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Editor's e-Note
It’s almost here. No longer is it some mythic figure off in the distance. The anticipation is palpable. Yes, ICD-10 is around the next bend.

Is your coding staff ready? Who can really say for sure until the ball drops on October 1? Nevertheless, it wouldn’t hurt to feel confident, knowing you’ve done everything possible to be prepared. To get a better read on where your staff stands, check out this month’s E-News Exclusive which presents four suggestions for conducting reliable coder assessments.

Lee DeOrio, editor
e-News Exclusive
Assessing Your ICD-10 Coder Performance —
Four Steps to Move From Predictions to Certainty

By Paul Strafer, RHIA, CCS

It’s the question on every coding manager’s mind: How can one truly know how coders will perform once ICD-10 goes live? Much is banking on this answer. Claims denial rates are predicted to rise 100% to 200% in the early stages of ICD-10. Coders are expected to be up to 50% less productive and diagnosis-related group (DRG) shifts are predicted. The good news is that the Centers for Medicare & Medicaid Services’ end-to-end testing results thus far in 2015 have been positive for ICD-10 coding accuracy—only 3% of claims were denied due to ICD-10 coding errors during the January 2015 testing period.

With only two months ahead, now is the time for HIM directors to move from these early coding predictions to today’s coding reality. This article provides four tips to efficiently and effectively assess coder performance in preparation for October 1.

Full Story »
Industry Insight
Clinical Decision Tools in EMRs Can Reduce
Childhood Radiation Exposure

Childhood exposure to ionizing radiation increases lifetime malignancy risk, but a team of researchers has found that with just a little bit of education, the risk can be significantly reduced. Currently, up to 40% of CT scans are ordered unnecessarily for those of all ages. The study, “Point-of-Care Estimated Radiation Exposure and Imaging Guidelines Can Reduce Pediatric Radiation Burden,” appears in the Journal of the American Board of Family Medicine.

Researchers from the Uniformed Services University of the Health Sciences (USU), Cincinnati Children’s Hospital Medical Center, National Library of Medicine, and Clemson University, led by Air Force Major Christopher W. Bunt, MC, FAAFP, an assistant professor in the department of family medicine at USU’s F. Edward Hébert School of Medicine, conducted a study of 115 physicians from 17 military family medicine training programs to determine whether the clinical decision support system, which encompasses a variety of tools to enhance decision-making in the clinical workflow, and the order in which decision-support information is presented would impact physician imaging choices.

Read more »
In this e-Newsletter
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This Will Go On Your Permanent Record — Or Will It?
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How Togetherness Can Divide
If not properly managed, hospital mergers can wreak havoc on organizational workflows. Read more »

The Human Touch
A recent study shows that dictated reports need quality assurance steps to maintain data integrity. Read more »

Short-Stay DRGs: Fix or Fiasco?
Industry experts question whether tying short inpatient stays to diagnosis-related group payments is a good idea. Read more »
Other News
Scribe Value in Easing Burnout
Is an Ongoing Debate

One oncologist thinks having a medical scribe to assist with documentation would be ideal, but doubts scribes have enough oncology training, according to OncLive.

Computer Outage Disrupts
Missouri Health System

BJC HealthCare, a large hospital provider based in St. Louis, experienced a computer outage lasting 20 hours that temporarily disrupted its operations systemwide, reports
A Secure, Anonymous Résumé Bank
Job Alerts Sent to Your E-mail
AHDI Healthcare Documentation Integrity Conference 2015
By Carrie Boatman, CHDS, AHDI-F

Wow! What a conference. It started off in Washington, D.C., on August 7, and it was awesome. This year’s focus was on documentation integrity and each session focused on a different aspect of that complicated process. Attendees were given an opportunity to hear about various aspects of the process to give them a broader and deeper understanding of all the moving parts.

There were several presentations that addressed the query process used to drill down on specific information necessary for ICD-10 coding. We all know it’s vitally important to have the information, but how to ask it in an appropriate manner so there can be no hint of “leading” the physician was addressed by a number of speakers. One had an interesting idea of opening up the EHR architecture to allow health care documentation specialists (HDSs) to do direct queries of providers to assist in speeding up the process. For example, if the HDS is doing an operative report for a total hip and the provider fails to identify the components used (eg, metal, metal on metal, ceramic, etc), there would be a mechanism built into the platform to allow the HDS to simply query in a straightforward manner. This saves time and effort downstream for coders and others who analyze the documents for statistical and medical information.

Read more »
Featured Jobs
The nation's top employers and recruiters of HIM talent advertise in For The Record magazine and post their job openings on Check out the most recent opportunities that have been submitted by employers across the country!

Certified Medical Coders, Clinical Documentation Specialists,
Revenue Cycle Specialists, and More
—Anthelio Healthcare Solutions
Coders/Coding Consultants—Amphion Medical, FT/PT, Home-based
MLS/Speech Understanding Editors—Amphion Medical, FT/PT, Home-based
Coding Opportunities—Health Information Associates
Remote Inpatient Coders—M*Modal, Remote (Telecommute)
RN, Clinical Documentation Improvement Specialist—Bayfront Hospital St. Petersburg
RHIT, RHIA, CCS Certified Coders—Healdsburg District Hospital, CA
Manager HIM Coding/Clinical Documentation, Coding Quality Auditor—UFHealth Shands Hospital, Gainesville, FL
Hospital Coding Opportunities—Piedmont Healthcare, Atlanta, GA
Ak the Expert
Have a coding or transcription question? Get an expert answer by sending an e-mail to

This Month’s Selection:
Anesthesia/CPT code for a planned electrophysiology study (EPS) in the cath lab that was not done because of rarity of PVCs [premature ventricular contractions], but an Isuprel infusion was given?

Karen Prater, CPC
Palmetto Health Richland

It appears that the patient was in the cath lab and received anesthesia along with Isuprel to induce an arrhythmia for the EPS. This question seems to be focused on the anesthesia billing, however, we aren’t certain what perspective this question is coming from, so we’ve provided our response as noted below:

• Hospital Outpatient Facility: The appropriate EPS code should be reported with modifier 74 (discontinued procedure after anesthesia administration) to indicate the procedure was discontinued after administration of anesthesia. No anesthesia CPT codes would be reported since this is integral to the procedure and is included in the EPS code/procedure. The medicinal agent and appropriate drug administration charge for the Isuprel may also be reported.

• Professional Billing, Cardiologist: The appropriate code for the EPS should be reported using modifier 53 (discontinued procedure).

• Professional Billing, Anesthesiologist: The anesthesiologist would report the appropriate anesthesia code, eg, 00537 (anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation). This code is eligible for time-based payment so the start and stop times would reflect the shortened anesthesia time.

— Jodi Stewart, RHIA, CCS, is an AHIMA-approved ICD-10-CM/PCS trainer and director of inpatient coding and content services for VitalWare.
Tech & Tools
ICD-10 Code Translation Tool
Includes CPT/HCPCS Codes

3M has released a new version of the 3M ICD-10 Code Translation Tool, which has been expanded to include CPT and other HCPCS codes. Using sophisticated translation technology, the software automatically reviews lists of ICD-9 or CPT and other HCPCS codes and finds the associated ICD-10 codes. ICD-10 transition teams can use the software to normalize reports, help educate staff, update processes, and reduce the time and resources devoted to code conversion. The tool is a cloud-based application that can be used to convert ICD-9 and CPT coding-based forms, reports, reimbursement contracts, policies, and systems to ICD-10, and to identify the financial impact of ICD-10 on future reimbursement. Learn more »

Medaxion Mobile-Based
Anesthesiology EHR

Medaxion has developed a mobile-based EHR offering for anesthesiologists. Medaxion Pulse, which is available on iPads and iPhones, helps anesthesiologists with documentation and communication. After practitioners enter data into Medaxion Pulse, the system will send updates to the clinical team and administrative staff, including event times, case providers, vital signs chart, procedures, and patient history. Relevant team members also receive detailed text messages when certain events occur (eg, when there’s a role handoff, incomplete case record alert, conflicting schedule data warning, or fax printing error). Medaxion Pulse will use these data to create quality improvement reports and management reports, which include billable hours by provider, procedures by provider, and operating room utilization. Learn more »
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Coming up in our September issue is our CDI Showcase. Contact sales for more information. is the premier online resource to recruit HIM professionals. Post your open positions, view résumés and showcase your facility's offerings all at!