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 […]

Internal Coding Audit Best Practices

Now that we are six months into the new ICD-10 classification system, it’s important to determine whether coders have incorporated all their pre-ICD-10 education and are applying it appropriately. One critical way to provide assurances regarding coding accuracy and compliance is to perform regular, ongoing internal auditing. Additional benefits include reducing payer denials, improving clinical […]

Top 10 Best Practices for Outsourcing Coding Services

Medical Coding Outsourcing We live in a constantly expanding environment for outsourcing services, and the coding and health information industry is no stranger to outsourcing. Whether it is full department outsourcing, hand-picked silos of outsourcing for specific hard to fill or hard to train services or outsourcing to augment your current staff, utilizing contract labor […]

Have You Performed A Case Mix Index Check-up Post ICD-10 Go Live?

Organizations did a fantastic job preparing for ICD-10. However, now that the dust has settled, we need to drill down into the data. Specifically, case mix index (CMI). With more than two months’ worth of ICD-10 data, it’s easier to make comparisons and draw logical conclusions. If coding and/or documentation problems exist, they’re likely starting […]

7 Questions For Vendor Relationships In ICD-10

  The following Latin proverb seems to be particularly relevant in light of ICD-10: “Times change, and we change with them.” By now, ICD-10 has spurred many changes in technology, templates, coding, documentation, and more. However, to be truly successful, organizations must look beyond their HIM internal processes and ask this question: Must the organization’s […]

Think “Reciprocity” To Combat Coder And CDI Turf Wars In ICD-10

Unfortunately, the silos between coders and CDI professionals still exist in many hospitals. In some organizations, the walls may be slowly coming down, but in others, the silos stand tall. The irony is these two roles actually have more in common than they might realize. With communication and collaboration, coders and CDI specialists actually have […]

Dissect The Operative Note With CDI Specialists To Ensure ICD-10 Readiness

As the ICD-10-CM/PCS deadline approaches, it behooves HIM professionals to remind CDI specialists and physicians about important components of a thoroughly-documented operative note. Such a note supports accurate code assignment for reimbursement, and it also provides an accurate record for continuity of care as well as quality initiatives and legal and research purposes. Most Important […]