This research study examined the gaps in documentation that occur when coding in ICD-10-CM. More than 4,000 diagnoses from all chapters were coded from 656 electronic documents obtained from a large integrated healthcare facility at the time the study was conducted (2012). After the documents were coded, areas for documentation improvement were identified for chapters that resulted in deficiencies in documentation, and a quick reference guide was developed.
An exploratory study was undertaken to determine the role and practice issues of radiology coding in health information management (HIM) practice. The study sought to identify the challenges of radiology coding and the solutions implemented to address these challenges. A self-report survey was sent to 828 American Health Information Management Association (AHIMA) members identified as directors, managers, or supervisors of HIM departments and/or coding.
Conference Proceedings by Sean Benson Abstract The use of computer-assisted coding (CAC) software is becoming more common at the point of care. Two main approaches to CAC software have been used—structured input (SI) and natural language processing (NLP). This study focuses on the use of SI software at the point of care and its impact […]
The processes of data mapping and concept modeling are required to help meet the goal of interoperability for an electronic health record (EHR). Interoperability, as defined by the Institute of Electrical and Electronics Engineers, is “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.”