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ABCs of Medicare Advantage

Author: Hernandez, Jeannette

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008


Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.

By June 2....

ACE Member Educates on Copy/Paste

Author:

Source: AHIMA Advantage

Publication Date: October 2009

An avid HIM volunteer, author, presenter, and Action Community for e-HIM Excellence (ACE) member, Diana Warner recently helped take on the copy/paste subject for an AHIMA toolkit and webinar detailing copy/paste best practices. Warner's close working relationship with physicians also led her to volunteer as co-chair of the AHIMA Physician Practice Council, a committee she has served on since its inception three years ago.

AHIMA Offers Tips, Tools for Auditing in Long-term Care

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2001


Once upon a time, the role of the medical records department in a long-term care (LTC) facility was to file and assemble discharge records. Those days are long gone. Today, it is critical for HIM practitioners to focus on the content and quality of the documentation in the medical record.
....

Amendment, Corrections and Deletions Technical Paper

Author: Wiedemann, Lou Ann

Source: AHIMA Convention

Publication Date: October 02, 2011


The health record is the legal and business record of the healthcare organization. As such, ensuring accurate and timely doucmenation is paramount for information management. The Centers for Medicare and Mediciad services (CMS) has patient safety goals. A key component to this process is to ma....

Appropriate Use of the Copy and Paste Functionality in EHRs

Author: AHIMA

Source: AHIMA position statement

Publication Date: March 2014

Use of the copy and paste functionality in EHRs can result in redundant, erroneous, and/or incomprehensible health record documentation. Misuse of this functionality has the potential to result in or contribute to several overarching challenges, with implications for the quality and safety of patient care, medico-legal integrity of the health record, and fraud and abuse allegations.

Assessing and Improving EHR Data Quality. Appendix A. Case Study: How One Hospital Improved Healthcare Data Quality in Its EHR

Author: Schleis, Kathy

Source: AHIMA web extra

Publication Date: March 02, 2007


Holy Family Memorial Medical Center (HFM), a hospital within a healthcare network, has a hybrid record-part paper, part electronic. In l989, HFM initiated the computerization of the diagnostic areas of the hospital such as the lab and dictated reports. Through the years, system implementation h....

Assessing and Improving EHR Data Quality: Model for Implementing an EHR Documentation Improvement Process

Author: AHIMA e-HIM Work Group on Assessing and Improving Healthcare Data Quality in the EHR

Source: Journal of AHIMA

Publication Date: March 2007


Improving data quality in an electronic healthcare environment requires a greater focus on standardized documentation procedures. With an EHR, the need to evaluate and improve healthcare data quality through concurrent assessment, data collection monitoring, and ongoing process improvement requ....

Auditing Copy and Paste

Author: AHIMA

Source: Journal of AHIMA

Publication Date: January 2009




For organizations that allow carrying forward clinical documentation, auditing its use is a key part of ensuring document integrity.




Copying clinical documentation can be a time-saver for busy clinicians. It also can pose a risk to document integrity. For org....

Best Practices: What Works

Author: Carrier, Danielle

Source: Journal of AHIMA

Publication Date: July 1999




Medical record accuracy, record completion time, physician satisfaction—all of these are indicators of how well an HIM department is performing. The findings of a UHC benchmarking study may point the way to best practices that can be shared and adapted.

What....

Bird’s Eye View of ICD-10 Documentation Gaps: Vendor analysis offers big picture look at nationwide documentation holes—and how to fill them

Author: Hinkle-Azzara, Barbara; Carr, Kimberly J

Source: Journal of AHIMA

Publication Date: June 2014



Increased clinical specificity is one of the greatest advantages of moving to ICD-10-CM/PCS. With specificity comes the ability to perform granular research that can help uncover significant trends and statistics to identify causes of diseases, links between diseases, and more. While heal....

Boosting Efficiency in Home Health Record Systems

Author: Abraham, Prinny

Source: Journal of AHIMA

Publication Date: April 2000


The growing pains of the past decade have led to medical record backlogs and record retrieval crises for many home healthcare agencies. These problems have pushed more than one agency director into enlisting the skills of an HIM professional to evaluate the medical record systems in pl....

Catching Up with PEPP

Author: Bryant, Gloryanne H.; Fletcher, Robin

Source: Journal of AHIMA

Publication Date: September 2000


A year ago, the Journal of AHIMA reported on the newly created Payment Error Prevention Program (PEPP), which went into effect in August 1999. What has happened since then?
Best Billing Practices

PEPP was created to reduce Medicare prospective payment system (PPS) ....

CDI: A Cog in the Wheel of Information Governance

Author: Downing, Katherine

Source: Journal of AHIMA

Publication Date: July 2016



Information governance (IG) is an emerging discipline in healthcare that focuses on how an organization ensures information is complete, accurate, trustworthy, and usable. The goal of information governance is to enable organizations to utilize a valuable strategic asset—information&....

CDI's Promise and Possibilities

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2014




“The first job of a leader—at work or at home—is to inspire trust. It’s to bring out the best in people by entrusting them with meaningful stewardships, and to create an environment in which high-trust interaction inspires creativity and possibility.”

"Chutes and Ladders" of the Revenue Cycle: Strategies to Understand Data and Coding Quality Issues That Impact Your Ability to Successfully Play the Revenue Cycle Game

Author: Bauman, Carrie M.

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

Since 1991, I have made a career in health information management. I entered the profession in the roles of assistant director and director of medical records in the acute care setting. After installing a Windows-based chart tracking system and a document imaging system, I f....

Clarifying Selected CPT Modifiers

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2000


Coding for professional services is complicated enough when coding professionals are charged with assisting the physician to select the best five-digit number for the services rendered. It becomes even more complex when circumstances of the case require the CPT code to be modified. Add....

Clinical Documentation Improvement Program Strategies

Author: Mills, Mary

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction
What Is CDIP?

Aclinical documentation improvement program (CDIP) is a program focused on improving clinical documentation on a concurrent basis where a coder or documentation specialist, such as a nurse, reviews the medical record and consults with physicians regarding....

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