Back to Basics – Section III. Reporting Additional Diagnoses

One of the more prominent guidelines found in the ICD-10-CM Official Guidelines for Coding and Reporting is Section III. Reporting Additional Diagnoses but it isn’t always applied appropriately. The guideline states: For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or […]

Matters of the Heart: FY2018 Code Changes Impacting Heart Failure

Heart failure is a serious medical condition that an estimated 5.7 million Americans are diagnosed with.  This is a condition that occurs when the heart muscle cannot pump enough blood and oxygen needed by the body to support the other organs.  According to the Center for Disease Control, the national estimated cost to treat heart […]

Rocky Roads: Patient Right of Access/ Compliant and Patient Centered ROI

With the OCR issued FAQs on patient HIPAA rights to access PHI being out now for over a year, I know many of you are feeling more confident than ever on how to handle these pesky third party requestors who demand records under the HITECH Act. Or perhaps you are just as challenged as the […]

What’s the Skinny on Obesity and BMI Coding??

Overweight and obesity are increasingly common conditions in the U.S. They are caused by the increase in the size and amount of fat cells in the body. Doctors measure body mass index (BMI) and waist circumference to screen and diagnose overweight and obesity. The National Institute of Health has deemed obesity as a serious medical […]

What do all those radiation treatment modality codes mean?

The regional treatment modality fields for radiation therapy can be tricky when deciding on the appropriate code to assign. The regional treatment modality field is used to record the dominant modality of radiation therapy used to deliver the most clinically significant regional dose to the primary volume of interest during the first course of treatment. […]

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 […]


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 […]