by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA You are reading a record. You see a medical term. You look in the index or check your ‘cheat-sheet’ and find a range of codes that contain that word. You read the description and find the one that is closest, probably. And you’re done. Next record. I am […]

For The Record Magazine Nov.-Dec. 2021 “In health care, there’s always something new to learn. An investment in education is an investment in yourself.  It’s part of a coder’s professional development and it can help advance careers and add value to the organization.  The more skills coders have in their toolbox, the more likely they […]

The following decision was released by CMS effective October 28, 2021. The main focus of this document and decision was that there will no longer be a National Coverage Determination (NCD) for this procedure and instead, coverage or non-coverage will be made at the local level by the Medicare Administrative Contractor (MAC). Additionally, based on […]

by Cari A. Greenwood, RHIA, CCS, CPC, CICA Healthcare delivery is not a static enterprise. The development of new procedures and the discovery of new diseases requires the introduction of new codes and sometimes new coding guidelines. The regulatory environment changes in significant and minor ways every year. Our complex reimbursement system, auditors and the […]

By Angela Lima, BS, CCS, CDIP, COC, CIC, AAPC-Approved Instructor The ‘Great Reshuffle,’ the idea that individuals are seizing this post-pandemic moment to make changes in their career, is creating an opportunity for healthcare organizations willing to fill their open coding jobs with candidates who may be long on enthusiasm but short on experience. While […]

by Laurie M. Johnson, MS, RHIA, FAHIMA, Senior Consultant, Revenue Cycle Solutions, LLC It’s hard to believe that we are already well into FY2022. While the changes to the codes and guidelines have been in effect for a while, if you haven’t completed all of your fall clean-up tasks, you should begin as soon as […]

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Which code would you use for incision and debridement of the infected port pocket? “The port pocket incision and neck dermatotomy site were reopened. Using manual pressure, purulent contents were expressed from the incisions. The pocket was copiously irrigated and anterior antegrade and retrograde […]

By Justin Bariso, Principal, EQ Applied Reprinted with Permission “You know, you’re the type of manager the rest of us hate.” I’ve never forgotten when someone told me that. I was only 23, and I was working in a factory in downtown Brooklyn. We were making encyclopedias (remember those?), and our job was to quality […]

by Cari A. Greenwood, RHIA, CCS, CPC, CICA In the past year AHIMA revised their requirements for candidates to be eligible to sit for the CCS examination. While AHIMA still recommends that a candidate meet one or more qualifications from a robust list of academic preparation, coding experience, and/or other professional credentials, it is no […]

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA It’s that time of year! No, I’m not talking about holiday preparation. I’m talking about the year-end activities you, as coding professionals, should be doing to ensure your HCC process is truly excellent: prior HCCs are captured in your records, documentation reflects the details that help […]

By Gail I. Smith, MA, RHIA, CCS-P What is the difference between a spine level, interspace and vertebral segment? Anatomy drives the answer to that question but CPT terminology used them interchangeably for posterior lumbar fusion. This caused coding professionals frustration for many years. Help is finally on the way for 2022. Anatomy Review Anatomy […]

by Barry Libman, MS, RHIA, CDIP, CCS Some auditors and educators have a stylistic habit of using the word inappropriate to describe coding choices that they advise against. I would rather they called it incorrect. “Inappropriate” refers most often to behavior and usually someone’s opinion of that behavior. It is considered inappropriate to visit the […]

By Cari A. Greenwood, RHIA, CCS, CPC, CICA The CCS certification is a mastery level medical coding credential that tells employers, right off the bat, that you have the knowledge and skill to tackle complex coding scenarios. AHIMA’s description of the CCS says: “Coding specialists are skilled in classifying medical data from patient records, often […]

By Angela Lima, BS, CCS, CDIP, COC, CIC, AAPC-Approved Instructor As a Coding Manager or Director, you are probably aware of the increased difficulty you face in hiring skilled and capable coders. While we look forward to research on the deeper dynamics causing this to occur, anecdotal information points to the disruptive effect of COVID […]

By Lisa A. Eramo, MA When COVID-19 struck, coders at Garnet Health in Middletown, NY did something they’d never done: They went 100% remote. With that came a whole host of challenges and opportunities for this unionized workforce, say Erica Burgos, system director of clinical documentation improvement (CDI) and coding, and Maryann Malamas, CCS, CIRCC, […]