Blog

The Privacy Mindset with Third Party Record Reviewers

As HIM professionals we expect others we encounter in our personal and professional lives to share our same high level of commitment and dedication to our professional career.  We also expect that from our team at the office, including external third-party auditors and record reviewers. External reviewers must share your organization’s commitment to protecting patient […]

Documentation Management in Support of the Electronic Health Record

Electronic Health Records (EHRs) continue to change the landscape of healthcare.  Although the technology and workflow of electronic documentation seems to make paper documents obsolete, a hybrid medical record exists in many healthcare settings.  Organizations need to determine which paper documents to include with the EHR, access to that documentation and when to include that […]

ROOT OPERATION DILEMMA: CONTROL vs. DESTRUCTION

A 67 year old male who had been experiencing frequent melena presents to the hospital for work up and treatment. An esophagogastoduodenoscopy (EGD) was performed with the finding of a medium sized angioectasia (AVM) seen in the mid jejunum which was thought to be the source of the bleeding.  As a result, the following procedure […]

2017 HIM Challenges in Data Integrity, Revenue Integrity & Denial Prevention

As we evolve in 2017, the challenges have settled for Health Information Management (HIM) post implementation of ICD-10.  Clinical Documentation Improvement (CDI) programs and Computer Assisted Coding (CAC) continue to bring value to data integrity.  Larger healthcare systems continue to centralize revenue services while their auditing efforts have improved with technology and resources to conduct […]

Insight into Coding Diabetic Eye Conditions

There are a variety of conditions that can impact individuals with diabetes.  People with diabetes are at greater risk for developing eye problems that could lead to blindness or serious deterioration of sight.  Age also plays a role in the progression of eye disease in individuals with diabetes.  Cataracts, glaucoma and retinopathy are the most […]

Bringing Awareness to Kidney Cancer

March is kidney cancer awareness month. So what is the role of our kidneys? The kidneys are bean shaped organs located on each side of the mid back. The kidneys are retroperitoneal organs that lie behind the peritoneum that lines the abdominal cavity. The main function of the kidneys are to filter the blood and […]

The Evolving Landscape for Health Information Management

What are the most significant challenges for Health Information Management (HIM) departments?  One of the challenges in 2016 includes the disappearing HIM department; physical downsizing as well as workforce downsizing.  With the workforce downsizing we see technology impacting traditional roles for transcriptionists, documentation specialists and coders. HIM professionals need to manage business, clinical and information […]

The Principal Diagnosis Effect

A sixty-nine year old male is admitted with severe abdominal pain and is found to have diverticulitis. He undergoes an open sigmoidectomy with pathology report revealing a peridiverticular abscess. The patient has other secondary conditions such as COPD, hypertension, Stage II chronic kidney disease, hypothyroidism and GERD. The coder codes K57.32 for the diverticulitis figuring […]

ICD-10-PCS Coding For Venous Access Lines and Catheters

One challenging coding area with the ICD-10 transition is the coding of venous and arterial lines and catheters. This article aims to provide greater clarity with regard to procedure coding tips for coding of venous catheters. Types of Lines: Central Lines– (CVC)- Central Venous Catheter or central lines are inserted into large veins, typically the […]

Top 7 Ways to Reduce Coding Audit Anxiety

Simply mentioning a coding audit sends shivers up a coder’s spine. Coders acknowledge and support the need for audits; however the mere thought of an audit presents a level of anxiety with thoughts of their coding quality being scrutinized, as they continually strive to balance quality and productivity. Here are the Top 7 Ways to […]