Beruflich Dokumente
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Life
After
ICD-10
HOW THE HEALTHCARE WORLD WILL CHANGE
AFTER ICD-10S IMPLEMENTATION
Welcome
TO THE DIGITAL EDITION OF THE
JOURNAL AHIMA
OF
ICD-10 in Action
REMEDIATING ICD-10
KNOWLEDGE LOSS
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10
Presidents Message
The Final Push to ICD-10 Implementation
12
Bulletin Board
pg. 34
Coders will soon be expected to do some heavy lifting with ICD-10.
Features
28
By Barbara Hinkle-Azzara, RHIA, and Kim Carr, RHIT, CCS, CDIP, CCDS
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38
42
16
21
Inside Look
Paving the Final Steps to ICD-10
72
Calendar
73
Keep Informed
74
Volunteer Leaders
77
96
Addendum
Voices from the ICD-10 Zeitgeist
46
50
48
Standards Strategies
Achieving Health Information
Systems Interoperability
54
Coding Notes
Quizzes
64
32
68
41
Practice Brief
56
71
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http://journal.ahima.org
Solving Unique ICD-10
Concerns for Physician
Practice and Outpatient
Coders How are physician
practice and outpatient coders
preparing for ICD-10? How
do their concerns and areas
of focus differ from those of
inpatient coders?
Data Revolution
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AHIMA CEO
EDITORIAL DIRECTOR
EDITOR-IN-CHIEF
ASSISTANT EDITOR/
ADVERTISING COORDINATOR Sarah Sheber
ASSOCIATE EDITOR
Mary Butler
CONTRIBUTING EDITORS
Sue Bowman, MJ, RHIA, CCS, FAHIMA
Patricia Buttner, RHIA, CDIP, CCS
`
Angie Comfort, RHIA, CDIP, CCS
Crystal Clack, MS, RHIA, CCS
Julie Dooling, RHIA, CHDA
Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, CDIP,
FAHIMA
Katherine Downing, MA, RHIA, CHP, PMP
Deborah Green, MBA, RHIA
Jewelle Hicks
Lesley Kadlec, MA, RHIA
Carol Maimone, RHIT, CCS
Paula Mauro
Anna Orlova, PhD
Kim Osborne, RHIA, PMP
Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA
Angela Rose, MHA, RHIA, CHPS, FAHIMA
Donna Rugg, RHIT, CCS
Maria Ward, MEd, RHIT, CCS-P
Diana Warner, MS, RHIA, CHPS, FAHIMA
Lydia Washington, MS, RHIA
Lou Ann Wiedemann, MS, RHIA, CHDA, CDIP, CPEHR,
FAHIMA
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JOURNAL OF AHIMA MISSION
The Journal of AHIMA serves as a professional development tool
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Furthermore, the Journal contributes to the field by publishing work
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hospital exchange, stated a blog coauthored by Erica Galvez, ONCs interoperability and exchange portfolio
manager, and Matthew Swain, program analyst at ONCs office of planning, evaluation, and analysis. Prior
research studies suggested that this
was due to competition and a weak
business model.
While the increase in exchange is
encouraging, major issues still stand
in the way of industry-wide interoperability of health information, DeSalvo said during a speech at the
Healthcare Information and Management Systems Societys annual
conference in April. DeSalvo said
there are three areas that need to be
addressed as quickly as possible to
foster interoperability: Establishing
standards, including APIs; achieving
clarity on data privacy and security
to foster trust; and practically tying
incentives to the use of electronic
health records, according to an article in Health Data Management.
Saudi Arabia
Launches National
HIM Association
The country of Saudi Arabia has established a national health information management (HIM) association that will work
to improve the clinical documentation
and quality of medical records used by
the countrys healthcare professionals.
The Saudi Health Information Management Association (SHIMA) was officially established in April, with Hussein
Albishi, an early advocate for an HIM
association, named SHIMAs first president. Albishi serves as the HIM and
clinical coding specialist and advisor to
the vice minister of health at the Saudi
Arabia Ministry of Health.
The International Federation of Health
Information Management Associations
(IFHIMA), the global organization representing national HIM associations
around the world, supported the establishment of SHIMA by writing a letter
of supports to the Saudi Arabian Ministry of Health. SHIMA is expected to
become an IFHIMA member soon.
Percent of Hospitals
70%
60%
50%
40%
30%
20%
10%
0
9.4%
12.2%
15.6%
27.6%
44.4%
59.4%
75.5%
2008
2009
2010
2011
2012
2013
2014
Source: Charles, Dustin et al. Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care
Hospitals: 2008-2014. ONC Data Brief, no. 23, April 2015.
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our physician utilization data, as well as our county-level geographic variation data and chronic condition data. All three of
those releases include Medicare-specific data.
JAHIMA: What other initiatives do you plan to work on
in 2015?
Brennan: We have a lot of new data sources that we are trying
to integrate and understand. Marketplace data is an excellent
example. We are into the second year of the health insurance
marketplaces, so there is a lot more data to analyze, and we
can begin to look at year-on-year differences and trends.
We also plan to get involved in greater analysis of Medicare
Advantage plan encounter data, which was recently submitted to the agency for the first time.
JAHIMA: What do you see as some of the major challenges in your new role?
Brennan: They are exciting and fun challenges. Changing
the culture around data at the agency is very important. I
often say that data transparency begins at home, and we are
working hard to ensure that all folks at the agency that need
data can get it in as seamless a manner as possible.
The other big challenge is continuing to push the envelope
on the development of internal analytics or advanced external
information products. We have had a lot of success in this area
with predictive modeling to identify fraud as well as real-time
analysis of claims data to track readmissions in near-real time.
But, obviously, there is much more that we can do in that area.
Finally, one of the big challenges that we are excited to confront is better integrating and coordinating of data from multiple sources into a single more cohesive framework where
we can use the best components of different datasets to develop insights. Just to clarifyI am not necessarily calling for
all of the data to be held in one giant database, but rather for
us to be able to combine or use data from multiple different
sources in a cohesive and collaborative way.
The best example is better linking the vast quantities of
quality data that we have with the payment and claims utilization data. We also should begin to link the data we have
from the HITECH [Health Information Technology for Economic and Clinical Health Act] payment incentive program to
traditional administrative claims.
In the longer term, the challenge that everybody faces is
better integrating clinical and administrative data for analytical purposes.
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put extra cash in the payroll coffers. She fears that the loss of
coder productivity could hurt providers bottom line. But she
emphasizes that practice makes perfect.
I think that anybody and everybody should be chomping
at the bit to do end-to-end testing. The end-to-end testing can
bring up many more problems than just coding problems. It
can help identify IT questions and demographics and claim
edits. The more you practice, the better off you are when you
go-live, Coplan-Gould says.
Come October 1, coders and HIM departments will need to
be prepared to defend their code assignments for accurate and
timely reimbursement. Danielle Reno, MHA, CHC, CCS, CCSP, ICD-10 director at Sutter Health, says the business validation
of report remediation is absolutely critical to ensure providers
have a seamless transition after ICD-10 go-live.
At Sutter, Reno says her team has taken reports to quality review
specialists, nurses, and HIM departments for review and asked,
Are these reports what you think you need to see in an ICD-10
world? and Can you help us understand if these are correct?
If you dont get that business validation, the meaning behind the
initial reporting might be changed, Reno says. There are so many
new codes in ICD-10 that when you map the ICD-9 codes to the
ICD-10 codes, it could be a one-too-many situation where you have
to have someone that really knows the code set or an HIM resource
that can validate a code set to be included in that new reporting.
Even among facilities that have been diligent in their preparations for ICD-10, close auditing of ICD-9 coding has revealed
weaknesses that could show up in ICD-10 coding as well. Unless
these weaknesses are addressed in training, they could persist
and cause problems after the transition. Foley says that conditions such as sepsis and procedures like spinal fusions are commonly coded improperly. Those topics are difficult in ICD-9,
they continue to be difficult in ICD-10. But you start to recognize some of the weaknesses in the coding staff regardless of the
coding system, Foley explains. Whether its understanding the
clinical process of sepsis, or whether its understanding whats
actually done during a fusion procedure and all the different
ways they can be done, you need an understanding.
April 2014
The Protecting
Access to Medicare
Act of 2014 is
enacted,
which contains a
provision prohibiting the HHS
Secretary from
adopting the
ICD-10 code prior
to October 1, 2015.
January 2015
CMS begins end to
end testing of ICD-10.
2012
Facing backlash from
physicians groups, HHS
publishes a final rule that
delays the compliance
date for ICD-10-CM/PCS
from October 1, 2013 to
October 1, 2014.
2007
HHS publishes a notice of
proposed rulemaking for the
replacement of ICD-9-CM
by ICD-10-CM and ICD-10PCS on October 1, 2011.
2010
CMS institutes a code freeze
in preparation for ICD-10.
1990
The National Committee
on Vital and Health
Statistics (NCVHS) sends
the Secretary of the US
Department of Health and
Human Services (HHS) a
letter saying ICD-9-CM
could stress the quality
of the healthcare system
to the point where quality
care could become
compromised.
October 1, 2015
ICD-10-CM/PCS
implementation deadline.
2009
HHS publishes a final rule
for adoption of ICD-10CM/PCS, pushing the
implementation deadline
to October 1, 2013.
1993
ICD-10 is released by the
World Health Organization.
1995-1996
The Healthcare Financing
Administration contracts with
3M to develop the procedure
classification system to
replace Volume 3 of ICD9-CM (hospital inpatient
procedures), known as ICD10-PCS. The new procedure
classification adheres to the
criteria established by NCVHS
for a procedure classification
system in 1993.
2006
Subcommittee on Health of
House Ways and Means Committee holds hearing on the adoption
of ICD-10-CM and ICD-10-PCS.
1999
ICD-10 is implemented in the
US for mortality reporting.
1998
The Centers for Medicare and
Medicaid Services (CMS) posts the
ICD-10-PCS coding system, training
material, and crosswalk to ICD-9-CM
procedure codes on its website.
1979
ICD-9-CM is implemented
in the United States.
Journal of AHIMA June 15/25
I think another piece in the short term [is] that it might actually level the playing field for newer coders because you just
think about it, Kersten says. If no one has much experience on
ICD-10 coding then maybe, if we need new coders, hospitals
will be a little more open to hiring coders with less experience.
Results of preliminary provider end-to-end testing with the
Centers for Medicare and Medicaid Services (CMS) is one encouraging spot for those concerned about denial rates. According to the results from one week of testing with CMS that ran
January 26, 2015 to February 3, 2015, 81 percent of test claims
submitted by providers were accepted. Whats more, the leading
reason for rejected claims was non-ICD-10-related errors, such
as use of an incorrect National Provider Identifier, an incorrect
health insurance claim number, or dates of service outside the
range valid for testing. Nearly 660 providers participated, submitting about 15,000 test claims.
By its very nature, coding in ICD-10 requires an elevated clinical understanding of disease processes, the clinical factors behind a diagnosis, and an ability to read and understand lab values and diagnostic reports. Maccariella-Hafey says the benefits
of a more sophisticated coding workforce will be evident well
before the five years post-implementation mark.
I can see that coders will be even more educated in the clinical aspects of medicine and surgery. So coders are going to
become more knowledgeable and the coding will be more accurate because there wont be problem areas that need to be addressed through Coding Clinics, she says.
Sutter Healths Reno strongly believes that the availability of
more precise, accurate data from ICD-10 will benefit the healthcare system within the first five years after implementation.
I absolutely believe were going to have better patient care. I
also believe that our payment and reimbursement systems are
going to change. The data that government and commercial
payers have right now doesnt really indicate how good or bad
patients are at taking care of themselvesor the quality of care
theyre receiving from practitioners, Reno says. I believe that
in five years from nowand I think its going to be even faster
than thatwere probably going to be able to monitor patients
investments in their own health and monitor the quality of care
from individuals to providers.
Rhonda Butler, CCS, CCS-P, senior clinical research analyst
at 3M Health Information Systems, has an optimistic shortterm outlook with regard to ICD-10 implementation. Many
have speculated that some hospitals wont make the transition
at all, and it is true that some hospitals and physician offices
have put off ICD-10 training and other transition planning until the last minute. But that doesnt mean October 1 is going to
spell disaster, Butler says.
I dont subscribe to the gloom and doom predictions of dire
impact on small hospitals, at least as far as coding goes, she
says. By definition, small hospitals have less complex cases to
code, and their coding tends to be the common scenarios for
which there is plenty of accessible coding advice and resources.
I believe that coders everywhere are rising to the challenge.
HIM departments need to be proactive in making sure their
vendors are ready before the transition, but tweaking will con26/Journal of AHIMA June 15
some of healthcares biggest challenges. John Hughes, MD, professor of medicine at Yale School of Medicine, has been using
ICD-9 data for 15 years for his research. Dr. Hughes research
focuses on patient classification systems with a specific interest
in readmission complications and predicting resource use.
Dr. Hughes says he started to become frustrated with the lack of
precision in ICD-9 about 10 years ago when he and his colleagues
were investigating causes of hospital readmissions but had to
create workarounds to identify various causes of complications.
We had to come up with combinations of diagnosis codes,
which might be vague, and then procedure codes to find what
the complication was or the severity of the complication. Very
often the procedure codes werent that precise either, Dr.
Hughes says. So that was just the way of the world and we dealt
with it. But, there was always that lack of precision.
A common cause of hospital readmissions is post-surgical complications. But for researchers like Dr. Hughes, its difficult to find
patterns in surgical complications when the codes arent specific
enough to capture an error with a technique or instrument.
To demonstrate the inadequacy, Dr. Hughes uses the hypothetical scenario in which a patient sustains a puncture wound
that severed the left femoral artery. The patient undergoes surgery where the damaged portion of the artery was replaced with
a synthetic graft, which is coded in ICD-9 as resection with replacement without any mention of the type of replacement or
which side of the body the procedure was done. This lack of detail is problematic when a complication such as bleeding at the
graft site occurs, and the ensuing surgical fix is coded in ICD-9
as mechanical complication of other vascular device or graft
with a procedure code of revision of vascular procedure.
When this event is coded in ICD-10 a researcher can learn
that the complication was a hemorrhage, know exactly where
it happened, and that the revision involved a procedure to resuture the graft using an open approach.
When we have new procedures, inevitably there are going to be
complications. Its very useful to be able to look to see what types
of complications are happening in relation to procedures and
to focus on possible problems with the procedures. A lot of that
stuff you cant do prospectively. Its only after people have been
performing the surgeries in the real world that you see these patterns emerge where there seems to be complications, Dr. Hughes
says.If theres patterns, you may be able to say This is a problem
with this particular technique or this particular procedure and we
need to examine why thats happening and try to fix it.
He notes that using ICD-10 for his and others research wont
start a revolution, just a much more sensible and effective way
to perform the task already being done.
Like a homeowner, the repairs and renovations (updates and
corrections) will never fully be done in ICD-10-CM/PCS. But
with the bulk of the implementation heavy lifting done in the first
couple years, healthcare professionals will be set up for years and
years of use of a new code set that provides more specificity, accuracy, and data that leads to a better quality of life for patients.
Smaller facilities typically lack funding for more than one project
at a time, and thus focused on immediate concerns during the past
year. Resources went first to electronic health record (EHR) systems,
and then to ICD-10. Each ICD-10 delay made it harder for HIM directors to convince team members that ICD-10 remained a priority.
But some remained vigilant in their ICD-10 preparations. Rochester Regional Health System, based in Rochester, NY, demonstrates
how strong HIM leadership helps to sustain ICD-10 momentum. By
maintaining their dual coding program and tightening collaboration
with their ICD-10 planning team, the HIM team at Rochester Regional has successfully progressed toward ICD-10 despite the delay.
For this organization, HIM is the epicenter of the ICD-10 change.
2. Provider Testing
Only 25 percent of respondents had begun external testing
and only a few others had completed this step, down from
about 35 percent in August 2014. Further analysis showed:
More than 50 percent of hospitals/health systems had
begun external testing.
Approximately 10 percent of physician practices had
begun external testing.
DELIVERS
ICD-10
SUCCESS
Consumable ICD-10
content, facilitating
organizational continuity
between physicians, CDIS,
coders and auditors.
GUIDES PHYSICIANS TO
COMPLETE AND ACCURATE
DOCUMENTATION
ENHANCES PHYSICIAN
PRODUCTIVITY
POWERED BY ICD SHERPA
Enhances clinical
documentation
improvement workflow
and process strategies
through dynamic,
interactive queries.
CODING RISK &
OPPORTUNITY ANALYTICS
IDENTIFICATION OF AT-RISK
CHARTS FOR REVIEW
SIDE BY SIDE
CODING AUDITS
REPORTING, TRACKING
AND MONITORING
D I S C E R N I N G
There is a great need for outpatient (OP) CDI, Linder adds. This
need is not greater than inpatient, but its just as important. The
clinics have been very receptive to our reviews and help.
Physician offices are generally places where people are coding, but they arent necessarily trained coders. Its just a part of
the job, not their designated role, Kelly says. Examples include
front desk staff, nurse assistants, and physicians handling coding assignments themselves. Because these are non-traditional
HIM areas, there is a strong possibility for pushback on more
education. We just want them to learn the basics at this point
and by doing so begin looking ahead to how much more ICD-10
information theyll need in the year ahead, Linder says.
Best practice is to begin with the top 10 DRGs for each specialty. HIM teams should conduct documentation reviews for their
affiliated practices and staff. Starting with notes for the physician visits, Rochester Regional has two resources dedicated to
conducting office documentation reviews.
Some doctors are going to hit a wall, Linder suggests.
Searching for ICD-10 narratives will take longer, and physicians may also experience a productivity setback on the number
of relative value units they generate. Linder expects that HIM
will be asked to do a lot more remedial work, education, and
support for medical practices once ICD-10 is implemented.
Kelly and her team suggested other HIM departments work
with their physicians to identify keywords that they can use
within EHR systems to limit searches and find ICD-10 codes
quickly. Physician practices are also advised to allow extra time
for patient visits during the upcoming conversion.
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retary Sylvia Mathews Burwell, former Workgroup for Electronic Data Interchange (WEDI) Chair Jim Daley expressed concern
about industry preparedness, stating that many organizations
failed to take full advantage of the additional time afforded by
the most recent one-year delay.4 Unless all industry segments
take the initiative to make a dedicated effort and move forward
with their implementation work, there will be significant disruption on Oct. 1, 2015, Daley says.
HIM professionals must lead the charge to regain ICD-10 momentum and keep that momentum going during the next few
months and beyond. This includes reaching out to affiliated
physician practices to provide support. Collaboration is the key
to success. The sooner organizations realize this, the better off
theyll be in this new world of ICD-10.
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REMEDIATING ICD-10
KNOWLEDGE LOSS
Remediating ICD-10
Knowledge Loss
IF YOU DONT use it, you lose it. This is true for much of what
we learn in life, and its particularly true when it comes to ICD10-CM/PCS. Although most organizations initiated ICD-10
coder training in 2013, many decided to cease training and dual
coding practice after the second ICD-10 implementation delay
was announced last year.
Now with the ICD-10 implementation deadline quickly
coming up, HIM directors and ICD-10 trainers must measure
coder knowledge loss, identify specific areas of concern, and
implement effective strategies to get coder know-how back
in shape by the October 1, 2015 compliance date. This article
explains how to restrengthen those coding muscles and go
from flab to fab.
Remediating ICD-10
Knowledge Loss
Debridement
Bypasses
Laparoscopic procedures
Spinal and ankle fusions
Epidural injections
Certain root proceduresespecially dilation, excision,
resection, and extirpation
Remediating ICD-10
Knowledge Loss
By Desla Mancilla, DHA, RHIA; Carolyn Guyton-Ringbloom, MBA, RD, CAE; and Michelle Dougherty, MA, RHIA
JOBS IN THE health information management (HIM) profession are becoming increasingly advanced in the need for both
technical expertise and leadership skills. This shift is particularly important to recognize as HIM professionals navigate new career opportunities and changes ahead. Strong leaders are needed in the profession to help guide and shape the future of HIM.
But what leadership skills have helped HIM leaders succeed
in the past? How does education and volunteerism support
leadership development? These questions were asked of several
HIM executive and director leaders at the 2014 AHIMA Annual
Convention and Exhibit in San Diego, CA. The insights gained
from that discussion provide the following picture of what skills
are critically important in these changing times.
Source: National Network of Business and Industry Associations. Common Employability Skills. July 22, 2014. http://businessroundtable.org/sites/default/
files/Common%20Employability_asingle_fm.pdf.
V
ision: The ability to see the whole picture, including
what the future will look like. From that big picture, the
ability to set future direction and strategy, understand
what is happening in the current environment, determine
how to get to a future state, and motivate others to follow.
Innovation: Become an intuitive thinker who looks for better
ways and is not constrained by the past (or current) practice.
Flexibility: Creativity and the ability to adapt and accept
change. Not only has a plan B, but also a plan C.
Integrity: Being a trusted leader, someone people want to
follow and believe in their direction. Loyalty and honesty
are important.
Collaborative Skills: Diplomatic and able to form relationships. Considers self a facilitator and part of the team.
peoples stories, since these are invaluable learning opportunities. They may have handled a situation similar to one you are
dealing with currently. Lastly, develop strategic planning skills.
A leader in any capacity must have this ability.
Getting to know someone through a volunteer opportunity
can lead to a job opportunity. Many within the focus group
shared how volunteering opened doors to promising career opportunities. An employer could see you as a leader in a volunteer role and then think of you for a position when it becomes
available. For the volunteer, it allows you to get to know others
and show off your strengths.
Resilience, grit, and confidence are three core leadership characteristics that author Lareina Yee identifies as necessary for
women to be successfully viewed as leaders in her recent article
Fostering Women Leaders: A fitness test for your top team.
In a female-dominated profession, these findings are important and also consistent with the focus groups insights. While
not necessarily referred to with the same words, the HIM leaders identified these characteristics as confidence, courage, and
the desire to achieve. To sum up their advice to future leaders of
the profession: Preparation begets opportunity, so prepare academically, volunteer, and network. Do this and you will be ready
to make your mark when opportunity arises.
Reference
Yee, Lareina. Fostering women leaders: A fitness test for
your top team. McKinsey Quarterly. January 2015. www.
mckinsey.com/insights/organization/fostering_women_
leaders_a_fitness_test_for_your_top_team.
Desla Mancilla (desla.mancilla@ahima.org) is senior director of academic
affairs and Carolyn Guyton-Ringbloom (carolyn.guyton-ringbloom@ahima.
org) is senior director of volunteer leadership development at AHIMA. Michelle
Dougherty (mdougherty@rti.org) is a senior health informatics research scientist with RTI Internationals Center for the Advancement of Health IT.
Privacy HOLES
in the Hidden
Healthcare
System
STUDENTS PHI-LADEN EDUCATION
RECORDS THAT ARE STORED AND
SHARED ELECTRONICALLY DONT
HAVE THE SAME SAFEGUARDS AS
MOST EHRS
By Daniel A. DuBravec,CHTS, CEHRS, and Matt Daigle
Notes
1. Lear, Julia. Health At School: A Hidden Health Care System Emerges From The Shadows. Health Affairs 26, no. 2
(March 2007): 409-419. http://content.healthaffairs.org/
content/26/2/409.full.
2. Robert Wood Johnson Foundation. School Nurse Shortage May Imperil Some Children, RWJF Scholars Warn.
December 12, 2013. www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/12/School-Nurse-Shortage-May-Imperil-Some-Children.html.
3. Center for Education Reform. K-12 Facts. September
2014. www.edreform.com/2012/04/k-12-facts/.
4. Johnson, H. K. and M.D. Bergren. Meaningful Use of School
Health Data. The Journal of School Nursing 27, no. 2 (April
2011): 102-110. http://jsn.sagepub.com/content/27/2/102.full.
5. Dinsmore & Shohl LLP. Understanding the Privacy Rights
of HIPAA & FERPA in Schools. The National Law Review.
January 7, 2011. www.natlawreview.com/article/understanding-privacy-rights-hipaa-ferpa-schools.
com/2014/05/20-million-student-records-put-at-risk.html.
13. Reidenberg, Joel et al. Privacy and Cloud Computing in
Public Schools.
14. Lynch, Matthew. Cloud Computing and K-12 Classrooms.
15. Atwal, Parmeeth. Improving Health Care in Schools: School
Nurse Leader Gives Districts EHR System an A+. HealthITBuzz. May 9, 2012. www.healthit.gov/buzz-blog/ehr-casestudies/improving-health-care-schools-nurses-week/.
16. Electronic Privacy Information Center. EPIC v. The U.S.
Department of Education. September 24, 2014. http://
epic.org/apa/ferpa/.
17. Amundson, Kristen. Avoiding a Privacy Headache. Washington Post. April 17, 2015. www.washingtonpost.com/opinions/how-virginia-avoided-a-privacy-headache/2015/04/17/
bd612202-da4c-11e4-8103-fa84725dbf9d_story.html.
18. Simon, Stephanie. Barack Obama to seek limits on student data mining. Politico. January 11, 2015. www.politico.com/story/2015/01/obama-limits-student-data-mining-114168.html.
19. Ghosh, D. Privacy Pledge. Student Privacy Pledge. 2014.
http://studentprivacypledge.org/?page_id=45.
Daniel A. DuBravec (ddubravec@lmi.org) is a senior consultant at LMI, a nonprofit government consulting firm. DuBravec holds multiple EHR certifications
and is a consultant for the government on EHR patient privacy and security
standards. Matt Daigle (mdaigle@lmi.org) is senior public affairs specialist for
LMI and holds a masters degree in journalism from Northwestern University.
www.iodincorporated.com
Inpatient & Outpatient Coding | Outsourced Coding | Coding & ICD-10 Training & Education | Coding Gym | Performance Analytics & Benchmarking
A clear definition of all roles involved in that process is necessary to help ensure an organizations success following the unwelcome attention that comes from a breach. The breach incidents reported in the media last year led to some top executives
losing their jobs because the incidents were handled poorly
within their organizations.
Privacy and security officers should be focused on organizational objectives that are audited for effectiveness, and reported
to executive leadership and the board of directors. The processes must be consistent, repeatable, and manageable. Incident
response should include:
Discovery of the incident
Timely reporting of said incident
Containment of the incident
Investigation
Documentation assessment
Notifications
For each incident it is important to break down the human
factor. According to a recent Ponemon Institute report, human errors and system problems caused two-thirds of data
breaches in 2012.1 An Ernst and Young analysis found similar
results.2 Thirty-eight percent of respondents said employee
carelessness or lack of awareness was the primary threat that
increased their exposure risk.
Both the nature and sheer volume of data have evolved and
grown at a rapid pace over the last two decades, and that trend
will likely continue. According to Cisco, global IP traffic has increased fivefold over the past five years, and will increase threefold over the next five years.3
So yes, the jobs have changed, but the continued focus must
be on education of the individuals working within the organization and those handling the information that privacy and security officers have been entrusted to protect.
Notes
1. Ponemon Institute. Cost of a Data Breach: Global Analysis. June 1, 2014. www.ponemon.org/library/2014-costof-data-breach-global.
2. Prince, Brian. Cybersecurity Requires Proactive Approach: Ernst & Young. Security Week. November 3, 2014.
www.securityweek.com/cybersecurity-requires-proactive-approach-ernst-young.
3. Cisco. Cisco Visual Networking Index: Forecast and Methodology, 2013-2018. June 10, 2014. www.cisco.com/c/en/
us/solutions/collateral/service-provider/ip-ngn-ip-nextgeneration-network/white_paper_c11-481360.html.
Rita Bowen (Rita.Bowen@HealthPort.com) is senior vice president of HIM,
privacy officer, at HealthPort.
AS FACILITIES APPROACH the final laps in the race towards implementation of the International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM), they should heed
the yellow caution flag warning of basic challenges with the vast
differences between inpatient and outpatient coding. It is important to use caution during our current race and to stay in the correct lane with code assignment of inpatient stays and outpatient
encounters. This article will provide some rules of the road as facilities stay focused on the implementation of ICD-10-CM.
and visit are often used interchangeably in describing outpatient services, but the term encounter will be used for this article. For diagnosis coding of outpatient encounters, one needs
a full understanding of the UHDDS definitions, anatomy and
physiology, Volumes 1 and 2 of ICD-9-CM, along with ICD-9CM instructional notations and conventions, and the current
version of ICD-9-CM Official Guidelines for Coding and Reporting. Diagnoses are assigned using the first two volumes of
the ICD-9-CM coding book, supplemented with AHAs Coding
Clinic for ICD-9-CM. Outpatient procedures are assigned from
the American Medical Associations (AMAs) Current Procedural Terminology (CPT) Manual which includes Level I modifiers
approved for hospital outpatient use and the Centers for Medicare and Medicaid Services (CMS) Level II Healthcare Common
Procedure Coding System (HCPCS), including Level II National
Modifiers. Procedure coding is supplemented with the AMAs
CPT Assistant and AHAs Coding Clinic for HCPCS. Although
outpatient encounters are not required by CMS or third-party
payers to report ICD-9-CM Volume III procedure codes, and do
not base reimbursement on the use of these codes, some facilities continue to utilize them for internal data capture.
discharge is qualified as probable, suspected, likely, questionable, possible, or rule out, and has not been ruled out at
the time of discharge, the condition should be coded as an existing or established diagnosis. In addition to assigning ICD-9-CM
diagnoses, hospitals are required to report present on admission
information for all diagnoses when submitting inpatient claims.
Although both inpatient and outpatient coding utilizes Volumes 1 and 2 of the ICD-9-CM manuals in the assignment of
diagnoses, there are vast differences. The UHDDS definition of
principal diagnosis applies to non-outpatient settings: acute
care short-term hospitals, long-term care hospitals, psychiatric
hospitals, home health agencies, rehabilitation facilities, nursing homes, and other settings.
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and
do not apply to outpatient coding. Do not code diagnoses documented as probable, suspected, questionable, rule out,
working diagnosis, or other similar terms indicating uncertainty
for outpatient encounters. Instead, code the condition(s) to the
highest degree of certainty for that encounter, such as symptoms,
signs, abnormal test results, or other reason for the encounter.
Instead of using the term principal diagnosis as with inpatient
stays, the term first-listed diagnosis is appropriate in the outpatient setting. The conventions of ICD-9-CM, along with the general
and disease-specific guidelines, take precedence over the outpatient guidelines of first-listed diagnosis. List first the ICD-9-CM
code for the diagnosis, condition, problem, or other reason for the
encounter shown in the medical record to be chiefly responsible for
the services provided. In some cases, the first-listed diagnosis may
be a symptom when a diagnosis has not been established or confirmed by the physician. Outpatient encounters for circumstances
other than a disease or injury are assigned ICD-9-CM codes under
The Supplementary Classification of Factors Influencing Health
Status and Contact with Health Services (V01.0-V91.99).
Furthermore, clarification on assignment of the first-listed diagnosis is based on the outpatient encounter service type. The
first-listed code for an outpatient surgical encounter should be
the reason for the surgery. Even if the patient is scheduled for
outpatient surgery and develops a complication requiring admission to observation, the first-listed code remains the reason
for surgery, followed by secondary diagnosis codes for all applicable documented complications.
However, if the postoperative diagnosis is known to be different from the preoperative diagnosis, select the postoperative
diagnosis because it is the most definitive diagnosis. An example of this is when a patient presents for outpatient surgery for
evaluation of rectal bleeding and after colonoscopy it is determined that the patient has bleeding from internal hemorrhoids.
The preoperative diagnosis is 569.3-rectal bleeding and the
more definitive postoperative diagnosis is 455.2-internal hemorrhoids with other complication. The first-listed diagnosis for
outpatient diagnostic and therapeutic services is the diagnosis,
condition, problem, or other reason shown in the medical record to be chiefly responsible for the outpatient services.
Codes for diagnoses (i.e., chronic conditions) may be se-
Coding
Auditing
ICD-10
implementation
Collections
Denials
management
Other revenue
cycle services
WITH THE GROWING adoption of health information technology (HIT), interoperabilityor the sharing of data between
systemshas become a topic that everybody in healthcare is
talking about. Interoperability impacts every stakeholder in
healthcare with each individual party involved in a complex
multi-dimensional, multi-domain, multi-stakeholder activity.
The ultimate aim of interoperability is to improve the safety,
quality, effectiveness, and efficiency of healthcare delivery, and
to improve individual and population health.
Healthcare is rather new to interoperability. Other industries
have been on the interoperability journey for several decades.
They include banking, transportation, and retail, and their successes are realized every day while managing personal and
business finances, traveling, and shopping. This success shows
that healthcare has a shot at achieving interoperability, though
the challenges it faces are unique to the industry.
Leadership
Leadership to establish public-private partnerships to define,
develop, and execute the interoperability agenda on the policy
and technical levels should be based on federal regulation and
the role of the federal government in standardization.
Accountability
Accountability ensures fiscal responsibility of participating
stakeholders in delivering standards-based interoperable solutions in healthcare for data, information, and knowledge
generation, sharing, and use. Accountability should be based
on federal regulation with checks and balances policies.
Methodology
Methodology is needed to enable the development, implementation, and operation of standards-based interoperable information and communication technology solutions in healthcare. As performed in other industries, methodology should
be based on merging two domains of knowledge: medicine
and computer science. This enables overall computer science
and information and communication technology methodologies to work in the healthcare environment. In merging these
two domains, there is a need for an overarching interoperability framework under which an interoperability methodology
will be employed.
Figure 1 on page 52 presents interoperability building blocks
for the proposed interoperability framework. The three pillars
of interoperabilitysemantic, technical, and functional
serve as pillars of the interoperability framework. Under and
across each pillar, computer science interoperability methodology will focus on the following activities:
1. Defining needs and priorities for interoperability
2. Defining and developing interoperability components for
semantic, technical, and functional interoperability
3. Testing interoperability components
4. Certifying interoperability components
5. Deploying interoperability components
6. Evaluating deployment outcomes
Accountability and leadership are positioned above the
methodology to ensure effectiveness of the framework. The
foundation for this framework is comprised of the following
three building blocks:
1. Policy (regulatory framework and governance)
2. Technology (standards-based technology including both
HIT and information communication and technology in
healthcare)
3. People (healthcare and HIT workforce and consumers
Journal of AHIMA June 15/51
Notes
1. Office of the National Coordinator for Health Information Technology. Connecting Health and Care for the
Nation: A Shared Nationwide Interoperability Roadmap.
2015. www.healthit.gov/sites/default/files/nationwideinteroperability-roadmap-draft-version-1.0.pdf.
2. Institute of Electrical and Electronics Engineers (IEEE).
Standards Glossary. www.ieee.org/education_careers/
education/standards/standards_glossary.html.
52/Journal of AHIMA June 15
3. Health Level Seven. Coming to Terms: Scoping Interoperability for Healthcare. February 7, 2007.
w w w.hln.com/assets/pdf/Coming-to-Terms-February-2007.pdf.
4. Ibid.
5. Healthcare Information Technology Standards Panel.
www.hitsp.org.
6. International Organization for Standardization. ISO/TC
215 Health informatics. www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/
iso_technical_committee.htm?commid=54960.
7. AHIMA. AHIMA Comments on Connecting Health and
Care for the Nation: A Shared Nationwide Interoperability Roadmap. Letter to Office of the National Coordinator for Health IT. April 2, 2015. http://bok.ahima.org/
PdfView?oid=300817.
Anna Orlova (anna.orlova@ahima.org) is senior director of standards at
AHIMA.
Ad Space
As a leader and
trusted source of CPT,
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Editors Note: This is the third in a series of four articles that discuss the eight Information Governance Principles for Healthcare.
Compliance Principle
Availability Principle
The availability principle is straightforward: An organization
shall maintain information in a manner that ensures timely,
accurate, and efficient retrieval. After all, if the ability to retrieve information is impairedeither because retrieval is untimely or incompleteboth trust in the organization and its
operations will be diminished. When the right information is
not available at the right time, patient care may be compromised. Availability is important to various stakeholders within
Operational Assessments
Temporary HIM Management
Coding Validation Audits and Coding Support
Scanning and Transcription Analyses
Scanning Software & Project Operations
Management
CAC Guidance & RFP Management
CAC Implementation Management
ICD-10 Coder and Physician Education
ICD-10 Project Management (Limited)
ICD-10 DRG Shift/Documentation Analysis
800-274-1214
www.FirstClassSolutions.com
www.Cortrak.com
Journal of AHIMA June 15/55
PRACTICE BRIEF
practice guidelines for managing health information
Editors Note: This Practice Brief supersedes the October 2012 Practice Brief Electronic Documentation Templates Support ICD-10CM/PCS Implementation.
IMPROVING PATIENT CARE continues to take center stage
in the healthcare industry, as demonstrated by an increased
emphasis on health IT and electronic health record (EHR)
implementation in programs like the American Recovery and
Reinvestment Acts (ARRA) meaningful use EHR Incentive
Program, the Accountable Care initiative, Patient-Centered
Medical Homes, and the Medicaid Chronic Care Management
program. These, and other initiatives, all require strategic organization-wide planning for ICD-10-CM/PCS implementation.
The implementation of ICD-10-CM/PCS will require organizations to capture detailed information at the point of care.
Since ICD-10-CM/PCS provides increased specificity in its code
sets, clinical documentation to support that specificity is critical. Specifically, providers dont need to provide a higher volume of clinical documentation, but rather need more precise
documentation (i.e., laterality, specificity, anatomic sites, etc.)
with the focus on quality, not quantity. Proper documentation
can be facilitated through the effective use of EHR templates
and prompts and the data repurposed throughout the EHR to
support the collect once, use many times concept.
The meaningful use EHR standards and certification criteria
have enhanced organizations ability to capture and exchange
standardized, structured clinical content. Templates can also
help support the capture of clinical content in a standardized and
structured manner. Prompts or clinical decision support rules
relevant to clinical specialties will result in meaningful patient
data as well as improvements in patient care. The added level of
specificity in ICD-10 is needed to bolster clinical decision support tools that provide alerts and reminders to clinicians during
patient care. This is an important patient safety consideration.
Leveraging these data collection tools will improve clinical
documentation, leading to a higher quality of care for the patient through a better understanding of complications, better
design of clinically robust algorithms, and better tracking of the
outcomes of care. Greater detail and specificity offer many advantages, including the ability to discover previously unrecognized relationships in data and the impact on public health by
detecting developing epidemics in their early stages.
Prior to ICD-10 implementation, healthcare organizations
will need to communicate with their EHR vendors and identify
methods for updating and/or creating templates that facilitate
compliance with new documentation requirements and code
56/Journal of AHIMA June 15
Practice Brief
In the outpatient setting, there are many advantages to creating templates in the EHR, there are also benefits to utilizing an
EHR with integrated practice management, billing, and documentation tools. To take full advantage of the EHRs efficacy, a
practice should look to the variety of methods for customization, according to an article posted on EMRapproved.com.3
Leveraging the use of tailored elements in a custom template design is a popular method for customizing the EHR. The
unique features developed through the customization of EHRs
allows practices to create an EHR best suited to their specific
needs. Some studies have found that an involved customization
is important in order for the adoption of any EHR to be successful for a given practice.4 Many EHRs allow providers to modify
generic templates or to create their own unique sets of templates with ICD, HCPCS, and CPT codes. This process can be
labor-intensive, and these templates will need to be updated or
replaced to meet the ICD-10 specificity requirements.5
When discussing the improvements that will need to be made
Practice Brief
excision, etc.)
Body Part: Specific part of the body and laterality where
the procedure was performed (i.e., appendix, liver, right
leg, etc.)
Approach: The approach taken to accomplish the procedure (i.e., open, laparoscopic, etc.)
Device: The type of device (if any) that remains in the
body upon completion of the procedure (i.e., grafts, implants, etc.)
Documentation areas for consideration when assigning ICD10-PCS code(s) include:
Root Operation: Selection of the root operation is dependent on properly determining the objective of the
procedure (i.e., what will be accomplished through the
procedure?) A thorough explanation of the purpose of the
procedure is necessary. For example, the terms excision
and resection were used somewhat interchangeably in
ICD-9-CM. In ICD-10-PCS, however, these terms represent completely different procedures.
Site: Does the operative report state the specific site of
the procedure? The body part selections and laterality are
much more specific in ICD-10-PCS. Documentation must
specify what body part was affected by the procedure.
Some of the specific body parts identifiable in ICD-10PCS are the anterior tibial artery, abdominal sympathetic
nerve, and the thorax muscle, left.
Devices: Devices that remain in the body after the completion of the procedure must be documented. These include devices such as drains, non-autologous tissue substitutes, radioactive elements, and infusion pumps.
Qualifiers: Qualifiers are represented as the seventh
character in an ICD-10-PCS code. These will vary depending on the ICD-10-PCS code. Some examples include the
types of pacemakers, graft materials, and hip prostheses.
Qualifiers can also represent anatomical locations which
are relevant to that particular procedure.7
Practice Brief
Considerations
More specific documentation of the site of an
injury, such as a fracture
Laterality of injury
Episode of care 7th character:
-- Initial encounter for care of fracture
-- Subsequent encounter for fracture with
routine healing
-- Subsequent encounter for fracture with
delayed healing
-- Subsequent encounter for fracture nonunion
-- Subsequent encounter for fracture with
malunion
-- Sequela
ICD-10-CM
Concepts
Under dosing
Considerations
New concept for ICD-10-CM that refers
to taking less of a medication than is prescribed by a provider or a manufacturers
instruction
May be classified as due to financial hardship or the age-related debility of a patient
Source: Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS
Coding Handbook. Chicago, IL: AHA Press, 2012: 501.
External
Causes of
Mortality
Obstetrics
New category for reporting medical devices associated with adverse incidents in diagnostic and
therapeutic use
Circulatory
System
Episode of care
First, second, or third trimester of
pregnancy
7th character to be assigned with multiple
gestations; identifies fetus to which the
code applies
Twin pregnancy may be classified as
monoamniotic/monochorionic
Neoplasms
Practice Brief
Patient Considerations
The patient audience is equally important to consider when developing documentation tools. Patients are increasingly experiencing visits where physicians face a computer and work their
way through the EHR during the encounter instead of engaging
in face-to-face conversation. The careful design of templates
and effective physician training may help reduce patient perception that a physician is focused on the computer rather than
the individual.
Daily progress note documentation is the responsibility of the
medical staff. The documentation should include required elements and updated diagnoses and procedures when applicable. The collaboration between vendor and hospital client base
should result in documentation tools that:
Reduce the amount of duplicative documentation by physicians
Contain key fields that will assist with accurate and specific code assignments
Automatically reproduce data on a coding worksheet to
assist with coding
Populate a discharge summary with diagnoses and procedures from progress notes, post-procedure notes, consultations, operative reports, and other specified documentation
Include required fields for Joint Commission requirements and medical staff rules and regulations for specific
documents (i.e., post-procedure notes, discharge summaries, etc.)
Include free text options to allow the healthcare provider(s)
to include additional patient-specific information
Vendors traditionally provide a basic EHR system that includes
limited design workflows and templates. Ultimately, it is the responsibility of the healthcare provider to enhance and maintain
additional workflows and templates. EHR vendors should have
an understanding of the importance of documentation for primary and secondary data use, such as:
Practice Brief
Medical necessity
Continuing care
Patient safety
Regulatory requirements
Coding
Charge capture
Quality measurement and reporting
Templates assist with the standardization of essential elements in clinical documentation. This standardization will,
in turn, result in the capture of data at the level of specificity
needed to support the timely display of results, expedited chart
searching, coordination of care among healthcare providers,
and improved patient outcomes.10 Well-formatted templates
also support quality programs such as the Accountable Care
initiative, the Patient-Centered Medical Home initiative, the
Medicare Chronic Care Management program (which requires
the EHR to generate and maintain health summaries and care
plans), and others.
Documentation templates should be designed to reflect clinical accuracy and ensure documentation integrity. Now is the
time for healthcare facilities to merge meaningful use and ICD10-CM/PCS planning initiatives to develop templates, prompts,
and overall systems that facilitate and encourage documentation needed for patient care, severity of illness, intensity of services, accurate code assignment, and reimbursement as well as
a variety of healthcare quality and reporting requirements.
Appendices
Three appendices are available in the online version of this
Practice Brief, located in AHIMAs HIM Body of Knowledge at
www.ahima.org:
Appendix A: Electronic Note Title and Template Policy
Considerations
Appendix B: Request Form for Note Title and Templates
Appendix C: Checklist for Template Review
Notes
1. Klauer, Kevin. The Problem with Prompts. Emergency
Physicians Monthly. July 19, 2010. www.epmonthly.com/
archives/features/the-problem-with-prompts-/.
2. Deloitte. Navigating the ICD-10 transition: Implementation imperative for hospitals and medical groups. 2013.
pg. 5. http://info.modernhealthcare.com/rs/crain/images/Deloitte_Navigating_ICD10.pdf.
3. EMR 105: EMR and EHR Templates. EMRapproved.com.
2011. www.emrapproved.com/pdf/phs-hitu/emru105_
course.pdf.
4. Bennett, Kevin J. and Christian Steen. Electronic Medical
Record Customization and the Impact Upon Chart Completion Rates. Family Medicine. May 2010. www.stfm.org/
fmhub/fm2010/May/Kevin338.pdf.
5. Stearns, Michael. EHRs and the ICD-10 Transitions:
Planning for 2015. Physicians Practice. June 9, 2014. www.
physicianspractice.com/ehrs-and-icd-10-transition-planning-2015.
6. Davis, Mike. ICD-10 Will Drive Enterprise Improvement
Opportunities. Healthcare Information and Management
Systems Society. December 15, 2010. www.himss.org/
News/NewsDetail.aspx?ItemNumber=6715.
7. Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS Coding
Handbook. Chicago, IL: AHA Press, 2012: 501.
8. Kallem, Crystal; Burrington-Brown, Jill; Angela K. Dinh.
Data Elements for EHR Documentation. Journal of AHIMA 78, no. 7 (July-August 2007): web extra. http://library.
ahima.org/xpedio/groups/public/documents/ahima/
bok1_034460.hcsp?dDocName=bok1_034460.
9. Healthcare Financial Management Association. Educational Report: Will Your Data Support Value-Based Payment? May 1, 2012. p. 5. www.hfma.org/hfma.org/datareadinessforvalue/.
10. Dellinger, Beverly. Personal interview. June 19, 2012.
References
Doty, Laura and Marion G. Kruse. Preparing for ICD-10
While in an ICD-9 World: The Importance of Clinical
Documentation and Coding Integrity (CDCI) Programs
Being Early Adopters of ICD-10. AHIMA Convention
Proceedings, 2011.
Capanna, Alaina and Valerie Watzlaf. Clinical Documentation
Improvement and Use of Templates and Standards. AHIMA
Convention Proceedings, 2011.
EHR Templates. 4MedApproved. August 2, 2012.
www.4medapproved.com/emr-ehr-templates.php.
Rashbaum, Kenneth N. EHR templates: Time-saver or
patient safety risk? Medical Economics. January 10, 2012.
w w w.modernmedicine.com/modernmedicine/article/
articleDetail.jsp?id=755244.
Authors
Patty Buttner, RHIA, CDIP, CCS
Sarah L. Goodman, MBA, CHCAF, COC, CCP
Tammy R. Love, RHIA, CCS, CDIP
Melissa McLeod, CCDS, CCS, CPC, CPC-I
Michael Stearns, MD, CPC
Acknowledgements
Katherine Andersen, RHIT, CCS, CRCS-I, CRCS-P
Angie Comfort, RHIA, CDIP, CCS
Susan Clark, BS, RHIT
Marlisa Coloso, RHIA, CCS
Kathy Downing, MA, RHIA, CHPS, PMP
Dwan Thomas Flowers, MBA, RHIA, CCS
Lesley Kadlec, MA, RHIA
Faith McNicholas, RHIT, CPC, CPCD, PCS
Janice Noller, RHIA, CDIP, CCS
Cindy C. Parman, CPC, CPC-H, RCC
Andrea Romero, RHIT, CCS, CPC
Journal of AHIMA June 15/61
Practice Brief
Authors (Original)
Jill S. Clark, MBA, RHIA, CHDA
Theresa A. Eichelmann, RHIA
Jan C. Fuller, MBA, RHIA, CPHIMS
Stephanie Hays, RN, CDIP, CPHQ
Becky B. Lobdell, MBA, RHIA
Nita Mangat
Maria Muscarella, RHIA
Kathleen Peterson, MS, RHIA, CCS
Carole Uknes, MHA, RHIA, CCS-P
Diana M. Warner, MS, RHIA, CHPS, FAHIMA
Acknowledgements (Original)
Sue Bowman, RHIA, CCS
Linda Darvill, RHIT
Beverly Dellinger, RN
Julie Dooling, RHIT
Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P
Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
Mary Beth Haugen, MS, RHIA
Pamela Heller, RHIA, CCS-P
Doreen Koch, RHIT
Priscilla Komara
Betty Lanzrath, MA, RHIA
Tammy R. Love, RHIA, CCS, CDIP
Jennifer McCollum, RHIA, CCS
Mary Reeves, RHIA
Theresa Rihanek, MHA, RHIA, CCS
Angela Dinh Rose, MHA, RHIA, CHPS
Allison Viola, MBA, RHIA
Jane Walters, MA, RHIA
Traci Waugh, RHIA
Lou Ann Wiedemann, MS, RHIA, CPEH, FAHIMA
The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.
62/Journal of AHIMA June 15
REGISTE
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performance and the value of health information education!
Coding Notes
ALL CODING PROFESSIONALS require the right clinical documentation at the right time in order to assign an accurate code.
This article reviews just what that requirement entails for ICD10-PCS coding.
Coding Notes
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
The American Hospital Associations (AHAs) Coding Clinic indicates when the providers operative note documentation does
not specify the end placement of the infusion device, the imaging report may be used to identify the required body part for the
ICD-10-PCS code assignment. This scenario illustrates how the
use of two procedure document types provide all the required
documentation necessary for the accurate ICD-10-PCS code assignment and emphasizes the need for facilities to define all the
appropriate procedure document types for ICD-10-PCS coding.
Note
1. Office of Inspector General. Publication of the OIG Compliance Program Guidance for Hospitals. Federal Register
63, no. 35 (February 23, 1998): 8,991. https://oig.hhs.gov/
authorities/docs/cpghosp.pdf.
References
American Hospital Association. AHA Coding Clinic. Third
quarter, 2014: 5-6.
Journal of AHIMA June 15/65
Coding Notes
Character 2
Body System
Character 3
Root Operation
Character 4
Body Part
Character 5
Approach
Character 6
Device
Character 7
Qualifier
Medical and
Surgical
Female
Reproductive
System
Resection
Uterus
Open
No Device
No Qualifier
Character 2
Body System
Character 3
Root Operation
Character 4
Body Part
Character 5
Approach
Character 6
Device
Character 7
Qualifier
Medical and
Surgical
Female
Reproductive
System
Resection
Cervix
Open
No Device
No Qualifier
Character 2
Body System
Character 3
Root Operation
Character 4
Body Part
Character 5
Approach
Character 6
Device
Character 7
Qualifier
Medical and
Surgical
Female
Reproductive
System
Inspection
Percutaneous
Endoscopic
No Device
No Qualifier
Character 2
Body System
Character 3
Root Operation
Character 4
Body Region
Character 5
Approach
Character 6
Method
Character 7
Qualifier
Other Procedures
Physiological
Systems and
Anatomical
Regions
Other Procedures
Trunk Region
Percutaneous
Endoscopic
Robotic Assisted
Procedure
No Qualifier
American Hospital Association. AHA Coding Clinic for ICD-9CM. July/August 1985: 3-8.
American Hospital Association. AHA Coding Clinic for ICD-10PCS. First quarter, 2015: 33-34.
American Hospital Association. AHA Coding Clinic for ICD-10PCS. Third quarter, 2013: 28.
Cassidy, Bonnie. Defining the Core Designated Clinical
Documentation Set for Coding Compliance. AHIMA
Thought Leadership Series, 2012. http://library.ahima.org/
xpedio/groups/public/documents/ahima/bok1_049822.pdf.
Centers for Medicare and Medicaid Services. 2015 Code
Tables and Index. 2015. www.cms.gov/Medicare/Coding/
ICD10/2015-ICD-10-PCS-and-GEMs.html.
66/Journal of AHIMA June 15
Centers for Medicare and Medicaid Services. 2015 ICD-10PCS Reference Manual. 2015. www.cms.gov/Medicare/
Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.
Centers for Medicare and Medicaid Services. ICD-10-PCS
Official Guidelines for Coding and Reporting 2015. 2015.
www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCSand-GEMs.html.
The Uniform Hospital Discharge Data Set (UHDDS) Reporting of
Inpatient Data Elements. Federal Register 50, no. 147. July 1985.
Karen Kostick (Karen.Kostick@nuance.com) is senior technical business
analyst, CLU and CAC content, and Gina Sanvik (Gina.Sanvik@nuance.
com) is manager, CLU and CAC content, at Nuance Communications, Inc.
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Coding Notes
WITH THE CONSISTENTLY rising value of highly skilled outpatient coders, numerous HIM departments are moving to a
staffing model that employs coding professionals who are well
versed in coding both inpatient and outpatient encounters.
Coders in the profession today should possess a mastery of the
complex inpatient coding rules as well as the very specificand
equally complexoutpatient coding rules.
One of the most demanding aspects of outpatient coding is
the selection of injection and infusion (I&I) codes. This set of
Current Procedural Terminology (CPT) codes, 96360 through
96549, is utilized to capture I&I administered in the emergency
department (ED). I&I coding is also appropriate in observation
patients who have been transferred from the ED. Rarely, if ever,
are I&I codes appropriate if the patient is transferred from the
ED to inpatient status.
When approaching I&I coding, it can be helpful to think of the
code assignments in terms of playing cards or a hand of poker. Its important to determine not only what you have in your
hand, but also which cards trump the others. Coders must have
a firm grip on the definitions of several terms in order to achieve
success with I&I codesjust as a poker player needs to know
all their options when trying get their best hand possibleas
well as which I&I procedures will outrank othersjust as an
ace trumps a jack, so too does chemotherapy trump the other
procedures. This article gives an overview of the information essential to successful I&I coding.
Coding Notes
IV Push
Hydration
Coding Notes
Scenario #1
Scenario #2
1
9:21 Drug: morphine 4 mg Route: IVP; Site: left
antecubital
20:54 Follow up: Response: No adverse reaction;
Pain is decreased
1
9:21 Drug: morphine 4 mg Route: IVP; Site: left
antecubital
20:54 Follow up: Response: No adverse reaction;
Pain is decreased
1
9:21 Drug: NS 0.9 percent 1,000 ml Route: IV;
Rate: bolus; Site: left antecubital
20:54 Follow up: [no stop time documented]
1
9:21 Drug: NS 0.9 percent 1,000 ml Route: IV;
Rate: bolus; Site: left antecubital
20:54 Follow up: IV status: Completed infusion. IV
intake: 1,000ml
Day 1
Zofran
4 mg IVP
Morphine
4 mg IVP
ED Meds
Day 1
19:21
4 mg
Zofran
4 mg IVP
19:21
4 mg
19:21
4 mg
Morphine
4 mg IVP
19:21
4 mg
NS
19:21
1,000 ml IV bolus
NS
19:21
1,000 ml IV bolus
Day 2
20:54
complete
Coding Notes
Scenario #3
DOCUMENTATION FROM THE ED Physician Notes:
Administered Medications:
19:21 Drug: Zofran 4 mg Route: IVP; Site: left
antecubital
20:54 Follow up: IV status: Completed infusion
Response: No adverse reaction; Nausea is decreased
1
9:21 Drug: morphine 4 mg Route: IVP; Site: left
antecubital
20:20 Follow up: Response: No adverse reaction;
Pain is decreased
1
9:21 Drug: NS 0.9 percent 1,000 ml Route: IV;
Rate: bolus; Site: left antecubital
20:54 Follow up: IV status: Completed infusion
Day 1
Zofran
4 mg IVP
19:21
4 mg
20:54
complete
Morphine
4 mg IVP
19:21
4 mg
20:20
NS
19:21
1,000 ml IV bolus
Day 2
20:54
complete
should be assigned?
The three illustrated scenarios on pages 70 and 71 take this
basic premise and apply the guidelines discussed in this article,
assigning the appropriate CPT code for the infusion.
An additional two scenarios, available in the extended onlineonly version of this article in AHIMAs HIM Body of Knowledge,
change the documentation slightly to illustrate other important
factors to consider for I&I coding.
References
AHIMA. CPT Coding for Injections and Infusions. Audio
Seminar, May 8, 2012.
American Medical Association. CPT Professional Edition.
Chicago, IL: AMA, 2015.
Endicott, Melanie. Taking the Sting out of Injection
and Infusion Coding. Journal of AHIMA 83, no. 11
(November
2012):
74-76.
http://library.ahima.org/
xpedio/groups/public/documents/ahima/bok1_049797.
hcsp?dDocName=bok1_049797.
Johnson, Courtney. Injection and Infusion Coding.
Presentation during Baylor Scott and White Health Coder
Summit conference call, August 2012.
Garrett, Joyce. Basic Coding for Infusions and Injections.
Internal Presentation to Franciscan Health Services, 2008.
Charles Flewelling, Jr. (Charles.Flewelling@baylorhealth.edu) is a corporate remote coding auditor at Baylor Scott and White Health, based in
Dallas, TX.
Read More
More Example Scenarios Online
www.ahima.org
An additional two scenarios are available in the extended onlineonly version of this article in AHIMAs HIM Body of Knowledge.
Calendar
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
12
13
19
20
26
27
CSA MEETING:
KENTUCKY, Lexington, KY
WEBINAR:
ICD-10: The
Impact on
OP Coding
for Certain
High Volume
Diagnoses
Dover, DE
10
11
CSA MEETING:
CALIFORNIA, Palm Springs, CA
NEW YORK, Syracuse, NY
Building
Data Driven
Workflows in
HIM: More than
just an EHR
14
15
16
17
18
Evolving and
Adapting: The
Changing Role
of the CDI
Professional
21
22
23
24
25
28
CSA MEETING:
TEXAS, San Marcos, TX
29
30
2016 Baltimore, MD
October 15-20
72/Journal of AHIMA June 15
A Look Ahead
Keep Informed
JULY
79
1011
1314
1316
1517
1517
1517
1718
1822
2022
23
2324
2325
2931
August 4-5
August 5-7
August 6
August 6-7
August
12-14
August
12-14
August 13
Nominating Committee
Jill A. Finkelstein, MBA, RHIA, CHTS-TR
(954) 418-0938
jfinkelstein@browardhealth.org
Fellowship Committee
Mona Y. Calhoun, MEd, MS, RHIA, FAHIMA
(301) 352-0304
mcalhoun@coppin.edu
Envisioning Collaborative
Laura W. Pait, RHIA, CDIP, CCS
(336) 946-1750
lpait@novanthealth.org
House Leadership
Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
edelahoussaye@iodincorporated.com
AHIMA volunteers also make valuable contributions as facilitators for Engage Online Communities. To locate the facilitator(s), go to a particular community, click on the Members tab, then click on the
community administrator link.
Indiana
Deborah Grider, CDIP, CCS-P
McCordsville, IN
(317) 908-5992
deborahgrider@mac.com
Nevada
Gregory Schultz, RHIA
North Las Vegas, NV
(702) 526-8361
gschultz00@aol.com
South Dakota
Sheila Hargens, MSHI, CMT
Parkston, SD
(605) 928-3741
sheila.hargens@avera.org
Alaska
Janie Batres, RHIA, CDIP
Anchorage, AK
(907) 252-7228
janieleigh44@hotmail.com
Iowa
Mari Beth Schneider Lane, MS, RHIA
Sheldon, IA
(712) 324-5061
mlane@nwicc.edu
New Hampshire
Jean Wolf, RHIT, CHP
Gorham, NH
(603) 466-5406
jean.wolf@avhnh.org
Tennessee
Lela McFerrin, RHIA
Chattanooga, TN
(423) 493-1637
lela.mcferrin@hcahealthcare.com
Arizona
Christine Steigerwald, RHIA
Gilbert, AZ
(480) 292-8293
Christine.Steigerwald@bannerhealth.com
Kansas
Julie Hatesohl, RHIA
Junction City, KS
(785) 210-3498
phoebehat@cox.net
New Jersey
Carolyn Magnotta, RHIA
New Egypt, NJ
(609) 758-8890
magnottac@deborah.org
Texas
Terri Frnka, RHIT
Bryan, TX
terrifrnka@yahoo.com
Arkansas
Marilynn Frazier, RHIA, CHPS
Ozark, AR
(479) 667-5153
mfrazier@ftsm.mercy.net
Kentucky
Diba Thakali, RHIA
Lexington, KY
(859) 979-3049
diba.thakali@bhsi.com
New Mexico
Vicki Delgado, RHIT
Albuquerque, NM
(505) 948-6711
vicki.delgado@kindredhealthcare.com
California
Shirley Lewis, DPA, RHIA, CCS, CPHQ
Upland, CA
(909) 608-7657
shirley.lewis5@verizon.net
Louisiana
Lisa Delhomme, MHA, RHIA
Rayne, LA
(337) 277-5544
delhomme@louisiana.edu
New York
Sandra Macica, RHIA
Saratoga Springs, NY
(518) 584-0389
s.macica@elsevier.com
Colorado
Melinda Patten, CDIP, CHPS
Aurora, CO
(720) 777-6657
melinda.patten@childrenscolorado.org
Maine
Nora Brennen, RHIT
Topsham, ME
(207) 751-1853
Nora.Brennen@va.gov
North Carolina
Jolene Jarrell, RHIA, CCS
Apex, NC
jolene@drgreview.com
Connecticut
Elizabeth A. Taylor, MS, RHIT
East Hartford, CT
(860) 364-4417
liz.taylor@sharonhospital.com
Maryland
Sarah Allinson, RHIA
Baltimore, MD
(410) 499-7281
sarahballinson@gmail.com
Delaware
Marion Gentul, RHIA, CCS
Lewes, DE
(302) 827-1098
mgs60mga@yahoo.com
Massachusetts
Walter Houlihan, MBA, RHIA, CCS
Springfield, MA
(413) 322-4309
Walter.Houlihan@bhs.org
District of Columbia
Jeanne Mansell, RHIT, CHTS-CP, CHTS-PW,
CHTS-IM, CHTS-IS, CHTS-TS, CHTS-TR
Washington, DC
(202) 421-5172
jeanne87@hotmail.com
Michigan
Thomas Hunt, RHIA
Owosso, MI
(989) 725-8279
thunt@davenport.edu
Florida
Anita Doupnik, RHIA
Tampa, FL
(813) 907-9380
anita.doupnik@nuance.com
Minnesota
Jean MacDonell, RHIA
Grand Rapids, MN
(612) 719-3697
jean.macdonell@granditasca.org
Georgia
Allyson Welsh, MHA/INF
Decatur, GA
Allysonwelsh@gmail.com
Mississippi
Phyllis Spiers, RHIT
Carriere, MS
(601) 347-6318
pspiers@forrestgeneral.com
Hawaii
Marlisa Coloso, RHIA, CCS
Wailuku, HI
(808) 442-5509
mcoloso@hhsc.org
Missouri
Angela Talton, RHIA, CCS
Florissant, MO
(314) 276-4180
afranks@swbell.net
Idaho
Mona P. Doan, RHIT, CCS-P
Boise, ID
(208) 484-7076
monadoan@hotmail.com
Montana
Vicki Willcut, RHIA
Kalispell, MT
(406) 756-4758
vwillcut@krmc.org
Illinois
Teresa Phillips, RHIA
Effingham, IL
(217) 347-2806
teri.phillips@hshs.org
Nebraska
Shirley Carmichael, RHIT
Fairbury, NE
(402) 729-6854
shirley.carmichael@jchc.us
Utah
Vickie Griffin, RHIT, CCS
Bountiful, UT
vickie.griffin@Parallon.com
Vermont
Charmaine S. Vinton, RHIT, CCS, CPC
West Chesterfield, NH
(603) 357-0170
cvinto@bmhvt.org
Virginia
Darcell Campbell, RHIA
Hampton, VA
(757) 788-0052
DACampbell@cox.net
North Dakota
Tracey Regimbal, RHIT
Grand Forks, ND
traceyregimbal@hotmail.com
Washington
Sheryl Rose, RHIT
Spokane, WA
(509) 624-4109
sherylrose622@hotmail.com
Ohio
Pamela Greenstone, MEd, RHIA
Mason, OH
(513) 403-9014
Pamela.Greenstone@uc.edu
West Virgnia
Kathy Johnson, RHIA
Sinks Grove, WV
(304) 772-5312
kjohnson@care-communications.com
Oklahoma
Christy Hileman, MBA, RHIA, CCS
Mustang, OK
(405) 954-2824
christy.hileman@faa.gov
Wisconsin
Susan Casperson, RHIT
Cecil, WI
(715) 853-1370
susan.casperson@thedacare.org
Oregon
William Watkins, RHIA
Oregon City, OR
(503) 867-5173
william.w.watkins@kp.org
Wyoming
Kimberle Johnson, RHIA
Gillette, WY
(307) 682-1251
kim.johnson@ccmh.net
Pennsylvania
Laurine Johnson, MS, RHIA, FAHIMA
Sarver, PA
(724) 295-9429
ljohnson@peakhs.com
Puerto Rico
Brunilda Velazquez, RHIA, CCS
Guayanilla, PR
(787) 505-1433
Rhode Island
Patti Nenna, RHIT
Bristol, RI
(401) 253-1686
pnenna@cox.net
South Carolina
Karen B. Farmer, RHIT
Greenville, SC
(864) 277-1982
kfarmer@ghs.org
Advertising Index
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DivisionofHealthInformatics&InformationManagement
TheWVUSchoolofMedicinesnewlycreatedDivisionofHealthInformatics&InformationManagementisseeking
applicationsforafulltime,12monthtenureorclinicaltrackfacultypositiontoserveasfoundingfacultymemberand
programdirectorfortheplannedbaccalaureatedegreeprograminhealthinformaticsandinformationmanagement.Rank
andsalaryarenegotiableandwillbecommensuratewithqualificationsandexperience.
Applicantsmustmeetthefollowingcriteria:
1.Bachelorsdegreeinhealthinformaticsandhealthinformationmanagement
2.CertificationasaRegisteredHealthInformationManagementAdministrator(RHIA)
3.MastersdegreeinHIMorarelatedfieldofstudy
Thefollowingareattributesthatwillbeviewedfavorably:
1.ThreeyearsofpracticalexperienceinthefieldofHIM
2.Someeducationalexperience,includingcoursedevelopmentandteaching(maybeonsiteoronline)
3.Supervisoryorleadershipexperience
Qualifiedapplicantsareinvitedtosubmitaletterofinterest,curriculumvitae,and3referencesto:
CorrieMancinelli,PT,PhD,AssociateProfessor
WestVirginiaUniversity,POBox9226
Morgantown,WV26506
cmancinelli@hsc.wvu.edu
3042931311
Thepositionwillremainopenuntilfilled.
WestVirginiaUniversityisalandgrantResearchUniversity(HighResearchActivity)asclassifiedbytheCarnegie
Foundation.WVUconsistsof15CollegesandSchools,197degreeprograms,andapproximately30,000undergraduateand
graduatestudents.TheHealthSciencesCentercampusislocatedinpicturesqueMorgantown,WV,whichisan
economicallythrivingsmallcityofapproximately32,000residents.Morgantownhasbeenratedoneofthebestsmallcities
intheUnitedStates.
ThesuccessfulcandidatewillcontributetotheeducationandscholarshipmissionsofthenewlycreatedDivisionofHealth
InformaticsandInformationManagement.ThisdivisionispartoftheDepartmentofHumanPerformance,consistingof
divisionsofphysicalandoccupationaltherapy,aswellasexercisescience.InJune,2014,theuniversityadministration
approvedtheIntenttoPlanforthebaccalaureatedegreetobeofferedinacademicyear20152016.Inordertoobtain
finaluniversityapprovaltoofferthedegree,thecoursesandcurriculummustbedeveloped.Developmentofthese
materialsandprogressionthroughtheuniversityprocesswillbethemainresponsibilityofthisposition.Afterthisapproval
isobtainedasanticipatedin2015,thepositionwillserveasprogramdirectortoinitiatetheaccreditationprocessandto
beginothernecessarystepstorecruitthefoundingcohortofstudents.
SchoolofMedicinehttps://www.hsc.wvu.edu/som/WestVirginiaUniversityhttp://www.wvu.eduMorgantownhttp://www.morgantownwv.gov
WVUisanEEO/AffirmativeActionEmployerMinority/Female/Disability/Veteran.WestVirginiaUniversityistherecipientofanNSFADVANCEDawardforgenderequality
Journal
Journal of
of AHIMA
AHIMA June
June 15/79
15 / 79
Upcoming Issues:
July
Clinical Documentation
Improvement
August
Special Issue:
Information Governance
September
Consumer Engagement
Limited space available!
Custom Packages available to fit your
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80/Journal
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AHIMA June
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JOURNAL AHIMA
OF
CONSULTING &
OUTSOURCING
GUIDE
2015
Journal of AHIMA June 15/81
CONTENTS
3M Health Information Systems.....................................82
Administrative Consultant Service, LLC. . ........................95
Amphion Medical Solutions...........................................83
Anthelio Healthcare Solutions.. ......................................84
Care Communications...................................................95
Career Step.................................................................83
Charts in Time, Inc.......................................................85
DocuCoders.................................................................95
eCatalyst Healthcare Solutions, Inc... .............................85
emids, Inc.. ..................................................................86
First Class Solutions . . ...................................................86
GeBBS Healthcare Solutions, Inc...................................95
Health Information Associates.......................................87
HealthPort...................................................................88
HRS............................................................................87
Just Associates, Inc.....................................................89
Kiwi-Tek......................................................................90
90%
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Percentage of cases measured
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88 CONSULTING
& OUTSOURCING GUIDE
/ June
2015
2015 AHIMA June Resource Guide Ad FINAL.pdf
1
4/7/15
3:08 PM
Audit Chaos
High volumes of audit requests arrive
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vs.
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CMY
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Transcripton
Full medical transcripton
services are available.
Cary Weltken
Sr. Vice-president - North America
San Francisco, California
Phone: 707-773-3325
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