Author: Bronnert, June; Daube, Julie L; Jopp, Gretchen; Peterson, Kathleen; Rihanek, Theresa; Scichilone, Rita A; Tucker, Vanna

Source: Journal of AHIMA

Publication Date: March 2014

Electronic health records (EHR) have changed the landscape for data representation. For many years health information management (HIM) professionals have relied on classifications for data representation and the support of clinical documentation. SNOMED CT is a data standard frequently used in electronic systems and has been included in the requirements for the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR Incentive Program. SNOMED CT is maintained and distributed by the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED CT is recognized throughout the world, and the terminology is available at no cost. The National Library of Medicine (NLM) serves as the US release center and the IHTSDO member country representative.

Author: McGinness, Doris; Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank

Source: Journal of AHIMA

Publication Date: February 2013

RxNorm is a public domain drug vocabulary maintained by the National Library of Medicine (NLM) on behalf of the United States. The purpose of RxNorm is to facilitate the sharing of electronic drug information between hospitals, pharmacies, and healthcare professionals. The scope of RxNorm....

Author: Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank; Rose, Eric; Aldin, Greg

Source: Journal of AHIMA

Publication Date: July 2012

Terminologies ensure that the 'languages of medicine' can be understood by both humans and machines.



Electronic health records (EHRs) are the industry standard for documenting patient care. Industry initiatives and government legislation have facilitated EHR i....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2011

One of the biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the "use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare p....

Author: White, Susan E; Kallem, Crystal; Viola, Allison F.; Bronnert, June

Source: Journal of AHIMA

Publication Date: June 2011

In April the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking for the Medicare Shared Savings Program. The program was mandated by the Affordable Care Act to encourage the development of accountable care organizations (ACOs) in Medicare.

The....

Author: Smith, Gail I.; Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010

The coding world is not immune to technology advancements. Computer-assisted coding (CAC) technology is changing how the coding process is accomplished across all healthcare settings. CAC technology continues to integrate into a coding professional's daily life. This article focuses on the too....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2009

Two new E code sections go into effect October 1—E000, External Cause Status, and E001–E030, Activity. The sections will facilitate prevention strategies developed by epidemiologists and injury prevention specialists and bring ICD-9-CM E codes more in line with ICD-10-CM external c....

Author: Viola, Allison F.; Kallem, Crystal; Bronnert, June

Source: Journal of AHIMA

Publication Date: April 2009

A voluntary quality improvement program just under way will assist organizations in better understanding the underlying causes associated with adverse events.




Publication of the Institute of Medicine’s report To Err Is Human in 2000 placed substant....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2008

The term “long-term care hospital” (LTCH) can leave some in a quandary—do these facilities provide acute care or long-term care? Many people associate them with skilled nursing facilities.

However, LTCHs are not synonymous with skilled nursing facilities; each has....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: June 2007

by June Bronnert, RHIA, CCS, CCS-P

Chronic kidney disease (CKD) affects 20 million Americans, or one in every nine adults, and another 20 million Americans are at risk of developing CKD, according to the National Kidney Foundation. With this prevalence, it is important for coding professio....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: October 2006

While science and research have shed light on the various stages of fetal development, the process is still fascinating. This article details each month of a fetus’s development and reviews common delivery complications and where related information may be documented in the record.
....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: September 2006

Patients or residents are admitted to long-term care (LTC) facilities for a variety of reasons. While there, many receive some type of therapy, from physical to speech, during their stay. This article reviews the various procedures that may be provided to a resident at an LTC facility as well....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2006

All surgical procedures involve potential risks, which is why patients are asked to sign an informed consent. Conditions that arise after a procedure may be considered complications. Coding professionals must be able to determine if a condition is a complication per ICD-9-CM guidelines.

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: May 2006

In 2003 61 percent of adults drank alcohol, according to the National Center for Health Statistics.1 Illicit drug use for that same year is reported at 8 percent, with 6 percent using marijuana.2 With those statistics, it’s a safe bet that coding professionals will encounter records repo....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: March 2006

To code or not to code can be one of the toughest questions a coder faces on a day-to-day basis. Assigning the appropriate secondary diagnoses can be a challenge. This article describes appropriate coding of secondary diagnoses by reviewing documentation of a history and physical.

Un....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2005

With the many reimbursement issues and regulatory requirements surrounding coding, it is sometimes necessary for coders to refamiliarize themselves with what it means to code ethically. AHIMA’s Coding Policy and Strategy Committee developed the Standards of Ethical Coding, which were app....

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2005

The employment market for coders is expected to increase 36 percent or more between 2002 and 2012, according to the Bureau of Labor Statistics.1 Even now we are experiencing a shortage of qualified coders. Ask a coding manager to name the biggest challenges of the job, and recruitment and ret....