ahima-perspectives > Paper Categories > Coding & Reimbursement

Coding & Reimbursement

The Natural History of CDI Programs: A Metric-Based Model

By Howard Rodenberg, MD, MPH, and James D. Campbell, MD

The success or failure of a clinical documentation integrity (CDI) program is often evaluated using a designated set of metrics. However, these metrics change over time, and an understanding of these changes is critical to properly judge the efficacy of the CDI effort. The authors propose a...
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Procedure Code Utilization for Vascular Access Device Placement in the Inpatient Setting: A Retrospective Analysis

Erica DeBoer, RN, MA, CCRN-K, CNL, and Kimberly Alsbrooks, BSN, RN, RT (R), VA-BC

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in...
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The Coding Impact of Acute Kidney Injury in Pediatric Hospital Documentation

Ella Tierney; Ayesha Irani, DO; Meena Iyer, MD; and Alyssa A. Riley, MD, MEd

Acute kidney injury (AKI) increases patient morbidity and mortality. In value-based care, the documented and coded diagnoses during hospitalization influences an encounter’s relative weight (RW), including severity of illness (SOI), and risk of mortality, which ultimately determines...
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Improvements for the Prior Authorization Process for Elective Surgical Procedures at an Academic Medical Center

By Karen Y. Marble, MHS; Genie R. Briggs MHS; and Xiaoshan Z. Gordy, PhD

Prior authorization is an approval process to ensure that services provided by healthcare organizations will be reimbursed by insurance carriers. Prior authorization denials can result in revenue loss. Due to multiple prior authorization issues, over $21 million in charges was denied, and...
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Use of Dental Related ICD Coding to Determine Comorbidities in Mississippi

By Priscilla Nordan, MHIIM; Shamsi Daneshvari Berry, PhD, MS, CPHI; and Mary E. Morton, PhD, RHIA

Over the years, there has been a substantial effort to improve patient health and reduce healthcare costs through preventive medicine. Regular dental care prevents tooth decay; published research shows how oral health can impact other organs, such as the heart. Heart disease is the leading cause...
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Upcoding Medicare: Is Healthcare Fraud and Abuse Increasing

By Alberto Coustasse, DrPH, MD, MBA, MPH; Whitney Layton, MS; Laykin Nelson, MS; and Victoria Walker, MS

Medicare fraud has been the cause of up to $60 billion in overpaid claims in 2015 alone. Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursement. The purpose of this study was to assess the...
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