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Nonstop Change Leads to New Opportunities

Author: Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: August 2012


We live in a time of nonstop change. The pace is fast and constant. To thrive, HIM professionals need to do more than simply adjust-we need to completely shift into a new mindset, developing new work methods along the way.

This starts with accepting the realities of today's marketpl....

Not Your Average Encounter: Quirky ICD-10 Codes

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2012


One look at the ICD-10-CM/PCS codebook proves that life is full of surprises. With ICD-10 stepping up the specificity of clinical codes, coders now have access to descriptions that can accurately capture even the most surprising of medical conundrums.


The increased specificity is....

What’s the Delay in the ICD-10 Delay?

Author: Rode, Dan

Source: Journal of AHIMA - website

Publication Date: July 18, 2012





Just when the Department of Health and Human Services will announce its final decision on a delay for ICD-10-CM/PCS compliance is the question on many minds lately.


While a firm announcement date has not been determined, AHIMA’s Advocacy and Policy st....

ICD-10-CM Update 2012

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2012


This article highlights the 2012 ICD-10-CM update as approved by the ICD-9-CM Coordination and Maintenance Committee. The 2012 ICD-10-CM update includes the addition of new codes that already exist in ICD-9-CM, implemented in the FY 2012 ICD-9-CM update or recently incorporated into ICD-10 th....

Top RAC Target Areas

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2012


If you bill fee-for-service programs, your claims will be subject to review by the Recovery Audit Contractor Program (RAC). That was the promise made by the Centers for Medicare and Medicaid Services when it expanded its once-experimental program to all 50 states in 2010. The RAC's mission....

Problem-Centered Care Delivery: How Interface Terminology Makes Standardized Health Information Possible

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....

Managing Health Information in Mobile Devices

Author: Washington, Lydia

Source: Journal of AHIMA

Publication Date: July 2012


While the jury is still out on whether mobile devices will eventually replace laptops and PCs, many observers are predicting that their use will continue to explode in the next few years. There are currently at least 10,000 health-related apps that could be downloaded to a mobile electronic de....

AHIMA Comments on Stage 2 Meaningful Use Measures

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2012


Increased quality measurement, better patient access to health information, and greater volume of information exchange is in store for providers and hospitals participating in the federal stage 2 meaningful use incentive program.

On March 7 the Centers for Medicare and Medicaid Servi....

Just Keep Swimming

Author: Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: July 2012


It's easy to feel overwhelmed as we work to navigate the dizzying speed with which technology is changing healthcare delivery-and every aspect of health information management practice. I often draw on my background as a competitive swimmer to help me address the resulting significant shifts t....

There Are Critical Reasons for Not Further Delaying the Implementation of the New ICD-10 Coding System

Author: Averill, Richard F.; Bowman, Sue E

Source: Journal of AHIMA

Publication Date: July 2012

Abstract: On April 17, 2012, the Department of Health and Human Services (HHS) published a rule proposing postponement of the implementation date for the International Classification of Diseases, 10th Edition diagnosis codes (ICD-10-CM) and procedure codes (ICD-10-PCS) by one year to October 1, 2014. An article in Health Affairs titled "There Are Important Reasons For Delaying the Implementation Of The New ICD-10 Coding System" asserts that the ICD-10-CM conversion will be "expensive, arduous, disruptive, and of limited direct clinical benefit." Contrary to the conclusions in this article, implementation of the ICD-10-CM and ICD-10-PCS code sets will provide major advantages over the existing ICD-9-CM code set. Implementation is long overdue and will provide significant cost benefits. Any further implementation delay will increase the cost of the transition as well as perpetuate the costs and negative consequences associated with continued reliance on imprecise diagnosis and procedure information.

Our Message: The Power of Data

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: July 2012


Lately, there have been constant reminders of the importance of health information in the current US healthcare landscape, as health information and data is a driving force behind most, if not all, of our current endeavors. A decade ago, I argued that healthcare data would become our new botto....

‘Don't Slow Down’: An ICD-10 Summit Wrap-Up

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2012


In an industry facing several distractions from various government initiatives and regulation changes, ICD-10-CM/PCS became the center of attention from April 16-17 as top experts and interested parties gathered in Baltimore, MD to discuss the ongoing transition to the new code set at the 2012....

Information Exchange Receives a Big Push in Meaningful Use, Stage 2: New Requirements Encourage Further Integration With EHRs

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: June 2012


As outlined within the HITECH Act of 2009, in order for providers to become meaningful users of electronic health records (EHRs), their use must, "in accordance with law and standards applicable to the exchange of information… improve the quality of health care, such as promoting care coordina....

AHIMA Comments on Certification Proposed Rule

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2012


Electronic health records could soon become more patient-centered, more secure, and more frequently used for treatment improvement-if provisions outlined in the EHR certification proposed rule are widely implemented.

Under the 2009 ARRA economic stimulus package, healthcare providers....

Details of Stage 2 Meaningful Use

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: June 2012


The release of STAGE 2 of the meaningful use program introduced adjustments that increased the challenges providers must overcome to meet the program requirements laid out by the Centers for Medicare and Medicaid Services (CMS). Stage 2 maintains the same core-menu structure and slightly incre....

Communication with a Side of Encouragement, Please: Effective Communication Strategies for a Smooth CDI Program implementation Transition

Author: Flood, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2012


Clinical documentation improvement (CDI) programs are spreading rapidly across the United States-and for good reason. They help facilities improve the level of documentation that goes into the patient medical record, leading to fewer errors and an overall improvement for continuity of care. Bu....

ICD-10: Our Red-Letter Day

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: June 2012



The first day of school. The day of your wedding. The first day of a new job. Each of these are big, memorable dates that first loom on calendars and then linger long in memory.


For many of us in the HIM profession, October 1, 2013, was a red-letter day too-the original impl....

Coding Diabetes Mellitus in ICD-10-CM

Author: Kostick, Karen M.

Source: Journal of AHIMA - website

Publication Date: May 16, 2012



ICD-10-CM diabetes codes complement present medical science—separate type 1 and type 2 diabetes category codes and body system combination codes represent a major improvement over ICD-9-CM.  Diabetes mellitus codes are no longer classified as controlled or uncontrolled. Instead ICD-10....

Bringing HIM to Consumers

Author: Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: May 2012


Each year I look forward to my annual spring break ski vacation in Steamboat Springs, Colorado. It's a great time to recharge batteries and gather with friends to celebrate spring break and share our passion for health information management.

On the way to Steamboat this year, one of....

Mandates Encourage E-Discovery

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2012


Today's US healthcare delivery system is facing an unprecedented sea change, led by federal initiatives that will foster a rise in the number of e-discovery requests hitting HIM departments.

Federal initiatives like the American Recovery and Reinvestment Act, the Patient Protection an....

Coding Diabetes Mellitus in ICD-10-CM: Improved Coding for Diabetes Mellitus Complements Present Medical Science

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2012


Results of a recent coding and clinical documentation pilot study indicate that the ICD-10-CM coding classification changes made for diabetes mellitus have significantly improved coding for this disease. The results of the study noted that although a few ICD-10-CM "unspecified" diabetes codes....

Why We Can’t Skip ICD-10

Author: Bowman, Sue E

Source: Journal of AHIMA - website

Publication Date: April 05, 2012





HHS’s intended delay of ICD-10 implementation has led to suggestions that the US simply skip ICD-10 altogether and wait for the next revision. It is true that ICD-11 is under development, but it is not as close as many perceive and the US simply cannot wait any lon....

Tips for Record Requests

Author: AHIMA

Source: Journal of AHIMA

Publication Date: April 2012


If patients have never requested their medical records from their doctor or hospital before, the process can seem complicated. However, a few basic steps can help streamline the process:

Read online or call the facility's HIM department for information specific to your request. This....

HIPAA Compliance for Clinician Texting

Author: Greene, Adam H

Source: Journal of AHIMA

Publication Date: April 2012



The HIPAA privacy and security rules need not act as an obstacle to efficient communications, but keeping texting compliant requires planning and diligence.

Text (or SMS) messaging has become nearly ubiquitous on mobile devices. According to one survey, approximately 72 perce....

Ensuring Remote Coding Compliance

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012


More and more HIM department managers are turning to remote coding. However, before implementing this staffing model, managers must answer several questions regarding the privacy and security of patient information, including:
What are the compliance risks?
How will privacy and secu....

Privacy—It’s Up to Us

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: April 2012



"Medical Record Breach at Stanford Hospital: 20,000 Exposed," "Texas Data Breach Affects Medical Records of 4.9 Million Patients," "Hospital Records Breach Involves 93,500 Patients"-these were just some of the headlines we saw in 2011 when privacy breaches and data security incidents invol....

ICD-10’s Impact on Quality Measures

Author: Giannangelo, Kathy; Hyde, Linda A.

Source: Journal of AHIMA

Publication Date: April 2012


Each year there has been a significant increase in the number of quality measures being used for public reporting across provider settings. Additionally, many of the new healthcare reform initiatives include quality measure reporting in their requirements. A small subset of National Quality Fo....

Setting AHIMA’s Course

Author: Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: April 2012



Know the way, show the way, go the way-those are the three objectives of AHIMA's 2012–13 strategic initiatives, a set of seven strategic goals that serve AHIMA and its members now and into the future. They are referred to by the acronym AIM FREE:
Agility-be agile and responsive to....

A New Age for Mental and Substance Abuse Health Records: Considerations for Protecting Highly Sensitive Records in Electronic Systems

Author: Gorton, Elisa R.

Source: Journal of AHIMA

Publication Date: April 2012


Mental health and substance abuse records are generally recognized as containing "sensitive" protected health information (PHI) in need of privacy and security measures above and beyond what is required by HIPAA. There was a time when this sensitive PHI was kept separate and apart from a patie....

FY 2012 ICD-10-PCS Updates

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012


Limited updates were made to ICD-10-PCS for fiscal year 2012 as set forth under the partial code freeze established by the ICD-9-CM Coordination and Maintenance Committee.1 The freeze is intended to aid the transition to the new code set by limiting updates for 2012 and 2013 to essential chan....

What’s New in 2: Top Changes in the Stage 2 Rule

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: April 2012


There are few surprises in CMS's proposed rule on stage 2 of the meaningful use program. The provisions generally reflect the recommendations of the Health IT Policy Committee made last year, and in the case of the intended change to the timeline, an announcement was made last December.
....

The New Privacy Officer

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: April 2012



It has been a decade since the first privacy officers took their jobs in response to the HIPAA privacy rule. A slew of changes since then have added more responsibility, required more skills, and demanded more time of them than anyone could have imagined.

When Nancy Davis, R....

Practice with PCS

Author: AHIMA

Source: Journal of AHIMA

Publication Date: March 2012

This example reviews procedures performed on a patient after he was admitted and diagnosed with coronary artery disease, and provides the ICD-10-PCS codes the hospital's coding staff would assign to the case.

Busy Year for the RACs

Author: Easterling, Sharon

Source: Journal of AHIMA

Publication Date: March 2012



Learning from last year's denials and preparing for what's ahead will help providers avoid being stung in 2012.


When the Recovery Audit Contractor (RAC) permanent program began in 2009, providers were hopeful that the process for identifying underpayments and overpayments w....

HIM Best Practices for Managing Patient Portals

Author: Dixon, Anne

Source: Journal of AHIMA

Publication Date: March 2012



The healthcare industry is on the cusp of changing the way providers communicate with their patients. Technology holds great promise in empowering patients to manage their health.


Patient portals are one way organizations can engage patients in their healthcare. They enable....

Creating a Career Blueprint

Author: Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: March 2012


Most of us don't begin our careers knowing exactly where we want to go, but we do have a general idea of the path we would like to take. Our career path inevitably takes on a life of its own based on our education, mastery of the five essential competencies (critical thinking, relationship bui....

Documentation Trends in the Health Record

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: March 2012


The meaningful use program is well under way, helping providers and organizations adopt EHRs to capture complete and comprehensive documentation. To qualify for incentives in stage 1, organizations have adjusted their documentation processes to meet certain objectives and measures and will con....

Automation for Privacy and Security Compliance

Author: McLendon, Kelly

Source: Journal of AHIMA

Publication Date: March 2012


There has been a lack of enforcement of the privacy and security rules ever since HIPAA's inception. As such the adoption of comprehensive HIPAA compliance programs has lagged behind EHR development and implementation.

This in turn has caused little funding to be budgeted by provide....

How to Request Your Medical Records

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: March 2012



If you’ve never requested your medical records from your doctor or hospital before, the process can seem complicated. However, understanding the law and the basic requirements will ease the process.

The Record Request Process


The basic process for requesting a medica....

CPT Code Updates for 2012

Author: O’Hara, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012


The 2012 updates to the CPT code set include 278 new codes, 139 code revisions, and 98 code deletions. This brings the total number of CPT codes to 9,641.

All major sections of the CPT code set, as well as the introduction and appendix A, have undergone changes. Beginning with the i....

Achieving Administrative Simplification

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: February 2012



Who doesn't appreciate the things that simplify our lives? Whether we find ways to shorten our commutes to work or clear the clutter out of our homes and offices, simplification gives us the time we need to pursue the things that give us the most pleasure-time with family, friends, and c....

CY 2012 OPPS Update

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012


The final rule for calendar year 2012 Hospital Outpatient Prospective Payment System (OPPS) was released on November 30, 2011. The rule went into effect for outpatient hospital-based services January 1, 2012.

This article outlines the updates in the final rule.
Financial Impact....

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