308 results.
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Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS (2013 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Telemedicine Services and the Health Record (2013 update)
Author: Johnson, Marlene L.; Warner, Diana
Source: AHIMA practice brief
Publication Date: May 2013
Editor's Note: This practice brief supersedes the April 1997 practice brief "Telemedical Records."
Telemedicine is a rapidly growing industry in the medical practice. Telemedicine is defined as telecommunications systems that link healthcare organizations and patients from d....
Rules for Handling and Maintaining Metadata in the EHR
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: May 2013
Metadata is the foundation on which information management systems are built. It is required to support the various uses of data, to manage the information and record lifecycle, to verify data integrity, authenticity, and reliability, and to evaluate the relative importance of data and informat....
Mitigating Coding Risks in the EHR: Physician Coders More Valuable With EHR Implementation
Author: Huey, Kim
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2013
Though it may seem contrary to popular opinion, electronic health record (EHR) products will make providers' coders more necessary and valuable than ever. Physicians who trust only EHR and computer-assisted coding software to choose the codes they bill, without any training or oversight, a....
Assessing and Improving EHR Data Quality (2013 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: March 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Breaking Free of Copy/Paste: OIG Work Plan Cracks Down on Risky Documentation Habit
Author: Robb, Deborah; Owens, Lori
Source: Journal of AHIMA
Publication Date: March 2013
According to the Centers for Medicare and Medicaid Services, evaluation and management (E/M) services accounted for $28 billion in Medicare Part B payments during a one-year period.1 And of these, 8.4 percent were billed at the wrong level-either too high or too low. Chasing these potentia....
Testimony to the HIT Policy Committee Hearing on Clinical Documentation February 13, 2013. Panel 4: Role of Clinical Documentation for Legal Purposes
Author: Dougherty, Michelle
Source: AHIMA testimony and comments
Publication Date: February 13, 2013
Leaders of e-HIM: Three Grace Award Finalists Share Data Integrity, Documentation Improvement, and HIE Plans and Practices
Author: Dooling, Julie A
Source: Journal of AHIMA
Publication Date: January 2013
In October 2012, AHIMA's Grace Whiting Myers Award was presented to the University of Wisconsin Hospital and Clinics in recognition of excellence in health information management (HIM). This inaugural award focused on organizations who have demonstrated effective and innovative approaches....
Holistic Coding Requires Amped Up Clinical Documentation
Author: Alonso, Paula; Love, Tammy R.
Source: Journal of AHIMA
Publication Date: January 2013
Accurately coded data does more than just provide the mechanism for appropriate reimbursement. It also tells the story of the patient, the complexity of the patient’s case, and reflects the care provided to the patient. This growing trend of “holistic coding” seems to be....
Using CDI to Meet Federal Quality Measures
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: January 2013
Clinical documentation is the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has been an ongoing challenge to health informati....
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