Archive for Health Information Management
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Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
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Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
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Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
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Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.
Prepare for miscellaneous costs that may arise during the transition to ICD-10
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Follow these steps when researching an ICD-9-CM coding question:
- Start with the ICD-9-CM Manual. You can resolve many ICD-9-CM coding questions by carefully studying the ICD-9-CM Manual itself, paying particular attention to typographical conventions and the various notes included throughout the Manual.
- Review the official guidelines. The Public Health Service and CMS jointly publish the Official ICD-9-CM Guidelines for Coding and Reporting. The following organizations helped develop and approve these guidelines:
- American Hospital Association (AHA)
- AHIMA
- CMS
- National Center for Health Statistics
- Review Coding Clinic. Coding Clinic is a newsletter published by the AHA. Representatives from the four organizations listed above review and approve each issue of Coding Clinic. You can order a subscription or back issues of Coding Clinic from the AHA by calling 800/AHA-2626.
This tip was adapted from the handbook, Coding and You: What Every Healthcare Professional Should Know. For ordering information, visit the HCMarketplace.
The Health and Human Services (HHS) department has named Dr. David Blumenthal as the national coordinator for health information technology, according to a March 20 Associated Press/Miami Herald news release. Blumenthal, who had most recently been the director of the Institute for Health Policy at The Massachusetts General Hospital/Partners HealthCare System, will help determine how to spend the $19 billion outlined in the American Recovery and Reinvestment Act of 2009 that President Obama signed into law on February 17.


