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Reinventing CDI: Organizations Relaunching And Reworking Data Integrity Efforts, And Coding Roles, With Clinical Documentation Improvement Programs

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2014



It’s a particularly busy night in the local hospital’s emergency department, which is running—as usual—slightly short-staffed. The on-call attending physician goes from room to room treating and diagnosing patients with typical emergency department maladies: influenza, fractured ankle, in....

Use Data Mining Findings as a Tool to Support CDI Education

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

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

Publication Date: July 2014



Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

Using the C-CDA Standard to Meet Meaningful Use

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: July 2014



The Centers for Disease Control and Prevention reported that in 2010, 35 million patients were discharged from non-federal short-stay hospitals in America.1 Vitally important not only to those discharges—but to every discharge that takes place—is whether important information about the pa....

Clinical Documentation Guidance for ICD-10-CM/PCS - Retired

Author: Bielby, Judy A; Comfort, Angie; Reed, Andretta; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2014


Organizations were well on their way to an October 1, 2014 implementation of ICD-10-CM/PCS when Congress passed H.R. 4302, the Protecting Access to Medicare Act of 2014. This bill contained a section stating that the Department of Health and Human Services (HHS) could not adopt the new code set....

Improve Data and Outcomes with CDI

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: July 2014



ICD-10-CM/PCS will require significantly more clinical detail than ICD-9-CM, making clinical documentation improvement (CDI) efforts paramount for healthcare providers across the continuum of care. While CDI programs aim to substantiate claims and improve revenue streams, CDI itself shoul....

Overcoming the Challenges of Adolescent EHRs

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: June 2014




In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems. This month features the conclusion to a two-part series discussing the unique challenges HIM professionals face in deploying EHRs customized to serve pediatric and adolesce....

ICD-9-CM Refresher

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2014





Focus has been on training in ICD-10-CM/PCS for the past few years. With yet another delay, many organizations are slowing down their ICD-10 training and changing their focus back to ICD-9-CM.


The first quarter of 2014 was historic in “coder world” since t....

Navigating a Compliant Breach Management Process

Author: Downing, Katherine

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2014

The purpose of AHIMA’s new Breach Management Toolkit is to provide a comprehensive collection of resources and best practices to help healthcare organizations and health information management (HIM) professionals navigate their way through the Health Insurance Portability and Accountability Act (HIPAA) Breach Notification Rule and the overall breach management process. The toolkit is intended to raise awareness of the importance and responsibility of everyone within the organization to report HIPAA breaches to the appropriate designated personnel, as well as provide breach prevention education and training.

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....

'Recalculating' the Route to ICD-10

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: June 2014



Have you ever driven a car using a global positioning system? If so, you’ve heard what happens when you take a turn that’s not on the system’s expected route: an annoyed-sounding voice will say “Recalculating!”


Since early April, the entire healt....

Things Overheard at the ICD-10 Summit

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2014


Coming on the heels of an unexpected delay of the implementation of the new code set, this year’s ICD-10-CM/PCS and Computer-Assisted Coding (CAC) Summit, held in Washington, DC from April 22–23, was rife with uncertainty and questions—as well as some zingers from federal health officials.

Cultivating Opportunities to Lead in the Face of Delay

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: June 2014



The International Classification of Diseases (ICD) is a language used to capture morbidity and mortality data and helps to provide a snapshot of population health around the world. ICD-9-CM was implemented in the United States in 1979 and is long overdue for replacement. The system is obs....

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Osteopathic, Other Procedures, and Chiropractic

Author: Barta, Ann

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

Publication Date: June 2014


Editor’s note: This is the third in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.

IN THIS ARTICLE, the Journal of AHIMA continues its three-part Coding Notes series focusing on the nine Medical and Surgical-related sections of ICD-10-PC....

Don’t Deny the Denials: Experts Recommend Implementing a Strong Claims Denial Strategy to Offset ICD-10-based Coder Productivity Loss

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: June 2014



As organizations prepare for the implementation of ICD-10-CM/PCS next year, many are looking for creative strategies to mitigate anticipated decreases in coder productivity that will come with the switch. Some are ramping up education, others hiring additional staff members or implementin....

Overcoming the Risks of Copy and Paste in EHRs

Author: Haugen, Heather

Source: Journal of AHIMA

Publication Date: June 2014



With warm weather comes allergy season and possibly hundreds of patients visiting a physician who have similar symptoms, diagnoses, and treatment recommendations. Challenged by the documentation processes in the electronic health record (EHR) and starved for time, the physician may resort....

Overcoming the Challenges of Pediatric EHRs

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: May 2014




In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems. This month features the first in a two-part series discussing the unique challenges HIM professionals face in deploying EHRs customized to serve pediatric providers.

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Measurement and Monitoring, Extracorporeal Assistance and Performance, and Extracorporeal Therapies

Author: Barta, Ann

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

Publication Date: May 2014



Editor’s note: This is the second in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.


In this article, the Journal of AHIMA continues its three part Coding Notes series focusing on the nine Medical and Surgical-related secti....

Unforeseen Delay, A Determined Call to Action

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: May 2014



President Barack Obama signed H.R. 4302, the Protecting Access to Medicare Act of 2014, into law April 1, 2014. Though the bill’s main purpose was to create another temporary “patch” to the Medicare sustainable growth rate, language in a section of the bill effectively delayed the ICD-10-....

Download Two Apps and Text Me in the Morning: Physicians are Increasingly Prescribing mHealth Apps, but Privacy and Security Worries Remain

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2014



While physicians are increasingly likely to pull out their prescription pad and say, in all earnestness, “There’s a new app for that,” recent research suggests the decision to do so is fraught. A survey of 1,500 physicians found that while 37 percent have prescribed an app, 42 percent ref....

Managing the Integrity of Patient Identity in Health Information Exchange (2014 update)

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2014

This Practice Brief explores the complexity of patient identification integrity, including how organizations can manage patient identification systems from front end data capture to back end quality control as an ongoing process and carry local quality operations into health information exchange efforts. It urges industry stakeholders to recognize that now is a critical time to address accuracy in patient identification systems.

HIM at the Heart of Healthcare

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: May 2014



As data becomes central to the process of providing healthcare, HIM finds itself at the center of everything.


This rang true to me earlier this year, when the American College of Healthcare Executives released the findings of its annual survey of hospital CEOs, asking them to....

The Role of Analyzing Healthcare Data: Health Data Analysts Aggregate, Evaluate, and Validate Information for Key Healthcare Stakeholders

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: May 2014



Data are the assets that healthcare relies upon to provide needed information for making decisions and ultimately, hopefully, improving patient care. The volume of data collected today is staggering and continues to grow with the advent of electronic health records (EHRs). The healthcare d....

Weaving Together a Healthcare Improvement Tapestry: Learning Health System Brings Together Health IT Data Stakeholders to Share Knowledge and Improve Health

Author: Rubin, Joshua C; Friedman, Charles P

Source: Journal of AHIMA

Publication Date: May 2014



As the “Vision” section of AHIMA’s website states, AHIMA aims to “lead the advancement and ethical use of quality health information to promote health and wellness worldwide.” In many ways, the Learning Health System’s (LHS) overarching vision represents....

Too Many Coding Systems, Too Much to Do: Different Clinical Classification and Clinical Terminology Systems Uniquely Impact IT, Quality Management

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2014



The notion of managing and being accountable for the health status of defined populations requires much more sophisticated clinical data collection methods and skills than most healthcare organizations have today. Numerous “coding systems” have been used for decades to successf....

Pledge Your Allegiance

Author:

Source: Journal of AHIMA

Publication Date: April 2014


Patient empowerment is only one button click away for thousands of Americans thanks to the growing Blue Button Initiative, a collection of data-sharing applications that connects patients to their records instantly.


The Blue Button Initiative, which healthcare providers and othe....

On the HIPAA Hook

Author: Hicks, Andrew

Source: Journal of AHIMA

Publication Date: April 2014



Some healthcare business associates are still asking if HITECH-HIPAA impacts them. The answer is just as important to their affiliated healthcare providers.


Thousands of companies are now legally obligated to comply with the HITECH-HIPAA regulations because of their busines....

Emerging Role of eHIM Director

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: March 2014




In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems.


The HIM Problem


Defining the responsibilities for the role of “eHIM Director” in an increasingly electronic HIM world.


The HIM Prob....

Prepare Now for Meaningful Use Attestation and Compliance Audits

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: March 2014

A warning issued in 2013 by the Centers for Medicare and Medicaid Services (CMS) has come to pass. “Meaningful use” Electronic Health Record (EHR) Incentive Program audits have begun. The College of Healthcare Information Management Executives (CHIME) reported that out of their 1,400 member organizations, almost 100 received audit notices in October 2013, totaling six percent of membership. In order to protect incentive payments earned through the meaningful use program, organizations need to be prepared for every audit contingency and know exactly what to expect. Organizations also need to avoid common mistakes that could lead to an audit and follow best practices for staying compliant to meaningful use standards.

WARNING Health IT May Be Hazardous to Your Healthcare: New Health IT Hazard Manager Helps Providers and Vendors Track Electronic Health Systems’ Side Effects

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2014



Some in the healthcare industry feel electronic health record (EHR) systems are a miracle cure for what ails a US healthcare system plagued with bloated costs, an inability to communicate, and stunted growth in the use of advanced tools. There are still others who equate some of the promis....

Privacy and Security Audits of Electronic Health Information (2014 update)

Author: Walsh, Tom; Miaoulis, William M

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2014

In a perfect world, access controls alone would ensure the privacy and security of electronic protected health information (ePHI). However, the complexities of today’s healthcare environment make it extremely challenging to limit access to the minimum information necessary that members of the workforce require in order to perform their jobs.

Man Your Battle Stations: Feds Plan Cyber Security Hack Attacks

Author:

Source: Journal of AHIMA

Publication Date: March 2014



Frantic instructions to “man your battle stations” is not a command civilians and health information management (HIM) professionals are accustomed to hearing. However, that could soon change as healthcare organizations heed numerous cyber security warnings and prepare for government-plann....

Optimizing Data Representation Through the Use of SNOMED CT

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.

EHR in Place? Now the Real Work Begins

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: March 2014

With the deadline for ICD-10-CM/PCS on the horizon and electronic health records now in place in the majority of hospitals, HIM professionals may find themselves asking, “What comes next?” Until recently, the biggest challenges in electronic health information management were first to be able to collect the data, then to sort through the high volume of data coming from a variety of systems.

Health IT Standards Committee Takes On Patient-Generated Health Data

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: March 2014

Efforts from the Office of the National Coordinator for Health IT (ONC) in the area of patient-generated health data began in 2011. With mobile health on the rise and the “meaningful use” EHR Incentive Program progressing throughout the US healthcare system, these efforts continue to grow in importance to the future of healthcare and health information.

HITECH Frequently Asked Privacy, Security Questions: Part 3

Author: Rose, Angela Dinh; Greene, Adam H

Source: Journal of AHIMA | AHIMA Q and A

Publication Date: March 2014

This article concludes a three-part series discussing the most commonly asked questions regarding compliance requirements surrounding the final HITECH Omnibus Rule, released in January 2013. It highlights the updated requirements and provides answers to questions regarding decedent protected health information (PHI), the release of immunization records to schools, and the enhanced request for restrictions requirements.

Peer-to-Peer ICD-10 Training

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: February 2014




In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems.


The HIM Problem


Engaging the practicing physicians in the ICD-10-CM/PCS transition.


Getting physicians on-board with ICD-10-CM/PCS....

Seniors Want Their Health IT

Author:

Source: Journal of AHIMA

Publication Date: February 2014


Still think that senior citizens don’t know the difference between a computer mouse and the ones that like hiding out in floorboards? Think again.


According to a survey conducted by Accenture, more seniors than ever are picking up a mouse in their quest for online health informa....

HITECH Frequently Asked Privacy, Security Questions: part 2

Author: Rose, Angela Dinh; Greene, Adam H

Source: Journal of AHIMA

Publication Date: February 2014

The final HITECH-HIPAA Omnibus Rule was released in January 2013 and expanded some of HIPAA’s original requirements involving its privacy, security, and enforcement components. The Omnibus also finalized the Breach Interim Final Rule as well as the Genetic Information Nondiscrimination Act (GINA).

The following are some commonly asked questions about the HITECH Omnibus Rule implementation and compliance requirements, specifically regarding the rule’s areas addressing business associates, breaches, and GINA.

Making Data Smart: Practical Informatics is Helping Transform Data into Health Intelligence, and Now Moving into Day-to-day HIM Work

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: February 2014



Health informatics is often considered to be an advanced level of health information management (HIM). It’s also in high demand—in addition to handling, storing, and retrieving health data more HIM professionals are getting involved in the decision-making process regarding what types of i....

Seeing Informatics in Action

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: February 2014



Last year, as AHIMA developed our strategic plan, we began to use the phrase “transforming data into health intelligence.” It’s a familiar concept, but what does it really mean? One way to understand this idea is by looking at one of AHIMA’s strategic pillars—....

Peeking Over the Fence: a Look at Canadian Coding and CDI Processes, and How They Differ From the US Due to Varied Financial Structures

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: February 2014

Even with different payment models, Canada and the US are both working to reform healthcare with pay-for-performance and quality measurement reforms. Though using a single payer system, Canada still struggles with many of the same US HIM concerns—coding accuracy, clinical documentation improvement, and proper reimbursement.

How to Prepare the Record for an E-Discovery Request

Author: Kearney, David

Source: Journal of AHIMA

Publication Date: February 2014



At a minimum healthcare organizations should identify the components of their legal health record. The legal health record is a consistent declaration of what patient care information is maintained within an organization and what information would be released during a legal or investigato....

Modifications to ICD-10-CM/PCS Under Review

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: February 2014

The ICD-9-CM Coordination and Maintenance (C&M) Committee, a public forum on ICD-9-CM and ICD-10-CM/PCS code updates, met in September 2013. Meetings of this committee are co-chaired by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). Coding proposals are presented at these meetings and the public is given the opportunity to comment. No final decisions regarding the adoption of code proposals are made at the meetings, but are made by the director of NCHS and the administrator of CMS.

Enabling Consumer and Patient Engagement with Health Information - Retired

Author: Washington, Lydia

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2014

The purpose of this Practice Brief is to understand the relationship between health information management and consumer/patient engagement, and examine how HIM professionals can advance and support engagement. Its focus is on policies and practices that enable the individual’s access to and use of health information.

CPT Receives Update for 2014

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2014



On January 1, 2014, the American Medical Association’s Current Procedural Terminology (CPT) was updated with additions, revisions, and deletions. In total, 175 new codes were added, 107 codes were revised, and 47 codes were deleted. In addition, editorial changes and coding guideline addi....

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