CODING & CDI GUIDE - AHIMA 2019 | RESOURCE GUIDE - Journal of AHIMA
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A H I MA
2019 | RESOURCE GUIDE
CODING
& CDI GUIDE
Journal of AHIMA April 19 / 51
52 CODING & CDI GUIDE / April 2019
CODING ADVICE
CONTENTS FROM THE
CODING EXPERTS
AHA Central Office ......................52
American Society of
Anesthesiologists ........................54
ICD-10-CM AND ICD-10-PCS
Aviacode .....................................55 CODING HANDBOOK
Coding Concepts .........................55
First Class Solutions ....................56
Healthcare Cost Solutions ...........59
Indiana University School of Informatics NELLY-LEON CHISEN, RHIA
and Computing at IUPUI ...................56 AUTHOR OF 2019 HANDBOOK
EDITOR OF CODING CLINICS
Labouré College ..........................57
SourceHOV Healthcare, Inc. .........58
Stat Solutions, Inc. ......................59
see our full profile on AHIMA www.ahacentraloffice.com
ResourceConnect at
resourceconnect.ahima.org
AHIMA ResourceConnect advertisers as of 3/4/19.
April
Month2019
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Become a Code Cracker and
Documentation Detective
LIKE THE HEALTHCARE profession itself, healthcare basement of a hospital, still coding from paper charts,
coding and clinical documentation improvement the idea of being able to work from home much more
(CDI) are dynamic, ever-changing industries that re- dream than reality. Now that the telecommunting coder
quire professionals to stay vigilant with their training. is indeed reality, some wonder what impact—postive or
Hoping to help coding and CDI professionals with this negative—this is having on work dynamics and quality.
task, the Journal of AHIMA’s Code Cracker and Docu-
mentation Detective web-exclusive columns feature Coding Diabetes Mellitus with Associated Conditions
industry experts diving into the details and offering One of the most popular Code Cracker articles, this
readers best practices that ensure quality clinical in- post reviews the confusion among coding profession-
formation and properly coded and billed cases. als regarding interpretation of the coding guideline
Specifically, Documentation Detective discusses “with.” An area that contains many instances of using
how to achieve quality clinical documentation with a this guideline in ICD-10-CM is coding Diabetes Melli-
comprehensive approach aimed at covering all realms tus with associated conditions. There are 53 instances
of the healthcare industry—inpatient, outpatient, phy- of “with” subterm conditions listed under the main
sician office, and beyond. Code Cracker acts as both term Diabetes.
a job aid (How do I code diabetes mellitus with as-
sociated conditions again?) as well as a forum to vet Documentation Detective Highlights
big picture questions about the industry at large (Just Documentation Detective is updated monthly and
how effective is computer-assisted coding?). available at https://journal.ahima.org/category/blogs/
The vendors in this Resource Guide aim to of- documentation-detective/.
fer services that help healthcare organizations get
their coding and CDI work done right. This is also The Impact of Neonatal Abstinence Syndrome on Clinical
the objective of the Documentation Detective and Documentation
Code Cracker blogs—illustrated below with a se- While neonatal abstinence syndrome is a serious con-
lection of popular recent posts that show a coding dition, the lack of a standard clinical definition makes
professional or CDI specialist’s work and training is it difficult for providers to recognize the symptoms
never finished. and accurately diagnose and treat newborns. If the
syndrome is not recognized, and thus not document-
Code Cracker Highlights ed, then the correct diagnosis code will not be as-
Code Cracker is updated monthly and available at signed—which in turn impacts the state and national
https://journal.ahima.org/category/blogs/code- statistics regarding this syndrome.
cracker/.
Temporary Newborn Name Compliance: A Focus on
Computer-Assisted Coding: Helpful or Hurtful? Patient Safety
Computer-assisted coding (CAC) has become a com- Assigning newborns temporary names at birth is a
monly recognized presence on the health information common practice for hospitals. As a result, a large
management scene, so much so that we now have volume of patients with similar identifiers could po-
coders in the workforce that have likely only ever tentially result in duplicate records and increase the
briefly trained on coding without CAC—or potentially risk for sentinel events.
have never worked without CAC at all. But what im-
pact does that have on the profession? It’s Complicated: Post-Operative Complications
The challenge for CDI specialists is in determining if
Will Coders Ever Return to the Office? the condition is an expected outcome of the proce-
It feels like it has been much longer since the days dure or patient’s disease process, or if it is an actual
when many coding professionals were working in the post-operative complication. ¢
54 CODING & CDI GUIDE / April 2019
Claims errors are costing you.
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Code accurately and compliantly with the 2019 editions of
CROSSWALK® and Relative Value Guide®.
These essential tools are available as print and electronic files.
Get started today
asahq.org/billing-coding
18-038
April
Month2019
2014/ CODING
/ GUIDE &NAME
CDI GUIDE
HERE 55
Maximize Revenue,
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56 CODING & CDI GUIDE / April 2019
70
If you want white glove
ser�ice, you need white HEALTH INFORMATION
MANAGEMENT
glove professionals. 1949 Ñ 2019
OUR LONGEVITY
Serving up ‘first class’ coding and documentation
improvement guidance since 1988, we’re honored
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Health Information Management
• Clinical documentation reviews to boost coding
accuracy and identify educational opportunities
and Medical Coding programs?
• Coding compliance audits (APCs, DRGs, E/M, You can trust that our graduates receive the
and HCCs) to mitigate risk and ensure accurate very best preparation available from an
payments industry-recognized, established program
• Denial management support to identify root at an internationally-respected university.
causes and prevent revenue loss
• ICD-10 education for coding and MDS staff
• Temporary and long-term coding support (APCs,
DRGs, E/M, and HCCs) to fill staffing vacancies CAHIIM- Possible
discounted
and address backlogs accredited
scholarship
At First Class Solutions, we aren’t satisfied
until we’ve exceeded your ex�ectations.
Let us show you what we can do.
Offered 100% Operated by
online and 100% Indiana University
on campus since 1949
go.iupui.edu/soic-him
To learn more about our programs
and our graduates, please contact:
Lisa DesNoyers
HIM Program Director
317-278-8592
ldesnoye@iu.edu
SEE OUR DISPLAY AD ON PAGE 25.
April
Month2019
2014/ CODING
/ GUIDE &NAME
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HERE 57
CDI
Earn 8 credits
with the first
college-level
CDI program in
the country
Labouré College’s online Clinical Documentation Labouré’s Program v. Boot Camp Webinars:
Improvement Certificate is a structured, academic
program designed for credentialed healthcare workers Labouré’s program is different from webinar programs and
identified by ACDIS or AHIMA (RN, RHIA, RHIT, CCS, MD boot camps because it is a college credit-bearing program.
and DO).
Graduates gain a solid background in CDI and daily Labouré College’s CDI program stands alone in
processes and are ready to begin their clinical practice in the its structured, group approach to learning a new
CDI department immediately – without preparatory training
by the healthcare facility. healthcare discipline in an online format.
Quick Facts: All courses are online and taught by nurses and doctors
credentialed in CDI. The program includes weekly
• Start in September, January, or May assignments, recorded lectures, hands-on practice activities,
• Can be completed in two semesters and discussion groups. Most importantly, the program
• Earn eight college credits provides students with an experienced instructor who is
• College accredited by NECHE available to answer their questions. Students also have
• Taught by CDI credentialed nurses and doctors the opportunity to learn from fellow classmates with diverse
• Graduates are fully prepared to begin clinical practice professional backgrounds.
in CDI departments
• Tuition: $2,920 - payment plans are available Each of the four courses covers one or more of the six CDI
(because this program qualifies for college credit it is core competency groups. The eight credits of academic
commonly approved for tuition reimbursement by hospitals coursework represent 120 hours of instruction and
and healthcare organizations) approximately 250 hours of reading or written assignments.
In total, this program represents approximately 10 weeks
of training. This is a significant bonus to healthcare
Courses: 2 credits each organizations hiring Labouré CDI graduates - they can
• Record Review and Document Clarification start immediately on the clinical practice component of their
education and training.
• Clinical Coding Practice
• Metrics and Education
• Compliance and Leadership
For more information:
Please visit laboure.edu or contact the Admissions team at
(617) 322-3575 or admissions@laboure.edu. Educating exceptional nurses and
Program Chair, Elise Belanger, RHIA is also available at healthcare professionals since 1892
elise_belanger@laboure.edu.
Labouré College · 303 Adams Street · Milton, MA 02186 · (617)322-3575 · laboure.edu
58 CODING & CDI GUIDE / April 2019
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April
Month2019
2014/ CODING
/ GUIDE &NAME
CDI GUIDE
HERE 59
Healthcare Audit Resource Technology
Database Solution for the Ever-Changing
Environment of the External Audit
Stat Solutions, Inc. provides tailored
Coding Compliance Audits: solutions for all your HIM needs. We
Inpatient/Outpatient / Clinic focus our efforts on providing the
• Concurrent highest level of quality credentialed HIM
• Retrospective professionals along with the finest
• HCC / Risk Adjustment personalized customer service.
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Remote Coding Support: Coding Quality Reviews
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Healthcare Cost Solutions, Inc.
For more information please call
866.427.7828 / 949.721.2795 888-297-7212
www.hcsstat.com www.statsolutionsinc.com
info@statsolutionsinc.com
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