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Renewing the Vision of the Digital Medical Practice

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: August 2008


I recently observed a series of focus groups in which high school students, “Generation Y” young adults, working parents with small children, and “pioneer” baby boomers discussed health IT. As you would expect, there were many differences in how these groups use technology.


Ho....

Weighing the Stark Law Exceptions

Author: Howrey, Linda

Source: Journal of AHIMA

Publication Date: August 2008


Donations of software and services to physicians allowed under the anti-kickback exceptions are meant to spur health IT adoption, but evaluating the potential is a complex exercise for both donor and recipient.

Exceptions to the Stark Law and the anti-kickback statute enable hospital....

Running a Successful CDIP

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: July 22, 2008





Clinical documentation improvement programs can enhance the clinical record and capture lost reimbursement. But they can be a challenge. Getting physician buy-in, avoiding turf wars between documentation specialists, coders, and nurses, and measuring program succes....

Skilled Knowledge Workers in Short Supply

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2008


This is a demanding time for coders. MS-DRGs and present on admission requirements would have been challenging on their own; however, both came at virtually the same time, straining coders already stretched to meet their job requirements.

Recruitment and retention of coding staff is....

Taking Coding to the Clinical Floor

Author: Featheringham, Meg

Source: Journal of AHIMA

Publication Date: July 2008


As documentation specialist at Deaconess Medical Center in Spokane, WA, Amy Gardner walks a tight rope between the HIM and clinical worlds. Gardner, RHIT, reviews charts on the cardiovascular floor of Deaconess, identifying gaps in documentation and querying physicians for follow-up.

Coding’s Biggest Challenges Today

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: July 2008




Coding departments are hectic places in 2008, busy adapting to new requirements. To meet the challenges, they are seeking the right staffing, education, and coordination.



How many challenges does coding face today? Open positions, revenue cycle, MS-DRGs, POA, RACs,....

PHRs—The Hook to Engage and Inform Consumers?

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: June 2008


The Internet, cell phones, and other technologies have forever changed how we communicate and gain access to information. We manage and track our finances and medical and other benefits online. Some are even fortunate enough to be able to communicate with their physicians through secure e-mail....

Clarifying Patient Status Code

Author: Bryant, Gloryanne H.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2008


The patient status code reflects the level of care a patient was discharged or transferred to when leaving an acute care hospital as an inpatient or outpatient (i.e., emergency department or emergency room). A recent Centers for Medicare and Medicaid Services MLN Matters publication provides a....

Risk-Based MPI Management

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: June 2008


Meticulous management of the master patient index (MPI) has always been a mission-critical data integrity function for HIM professionals. One advantage of having credentialed health information staff manage the index is their dual knowledge of the multiple legal dimensions of the MPI and their....

Member Advocates for PHRs, One Person at a Time

Author: Hicks, Jewelle E

Source: Journal of AHIMA

Publication Date: June 2008


As the manager of health information management for the NYU Clinical Cancer Center in New York, NY, Cindy M. Boester is accustomed to teamwork and problem solving. Boester, MS, RHIA, supervises a staff of 35 full-time employees at the outpatient facility, which has more than 600 visits a day.<....

States—Laboratories for E-Health

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: May 2008


States are often described as “laboratories of democracy.” Today they are also serving as laboratories for e-health. Virtually every US state is pursuing IT initiatives to improve the safety, quality, and affordability of healthcare. Leadership is coming from governors’ offic....

NHIN Show and Tell

Author: Rollins, Gina

Source: Journal of AHIMA

Publication Date: May 2008


Contractors in the NHIN trial implementations are working toward a demonstration of a “network of networks” this fall. Along the way they are generating specifications and refining issues.

In October 2007 the Health and Human Services Office of the National Coordinator f....

Taking Medical Records to the Bank

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2008


Banking health data like a financial transaction is the simplest solution to healthcare’s networking challenges says William Yasnoff, founder of the Health Record Banking Alliance.

There are a lot of plans for regional and, eventually, nationwide health information exchange, b....

Re-examining HIPAA Six Years Later

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2008


It was six years ago this month that the HIPAA privacy rule went into effect. For many in healthcare, compliance has become a routine part of doing business. But for too many, the current regulations remain poorly understood and poorly implemented. All the while, the environment has been chang....

On the Leading Edge in Long-term Care

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: April 2008


Margie White started out as a nursing assistant in acute care. A brochure for AHIMA’s independent study program introduced her to HIM. She completed the program and applied for a job as medical record clerk in a long-term care facility.

And she kept going. White earned her RHI....

Patient Identification in Three Acts

Author: Fernandes, Lorraine M.

Source: Journal of AHIMA

Publication Date: April 2008


As the curtain slowly rises on interoperable data exchange, the industry is still auditioning for the role of patient identification.

Throughout the past ten years, healthcare has been setting the stage for IT interoperability. With patient identification in a leading role, the scri....

Why ICD-10 Is Worth the Trouble

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: March 2008


Transitioning to ICD-10 is a major disruption that providers and payers may prefer to avoid. But it is an upgrade long overdue, and the benefits are far-reaching.

It has been nearly five years since the National Committee on Vital and Health Statistics recommended to the secretary o....

Managing Source System Content in the EHR

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: March 2008


Many of today’s healthcare entities have hybrid medical records, and policies abound describing what parts of the record are still accessed in paper and what components are now fully electronic. Wherever healthcare organizations are in the race to create fully accessible and secure elect....

ICD-10 in the Big Picture

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 2008


As a professor at Temple University, Margaret (“Maggie”) Foley, PhD, RHIA, CCS, has to have an eye for details. But she also has an eye on the big picture—specifically on ICD-10 and the benefits it could offer to healthcare.

Before she became a professor, Foley was....

Key Issues in the 2008 OPPS Final Rule

Author: Clark, Andrea

Source: Journal of AHIMA

Publication Date: March 2008



The main objective of the Centers for Medicare and Medicaid Services (CMS) implementation of the 2008 Outpatient Prospective Payment System (OPPS) final rule was to address the recent explosion of growth in program expenditures for hospital outpatient services. CMS has created additional i....

ICD-10 Malaise: A Symptom of US Healthcare’s Ills

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2008


Approximately 100 countries use some form of ICD-10 for clinical morbidity coding. That’s correct: 100 countries, and the US is not among them.

The World Health Organization released ICD-10 in 1990, and countries began implementing it in 1994. Most had fully implemented it by....

New Focus on Process and Measure: Raising Data Quality with a Standard Coding Workflow and Benchmarks

Author: Wilson, Donna D; Hampton-Bagshaw, Kim; Jorwic, Therese M; Bishop, Jean; Giustina, Elizabeth

Source: Journal of AHIMA

Publication Date: March 2008




Establishing a standard coding workflow that incorporates continuous improvement and creating performance benchmarks is key to improving the quality of coded data.



HIM professionals who assign codes or manage coded data take responsibility for translating clinical....

Brushing up on ICD-10-PCS

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: March 2008


ICD-10-PCS is intended to replace ICD-9-CM volume 3 for facility reporting of hospital inpatient procedures. It has a seven-character alphanumeric code structure. The letters I and O are not used to avoid confusion with the digits 1 and 0. A character is a stable, standardized code component th....

US Organizations Look Ahead

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2008


Transitioning to ICD-10-CM may seem like a distant problem. But SSM Integrated Health Technologies began its preparations about three years ago. Its reason is simple: “Something of this magnitude, you don’t want to be scurrying,” says Anne Stuckel, SSM’s manager of clini....

ICD-10 Preparation Checklist

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: March 2008




The content in this checklist has been updated. More recent information is available here.



Preparing for ICD-10 is a monumental process. But like any large task, it can be broken down into discrete steps. A multiyear plan can be approached in four major phases, begi....

Coding Preventive Care Services

Author: Wilkinson, Dianne

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2008


According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....

Bridging the Translation Gap from ICD-9

Author: Butler, Rhonda R.

Source: Journal of AHIMA

Publication Date: March 2008



A recurring theme in the ongoing ICD-10 implementation debate has been the need for a crosswalk between the old and new code sets to help the industry make the transition. The lack of an “official” mapping between ICD-9-CM and ICD-10-CM/-PCS has long been seen as a major challe....

Enterprise Content Management from the Ground Up

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: February 2008


How a project that began with 50 policies and procedures critical to Joint Commission standards is growing into a content management system encompassing thousands of documents from across an organization.
Optimally healthcare organizations should arrive at an enterprise content management....

Understanding Use Cases

Author: Washington, Lydia

Source: Journal of AHIMA

Publication Date: February 2008


As national health IT initiatives move forward, it is important that HIM professionals understand the role and functions of use cases. Use cases are an extension of workflow analysis, an early and essential step in selecting or designing new health information technology. This article defines....

Legal EHR—Friend, Not Foe

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2008


AHIMA has been working hard to advance the industry’s understanding of the legal electronic health record and to develop practical advice for ensuring that EHRs protect patients and providers at each stage of development. While descriptive, the phrase legal EHR seems to strike fear in some who....

Handling Sensitive Information in an NHIN

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2008


The topic of sensitive health data and how to keep it private in the electronic age is one of the most complex issues facing the development of a nationwide, interoperable health information exchange network.

Physicians need accurate medical records to provide adequate care. Yet pati....

Enterprise Content and Records Management

Author: Strong, Karen

Source: Journal of AHIMA

Publication Date: February 2008


The convergence of litigation and electronic records is raising the bar on managing content from multiple systems and multiple departments. That need is introducing healthcare to the practice of managing content and records enterprise-wide.
We’ve come a long way since the days of microfil....

Legal EHR Roundtable: Views and Needs Differ by Stakeholder

Author:

Source: Journal of AHIMA

Publication Date: February 2008


Raising awareness and working effectively on an organization’s legal EHR depends in part on understanding differing stakeholder perspectives.
Many people throughout an organization have a stake in ensuring that its electronic health record can serve as its legal business record. Depending....

2008 CPT Coding Update

Author: Jorwic, Therese M

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2008


The new CPT codes took effect January 1, 2008. Changes include 244 additions, 314 revisions, and 50 deletions. A comprehensive list of changes can be found in appendix B of the CPT book. Highlights of the changes by section are outlined here.
Evaluation and Management

A revised....

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