into coder productivity, and we value your input. The survey...
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Briefings on Coding Compliance Strategies, Issue 1, January 1, 2011
Learn about coding issues to include in your 2011 audit plan, the benefits of online social...
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HIM-HIPAA Insider, Issue 51, December 28, 2010
HCPro is conducting in-depth research into coder productivity, and we value your input. The survey...
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HIM-HIPAA Insider, Issue 51, December 28, 2010
Q: Our physician provided an illegible diagnosis of malnutrition, and when we queried him regarding...
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HIM-HIPAA Insider, Issue 49, December 14, 2010
The language physicians use to create a patient’s clinical picture doesn’t always...
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CDI Strategies, Issue 25, December 9, 2010
Editor’s note: ACDIS recently published Coding Clinic update, a review of the most recent...
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HIM-HIPAA Insider, Issue 48, December 7, 2010
What does “x” represent in ICD-10? What seemed like a fairly straightforward question...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2010
Learn about the OIG work plan, acute kidney injursy, acute kidney failure, documentation and DNFB...
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HIM-HIPAA Insider, Issue 47, November 30, 2010
Q: What code should I report for a patient who presents to the ED for removal of a...
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HIM-HIPAA Insider, Issue 46, November 23, 2010
Now that RAC medical necessity audits are well under way, the focus has shifted from anticipatory...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2010
Learn about medical necessity audits, linking signs and symptoms with definitive conditions...
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CDI Strategies, Issue 22, October 28, 2010
At the September 15, 2010 ICD-9-CM Coordination & Maintenance Committee Meeting, the committee...
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JustCoding News: Inpatient, Issue 43, October 27, 2010
The decision to implement a partial code freeze for ICD-9-CM and ICD-10-CM/PCS may not have come as...
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HIM-HIPAA Insider, Issue 42, October 26, 2010
The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor...
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HIM-HIPAA Insider, Issue 41, October 19, 2010
Coders and other HIM staff members can do several things to ensure that they report excisional...
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CDI Strategies, Issue 21, October 14, 2010
A recent MLN Matters article has changed the official coding guidelines to define what...
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APCs Insider, Issue 41, October 8, 2010
For 2010, only one code captured the variety of congenital malformations (code V13.69). That code...
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HIM-HIPAA Insider, Issue 39, October 5, 2010
Every October 1, new ICD-9-CM codes take effect. Others are revised or deemed invalid. What do you...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2010
Learn about new and revised ICD-9-CM codes, identifying high-risk vulnerabilities in preparation...
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APCs Insider, Issue 40, October 1, 2010
The 2011 update for ICD-9-CM codes adds specificity to the codes for flu due to H1N1 by including a...
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CDI Strategies, Issue 20, September 30, 2010
Just because physicians may document the term excisional debridement it doesn’t mean that...
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HIM-HIPAA Insider, Issue 38, September 28, 2010
The FY 2011 inpatient prospective payment system final rule released July 30 includes the usual...
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HIM-HIPAA Insider, Issue 37, September 21, 2010
Editor’s note: In the previous issue of HIM Connection there was a typo in the fifth digit of...
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HIM-HIPAA Insider, Issue 37, September 21, 2010
During the ICD-9-CM Coordination and Maintenance Committee meeting September 15, the committee...
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HIM-HIPAA Insider, Issue 37, September 21, 2010
Last month I discussed the importance of queries related to sepsis versus UTI due to an indwelling...
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HIM-HIPAA Insider, Issue 37, September 21, 2010
In the October issue of MRB, you’ll find articles on the following topics and more!
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APCs Insider, Issue 38, September 17, 2010
Q: With the move to ICD-10-CM October 1, 2013, will the ICD-9-CM Coordination and Maintenance...
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APCs Insider, Issue 38, September 17, 2010
Venoplasty, the mechanical widening of a narrowed or obstructed vein, is commonly performed on...
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HIM-HIPAA Insider, Issue 36, September 14, 2010
Q: Which ICD-9-CM code denotes chronic scapholutynate ligament tear?
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HIM-HIPAA Insider, Issue 35, September 7, 2010
The following four case studies test your knowledge of correct principal diagnosis (PDX...
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Briefings on Coding Compliance Strategies, Issue 9, September 1, 2010
Learn about the FY 2011 IPPS final rule, the three-day payment rule, documentaiton and coding...
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HIM-HIPAA Insider, Issue 34, August 31, 2010
Q: Which code should I report for a patient who has dyspnea due to respiratory ciliary dyskinesia?
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HIM-HIPAA Insider, Issue 33, August 24, 2010
Editor’s note: HIM Connection reprinted the following Q&A in our August 17 issue...
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HIM-HIPAA Insider, Issue 13, August 24, 2010
On August 13 CMS issued Transmittal 756, Change Request 7024, to instruct providers on...
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HIM-HIPAA Insider, Issue 13, August 24, 2010
Q: Which code should I report for a diagnosis of pregnancy-elevated primary glucose tolerance test...
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CDI Strategies, Issue 17, August 19, 2010
Q: Should coders wait for the discharge summary before coding?
A: The answer is complicated...
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JustCoding News: Inpatient, Issue 33, August 18, 2010
Aesop’s fable of the ant and the grasshopper teaches us the value of planning ahead. While...
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HIM-HIPAA Insider, Issue 32, August 17, 2010
Q: An auditor recently reviewed a chart for an inpatient stay. The patient was admitted due to an...
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JustCoding News: Outpatient, Issue 12, August 11, 2010
Providers must understand the signature guidelines outlined in MedLearn Matters article 6698 and...
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HIM-HIPAA Insider, Issue 31, August 10, 2010
V codes play an important role in painting an accurate picture of an admission and facilitating...
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CDI Strategies, Issue 16, August 5, 2010
It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart...
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HIM-HIPAA Insider, Issue 30, August 3, 2010
On July 30, CMS issued the inpatient prospective payment system (IPPS) final rule to update...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010
We all know that coders are under pressure to capture all relevant conditions (including CCs and...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010
It shouldn’t come as a surprise that HealthDataInsights—the RAC for Region D—is...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010
V codes play an important role in painting an accurate picture of an admission and facilitating...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010
Learn about avoidable V code traps, why you shouldn't bypass coding rules for more money, why...
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HIM-HIPAA Insider, Issue 29, July 27, 2010
A coder may delay sending a claim for many reasons, but should a missing discharge summary be one...
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HIM-HIPAA Insider, Issue 26, July 6, 2010
Editor’s note: There was an error in the last sentence of the Q&A on coding for signs and...
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APCs Insider, Issue 27, July 2, 2010
Q: Is billing for venipuncture in association with a blood draw relative to laboratory tests...
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APCs Insider, Issue 27, July 2, 2010
The AMA’s CPT Assistant advises in its December 2004 issue not to report code 30930 (fracture...
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Briefings on APCs, Issue 7, July 1, 2010
Many HIM professionals, coders, and billers continue to struggle with correct coding for injections...
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Briefings on APCs, Issue 7, July 1, 2010
The technical nature of the CPT coding system can be very challenging for coding specialists, and...
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Briefings on APCs, Issue 7, July 1, 2010
As reimbursement for complex pain management continues to decrease, your coding must drive accurate...
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Briefings on APCs, Issue 7, July 1, 2010
A patient comes into your outpatient facility for a minor surgical procedure and the physician...
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Briefings on APCs, Issue 7, July 1, 2010
Inside:
Is that E/M service really above and beyond the norm?
Cure what ails your pain...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010
What should coders do when advice is misguided?
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010
Coders and quality managers who lament that CMS processes a total of only nine diagnosis and five...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010
Inpatient admissions requiring mechanical ventilation tend to be high-dollar cases, which is...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010
There are many reasons why a coder could delay sending a claim, but should a missing discharge...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010
Learn whether coders should delay sending a claim because of a missing discharge summary.
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HIM-HIPAA Insider, Issue 25, June 29, 2010
Q: My question pertains to inpatient admissions during which the conditions are resolved at the...
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CDI Strategies, Issue 13, June 24, 2010
The new, revised, and deleted ICD-9-CM codes, effective October 1, 2010, are now out. You can find...
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CDI Strategies, Issue 13, June 24, 2010
Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not...
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HIM-HIPAA Insider, Issue 24, June 22, 2010
The fiscal year (FY) 2011 IPPS proposed rule released April 19 addresses several highly debated...
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HIM-HIPAA Insider, Issue 23, June 15, 2010
Q: A patient who has had multiple previous abdominal surgeries now presents with a small bowel...
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Briefings on Coding Compliance Strategies, Issue 6, June 1, 2010
Name as many reasons why a cancer patient may develop anemia as you can. Is anemia in neoplastic...
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APC Payment Insider, Issue 6, June 1, 2010
In this month's coding Q&A, our experts answer questions about how to report Unna boot...
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Briefings on Coding Compliance Strategies, Issue 6, June 1, 2010
The fiscal year (FY) 2011 IPPS proposed rule released April 19 addresses several highly debated...
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APC Payment Insider, Issue 6, June 1, 2010
The sheer number of modifiers can cause plenty of confusion for HIM staff. The rules about which...
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Briefings on Coding Compliance Strategies, Issue 6, June 1, 2010
Learn about the three-day payment rule, FY 2011 IPPS Proposed Rule, discharge disposition codes...
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APC Answer Letter, Issue 6, June 1, 2010
Learn about coding scenarios involving the ED, injections and infusions, observation, orthopedics...
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Briefings on APCs, Issue 6, June 1, 2010
CMS added 10 new HCPCS codes and six new APCs to the I/OCE as part of Transmittal R1927CP’s...
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HIM-HIPAA Insider, Issue 21, June 1, 2010
Motivation HIM department staff members is important because it affects performance. It is the...
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HIM-HIPAA Insider, Issue 21, June 1, 2010
Many reasons justify establishing an internal auditing program. An organization may have a...
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APCs Insider, Issue 21, May 21, 2010
In one-time notification R617OTN, CMS notes that organizations can report reasonable and necessary...
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HIM-HIPAA Insider, Issue 19, May 18, 2010
MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC...
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HIM-HIPAA Insider, Issue 18, May 11, 2010
On April 29, AHIMA issued a practice brief, “Guidance for Clinical Documentation Improvement...
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HIM-HIPAA Insider, Issue 18, May 11, 2010
Aside from being a catchy acronym, PEPPER (Program for Evaluating Payment Patterns Electronic...
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HIM Briefings, Issue 5, May 1, 2010
The many CPT and HCPCS modifiers can leave coders dazed and confused when it comes to appropriately...
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HIM Briefings, Issue 5, May 1, 2010
This month's issue includes an article on the EHR certification proposed rule, as well as advice...
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APCs Insider, Issue 18, April 30, 2010
Q: A patient is seen in the ED and based on the findings is sent to the OR for a procedure. May a...
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CDI Strategies, Issue 9, April 29, 2010
Q: Our CDI specialists tend to ask questions that provide the physician with multiple options to...
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HIM-HIPAA Insider, Issue 16, April 27, 2010
In the fiscal year (FY) 2011 Inpatient Prospective Payment System (IPPS) proposed rule, CMS...
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HIM-HIPAA Insider, Issue 16, April 27, 2010
Q. If an outpatient has a service on September 10, September 20, October 1, and October 15, 2013...
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CDI Strategies, Issue 8, April 15, 2010
Effective January 1, 2011, CMS is expanding the number of ICD-9 diagnosis and procedure codes...
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HIM-HIPAA Insider, Issue 14, April 13, 2010
RACs already are validating countless MS-DRGs in hospitals nationwide, and the number of eligible...
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HIM-HIPAA Insider, Issue 13, April 6, 2010
Coding managers often conduct internal audits, but other alternatives exist. Some organizations...
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HIM-HIPAA Insider, Issue 13, April 6, 2010
The statistic is striking. Nearly 18% of admissions result in readmissions within 30 days of...
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HIM Briefings, Issue 4, April 1, 2010
This month's issue includes an article on HIMs role in surviving recovery audit contractor (RAC...
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HIM Briefings, Issue 4, April 1, 2010
As recovery audit contractors (RAC) begin to roll out complex reviews and request medical record...
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HIM Briefings, Issue 4, April 1, 2010
This month's training tool is a quiz HIM directors can use to test staff members' knowledge of E...
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HIM-HIPAA Insider, Issue 12, March 30, 2010
Was it present on admission (POA) or did it develop during the patient’s stay? These...
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APCs Insider, Issue 12, March 26, 2010
In 2003 HCPro, Inc., Nimitt Consulting, Inc., and 3M Health Information Systems joined forces to...
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HIM-HIPAA Insider, Issue 11, March 23, 2010
Q: How should I code capillary leak syndrome secondary to biochemotherapy? Can you provide coding...
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HIM-HIPAA Insider, Issue 11, March 23, 2010
Memorial Hermann Healthcare System (MHHS) in Houston includes nine acute care hospitals, one...
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APCs Insider, Issue 11, March 20, 2010
Q: Does severity of illness affect APC reimbursement under the hospital OPPS as it does under the...
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HIM-HIPAA Insider, Issue 10, March 16, 2010
Just because your coding compliance program is in place doesn’t mean it’s doing its job...
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HIM-HIPAA Insider, Issue 10, March 16, 2010
Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...
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HIM-HIPAA Insider, Issue 10, March 16, 2010
In the April issue of MRB, you’ll find the following articles, and more!
EHR beat...
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HIM-HIPAA Insider, Issue 9, March 9, 2010
Q: What code should I use to report for Delleman syndrome?
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HIM-HIPAA Insider, Issue 8, March 2, 2010
CMS is taking a closer look at admissions to inpatient rehabilitation facilities (IRF) thanks to...
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HIM Briefings, Issue 3, March 1, 2010
Sarah Bush Lincoln Health Center in Mattoon, IL developed a productivity incentive plan for their...
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HIM Briefings, Issue 3, March 1, 2010
This month's issue includes an article on EHR meaningful use standards and what hospitals should do...
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Briefings on Coding Compliance Strategies, Issue 3, March 1, 2010
Coders don't need a RAC audit to tell them that reporting inpatient wound care is particularly...
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Briefings on Coding Compliance Strategies, Issue 3, March 1, 2010
Dust off a medical terminology book and start reviewing anatomy and physiology. This may be the...
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Briefings on Coding Compliance Strategies, Issue 3, March 1, 2010
In this issue, we detail how to ensure compliance and date accuracy by auditing...
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HIM-HIPAA Insider, Issue 7, February 23, 2010
Q: How should I code gastric lap band erosion with infection? The ICD-9-CM Manual instructs coders...
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CDI Strategies, Issue 4, February 18, 2010
Within the Alphabetic Index of ICD-9-CM is a Neoplasm table that assists coders in assigning...
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CDI Strategies, Issue 4, February 18, 2010
by Robert S. Gold, MD
Every so often, I come across some coding issues that recall other...
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HIM-HIPAA Insider, Issue 6, February 16, 2010
CDI programs can greatly enhance documentation, but what happens when a hospital's risk-adjusted...
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HIM-HIPAA Insider, Issue 5, February 9, 2010
HIM directors can evaluate their hospital’s potential risk for overcoding and unnecessary...
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HIM-HIPAA Insider, Issue 5, February 9, 2010
As RACs begin to roll out complex reviews and request medical record documentation, compliant...
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HIM-HIPAA Insider, Issue 5, February 9, 2010
In the March issue of MRB, you’ll find the following articles, and more!
EHR beat...
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APCs Insider, Issue 3, January 22, 2010
The AMA has significantly changed musculoskeletal system codes pertaining to soft tissue and bone...
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HIM-HIPAA Insider, Issue 3, January 19, 2010
Coders may often wish they could read physicians’ minds when clinical documentation is...
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HIM-HIPAA Insider, Issue 2, January 12, 2010
Chronic kidney disease (CKD) affects 26 million Americans, according to the National Kidney...
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HIM-HIPAA Insider, Issue 1, January 5, 2010
Q: How should we code a diagnosis of influenza type A? Should we report ICD-9-CM code 487.1?
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HIM Briefings, Issue 1, January 1, 2010
Learn to take advantage of opportunities the conversion to ICD-10 will present, and meet the...
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HIM Briefings, Issue 1, January 1, 2010
This month’s 16-page expanded issue includes our four-page quarterly insert that focuses on...
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HIM-HIPAA Insider, Issue 52, December 29, 2009
Q: How should we code H1N1?
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HIM-HIPAA Insider, Issue 52, December 29, 2009
You may think you have plenty of time to get ready for the conversion from ICD-9-CM to...
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HIM-HIPAA Insider, Issue 52, December 29, 2009
Editor’s note: We regret the error in last week’s Q&A on coding anemia due to...
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HIM-HIPAA Insider, Issue 51, December 22, 2009
Q: Can you explain the new ICD-9 guidelines for coding anemia due to antineoplastic chemotherapy...
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APCs Insider, Issue 48, December 11, 2009
Physicians sometimes decide to perform surgery in stages. These situations involve a planned return...
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HIM-HIPAA Insider, Issue 49, December 8, 2009
Connolly Healthcare has announced the first issues approved for complex RAC review, so providers in...
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HIM-HIPAA Insider, Issue 49, December 8, 2009
We’ve all read or seen news reports about horrific accidents that occur when people send text...
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APCs Insider, Issue 47, December 4, 2009
Procedural modifiers can provide a wealth of information to further describe services provided...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2009
Inside:
New E codes require detailed documentation
OIG focuses on hot-button issues in 2010 Work...
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HIM-HIPAA Insider, Issue 48, December 1, 2009
Q. A patient presents with breast pain and a physician diagnoses her with a diabetic abscess of the...
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CDI Strategies, Issue 24, November 26, 2009
The American Hospital Association’s Coding Clinic for ICD-9-CM contains official advice from...
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HIM-HIPAA Insider, Issue 47, November 24, 2009
Q. We have been told that coders are not allowed to code from nurses’ notes. Can anyone tell...
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APCs Insider, Issue 46, November 20, 2009
When coding OB/GYN procedures, remember that ICD-9 codes 630–679 in Chapter 11 (Complications...
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APCs Insider, Issue 46, November 20, 2009
Q: Can our hospital code and bill telemetry daily monitoring in conjunction with a chest pain...
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HIM-HIPAA Insider, Issue 46, November 17, 2009
Clinical knowledge is an essential element for capturing severity and MS-DRG assignment, according...
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APCs Insider, Issue 45, November 13, 2009
Q: A surgeon excises a lesion on a patient’s back, but fails to document its size or the...
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APCs Insider, Issue 45, November 13, 2009
When considering ways to reduce revenue loss at your facility, don’t look just for big-dollar...
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CDI Strategies, Issue 23, November 12, 2009
Implementation of ICD-10-CM/PCS remains three years away. But it is not too soon to find out more...
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APCs Insider, 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 Insider, Issue 43, October 30, 2009
Q. A patient who has undergone a kidney transplant and has plasmapheresis intravenously receives IV...
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APCs Insider, 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 Insider, 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 Insider, 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 Insider, 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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APCs Insider, 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 Insider, Issue 40, October 9, 2009
Coding a screening colonoscopy should be relatively straightforward. However, the interpretation of...
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APCs Insider, Issue 39, October 2, 2009
How can your facility ensure compliance with the physician supervision requirements for diagnostic...
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HIM Briefings, 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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HIM Briefings, 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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HIM-HIPAA Insider, 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 Insider, Issue 38, September 25, 2009
CMS created medically unlikely edits (MUEs) to ensure that providers don’t report excessive...
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HIM-HIPAA Insider, Issue 38, September 22, 2009
Follow these steps when researching an ICD-9-CM coding question.
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APCs Insider, 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 Insider, 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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HIM-HIPAA Insider, Issue 37, September 15, 2009
QUESTION: A patient undergoes outpatient surgery and is subsequently admitted due to acute blood...
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HIM-HIPAA Insider, 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-HIPAA Insider, Issue 36, September 8, 2009
The following ICD-9-CM codes denote acute respiratory failure (ARF):
518.81, ARF...
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APCs Insider, 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 Insider, 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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HIM Briefings, Issue 9, September 1, 2009
Just because coders have been reporting the present-on-admission (POA) indicator for nearly...
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HIM Briefings, Issue 9, September 1, 2009
The final phase of the national Recovery Audit Contractor (RAC) rollout began last month, and...
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HIM Briefings, 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 Insider, 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 Insider, 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 Insider, 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 Insider, 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-HIPAA Insider, 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 Insider, Issue 29, July 31, 2009
Q: What are the guidelines for physician supervision for physical therapy/occupational therapy and...
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APCs Insider, 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 Insider, Issue 28, July 24, 2009
Providers must ensure the medical necessity of procedures they perform. To reduce revenue loss...
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HIM-HIPAA Insider, 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 Insider, 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 Insider, Issue 28, July 17, 2009
When setting productivity goals, don’t forget to include non-coding responsibilities when...
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APCs Insider, 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 Insider, 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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HIM Briefings, Issue 7, July 1, 2009
This month’s expanded issue includes our 4-page quarterly insert about electronic health...
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HIM-HIPAA Insider, 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 Insider, Issue 25, June 26, 2009
Establishing coding productivity standards is a necessary and challenging aspect of managing an...
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APCs Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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 Insider, 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-HIPAA Insider, Issue 19, May 12, 2009
During the three-year RAC demonstration project, payment for several inpatient debridement...
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HIM-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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 Insider, 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 Insider, Issue 16, April 17, 2009
Christina Benjamin, MA, RHIA, CCS, CCS-P, presents several compliance traps that coders should...
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HIM-HIPAA Insider, Issue 15, April 14, 2009
Q: How should I code Shone’s syndrome with subaortic stenosis and coarctation...
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APCs Insider, 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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HIM Briefings, 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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HIM Briefings, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, Issue 10, March 10, 2009
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I have...
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HIM-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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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HIM Briefings, 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-HIPAA Insider, 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-HIPAA Insider, 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 Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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-HIPAA Insider, 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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HIM Briefings, 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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HIM-HIPAA Insider, 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 Insider, 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 Insider, Issue 21, May 23, 2008
Do CMS and the Office of Inspector General (OIG) consider the intentional unbundling of codes to be...
