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Measuring the Value of the Clinical Documentation Improvement Practitioner (CDIP) Credential - Retired

Author: Burgess, Sheila; Cooper, Sharon; Endicott, Melanie; Wallace, Susan; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2015


This Practice Brief has been updated. See the latest version here. This version is made available for historical purposes only.

The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first began in the late 1990s, the focus was almost....

Now is the Time: Realizing our Vision

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: January 2015



As I enter my 35th year as an AHIMA leader, educator, practitioner, and volunteer, I am excited to celebrate AHIMA’s 86 years of accomplishments and to have a role in paving the way for a bright future for HIM professionals everywhere.


I look forward to the months ahead, b....

Year in Review: Highlights from 2014

Author: Sheber, Sarah

Source: Journal of AHIMA - website

Publication Date: December 2014



The Journal of AHIMA’s ongoing web series “HIM Frontlines,” explores pressing obstacles that health information management (HIM) professionals encounter in a rapidly changing healthcare environment. Major federal initiativs such as the “meaningful use” EHR Incentive Program, HITECH-HIPAA,....

Coding Injuries in ICD-10-CM (update)

Author: Zeisset, Ann M.

Source: Journal of AHIMA

Publication Date: November 2014



ICD-10-CM provides greater specificity in coding injuries than ICD-9-CM. While many of the coding guidelines for injuries remain the same as ICD-9-CM, ICD-10-CM does include some new features, such as seventh characters.

Chapter 19 Overview


Chapter 19 is titled "In....

Cost of Converting Small Physician Practices to ICD-10 Much Lower than Reported

Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.

Source: Journal of AHIMA - website

Publication Date: November 2014




The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....

How to Respond to Subpoena and Discovery Requests

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: November 2014



Health information management (HIM) professionals are frequently pulled into litigation due to their role as custodians of health records and protected health information. This role also can categorize them as parties to civil litigation, which obligates them to produce any relevant infor....

Tips for Breaking into the Health Information Management Industry - Retired

Author: Camp, Michelle; Comfort, Angie; Endicott, Melanie; Howard, Artis; Kozee, Renee; Munive, Roberta; Novelli, Staci

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2014


Whether it is a first job or a career change, finding that first health information management (HIM) job following graduation is one of the biggest challenges that new graduates face. While some may find that breaking into the HIM industry takes time and persistence, it is a career choice that....

Making Health Information Exchange Work: HIOs Currently Not Ready to Support the Information Needs of a Reformed Healthcare System—But Small Changes Offer Big Outcomes

Author: Callan, Kathy; Fuller, Jan C.; Galterio, Louis; Just, Beth Haenke; Reich, Kimberly A. Baldwin-Stried ; Steigerwald, Christine; Turner-Combs, Mary Lou; Wolf, Sheldon H; Dooling, Julie A; Kirby, Annessa; Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: November 2014



Editor’s note: This article is part two of a two-part series analyzing the current state of health information exchange organizations and their operational models.


The question facing the healthcare industry is “will health information exchange organizations (HIOs....

HIM's Stake in Tracking and Treating Ebola

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2014


The victims of the Ebola virus, which has infected over 4,000 people in a handful of African nations as of press time, have benefitted—though in a limited capacity—by work performed by health IT professionals.


The Nebraska Medical Center in Omaha is one of a few healt....

Keeping Current in the Electronic Era: Data Age Transforming HIM’s Mandatory Workforce Competencies

Author: Sandefer, Ryan; DeAlmeida, Dilhari R; Dougherty, Michelle; Mancilla, Desla; Marc, David

Source: Journal of AHIMA

Publication Date: November 2014



Ponder this for a moment. From the beginning of recorded history to 2003, five exabytes (five billion gigabytes) of information was created by humans, according to recent IBM calculations. The rate at which that level of information is being created is increasing exponentially. In 2012, fi....

CMS Rule Allows CEHRT Flexibility

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: November 2014



On August 29, 2014, the Department of Health and Human Services (HHS) published a final rule that provides flexibility on how providers use certified electronic health record technology (CEHRT) and qualify for attestation to the “meaningful use” EHR Incentive Program for the 2014 reportin....

What’s the Difference? SNOMED CT and ICD Systems are Suited for Different Purposes

Author: Stearns, Mike; Fuller, Jan C.

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

Publication Date: November 2014



The International Classification of Diseases (ICD) and SNOMED CT are similar in that both systems have alphanumeric codes associated with clinical concepts. But the systems differ in their purpose and structure, and are best used in different ways in healthcare. For starters, ICD is a cla....

ICD-10's Impact Reaches Far Beyond Coding: Examining the New Code Sets' Revenue Cycle Implications

Author: Arends-Marquez, Alexa; Knight, Nicole; Thomas-Flowers, Dwan

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

Publication Date: November 2014



The implications of ICD-10-CM/PCS (ICD-10) for coding operations are a common topic of industry discussion, but the impact of ICD-10 reaches far beyond coding alone. ICD-10 is embedded in the entire revenue cycle for providers. The conversion will impact almost every aspect of operations,....

Take a "Deep Dive" into Information Stewardship

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: November 2014



Health Informatics and information management professionals have traditionally been focused on areas such as risk management, quality assurance, licensure, accreditation, privacy, and security requirements for their organizations. But compliance—conformance or obedience to procedures, rul....

Checks, Balances, and Ethics: Implementing Financial Controls for Associations

Author: Dunn, Rose T; Klaver, Jill Callahan; Rinehart-Thompson, Laurie A.

Source: Journal of AHIMA - website

Publication Date: November 2014


Health information management (HIM) professionals are recognized for their compliance-focused activities. Coding professionals, for example, assign codes based on the available documentation and the rules that define proper code application. When hospital coders are asked to resequence a condit....

New Changes De-Spookify Modifier -59

Author: Wilson, Donna D

Source: Journal of AHIMA - website

Publication Date: October 30, 2014



The proper application of modifier -59 (Distinct Procedural Service) has mystified many a coder. The Centers for Medicare and Medicaid Services (CMS) has recently indicated that modifier -59 is the most commonly used and abused of all the modifiers—mainly due to the fact that it is used to....

New Coordinator Shapes Direction of ONC

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: October 2014



Karen Desalvo, MD, MPH, MSc, believes it’s time to shake things up a little at the Office of the National Coordinator for Health IT (ONC). DeSalvo, who previously served as the New Orleans city health commissioner and senior health policy advisor to Mayor Mitch Landrieu, began her appoint....

Tracking HIE’s Ever Evolving Operational Models: Emerging health information exchange market still sorting out its business and governance models

Author: Callan, Kathy; Fuller, Jan C.; Galterio, Louis; Just, Beth Haenke; Reich, Kimberly A. Baldwin-Stried ; Steigerwald, Christine; Turner-Combs, Mary Lou; Wolf, Sheldon H; Dooling, Julie A; Kirby, Annessa; Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: October 2014



Editor’s note: This article is part one of a two-part series analyzing the current state of health information exchange organizations and their operational models.


Health information exchange (HIE) continues to be an embryonic domain—a swirling array of various pu....

Risks and Results of Data Spoliation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: October 2014



The September e-HIM Best Practices article answered some basic questions about preservation of records in the context of civil litigation. This article will consider the question, “What if something goes wrong?”

Spoliation Defined


Health information management (H....

Slow to the Information Governance Starting Line: First-of-its-kind Survey Tracks Healthcare’s IG efforts, Shows Most Organizations are Behind

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2014



Majority of Healthcare Organizations Lack Vital Information Governance Strategy


AHIMA has fired the starting pistol heralding in the urgent race to implement information governance (IG) practices within the healthcare industry. While some organizations were quick off the bloc....

Time for Information Governance is Now

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: October 2014



For AHIMA, 2014 has been the year of information governance (IG).


From Information Governance Month in February to this month’s 86th Convention and Exhibit, AHIMA has been breaking new ground in exploring, understanding, and making recommendations for IG in healthcare o....

Informatics Harnesses Healthcare’s Wild, Rich Data

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2014



Healthcare has become a data-rich field, and any data rich environment requires the ability to analyze large, complex data sets. The field of informatics provides tools to integrate data, information, knowledge, and wisdom when processing data. Good informatics includes many functions, and....

Law Changes Patient Access to Clinical Lab Reports

Author: McLendon, Kelly

Source: Journal of AHIMA

Publication Date: October 2014



The US Department of Health and Human Services (HHS) continues to look for avenues to allow greater patient access to their own health information so that they may be more active in their healthcare management. HHS recently created final rules that remove the Clinical Laboratory Improveme....

Leading Your Facility Through the ICD-10 Delay Storm

Author: Horn, Kelli

Source: Journal of AHIMA

Publication Date: October 2014



When the Centers for Medicare and Medicaid Services (CMS) announced in the spring of 2014 that ICD-10-CM/PCS would be unexpectedly delayed for at least one year, the health information management (HIM) community was shocked. Hospitals, healthcare facilities, and educational organizations h....

Low-Tech Approach to High-Tech Problems

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: September 2014



The HIM Problem


Transitioning from paper to electronic transcription processes; integrating fetal monitoring into an electronic health record (EHR); implementing an enterprise EHR that includes emergency room, radiology, laboratory, and operating room systems—and assimilating....

How and Why to Preserve Health Records During Litigation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: September 2014



The term preservation, when used in a legal context, refers to placing information identified as relevant to a civil or criminal US court case in a legal hold to ensure the data is not destroyed or tampered with.


Health information managers, or anyone who works with records....

Fast As You Can: US Lagging Behind in Broadband Internet Access

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2014


At a time when technology has been able to facilitate advancement in so many other areas, the United States is coming up surprisingly short when it comes to meeting its citizens’ Internet speed needs.


According to a new report from Akamai, the US has seen improvement in broadban....

Accessing and Using Data from Wearable Fitness Devices

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: September 2014



A rapidly aging global population in many industrialized countries accompanied by an increase in chronic diseases and the high cost of managing such diseases has led many to turn to a technological solution to ease the burden on healthcare professionals and provide useful tools to the elde....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: September 2014



Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....

Personal Health Information is 'Saving Grace'

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: September 2014



As a health informatics and information management professional and a parent of two adopted children, my desire for complete and accurate medical information rocks the top of my “Mom to-do list.” My children, Zach and Grace, are siblings, adopted at the ages of two and four. State laws va....

Why Standards Should Matter to HIM Professionals

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: September 2014



Editor’s note: This article introduces Standards Strategies, a new Journal of AHIMA department that will provide guidance to HIM professionals on applying health data standards in areas including business, clinical care, and compliance.


AHIMA has always been committed t....

Curing Inherited EHR Ailments: EHR Remediation Fixes System Issues and Better Aligns Clinical Workflow with Clinical Documentation

Author: Wieczorek, Michelle M.; Clark, Jill S

Source: Journal of AHIMA

Publication Date: September 2014



In recent years the introduction of the American Recovery and Reinvestment Act’s (ARRA’s) “meaningful use” EHR Incentive Program has encouraged more healthcare entities to chart their course toward electronic health record (EHR) system implementation, taking advanta....

Patient Engagement: In it for the Long Haul

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: September 01, 2014





Marc Perlman, global vice president, healthcare and life sciences at Oracle, recalls being “blown away” by the Patient Engagement Framework. The framework was developed after the National eHealth Collaborative merged with the Healthcare Information and Management Systems....

Coping with Government Audits

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: August 2014





The HIM Problem: Medicare Auditor Scrutiny of Inpatient Claims


This spring, the Centers for Medicare and Medicaid Services (CMS) issued its “two midnight rule” which was intended to define and clarify what Medicare considers to be criteria justifying an inpatient st....

3 Myths of ICD-10-CM/PCS: Addressing Why it is Not Feasible to use SNOMED CT in Place of ICD-10 or Wait for ICD-11—and Other Misperceptions

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: August 2014



As the US healthcare industry experiences yet another delay in ICD-10-CM/PCS implementation, misunderstandings surrounding the ICD-10-CM/PCS transition continue to perpetuate. This article addresses a few of the most common misperceptions—myths that need to be exposed with fact-based....

Using Our Influence to Lead for the Greater Good

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: August 2014



In a healthcare ecosystem where volume-based models are shifting to value-based ones, organizations will depend more and more on the use of informatics to drive decisions. Our success will depend on our ability to drill down to the level of detail required to support evidence-based medici....

Realigning HIM to the New Healthcare Environment: Case Studies in HIM Transformation Due to Accountable Care and Pay-For-Outcomes Initiatives

Author: Bower-Jernigan, Patricia L; Chenoweth, Ann; James, Jaime

Source: Journal of AHIMA

Publication Date: August 2014



The Affordable Care Act has been a catalyst for the transition to pay for outcomes. Through the Centers for Medicare and Medicaid Services (CMS) Innovation Center, dozens of new payment and service models have emerged that promise to deliver better care throughout the United States at a l....

Roles for HIM Professionals in HIOs

Author: Bailey-Woods, Linda; Dooling, Julie A; Fabian, Diane; Kuehnast, Tanya; Luthi-Terry, Stephanie; Raymond, Jackie; Rhodes, Harry B.; Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: August 2014



Simply stated the goal of health information exchange (HIE) is very clear-cut and easy to understand—establish networks that connect healthcare providers electronically in order to facilitate higher quality healthcare.


However, actual implementation of HIE business mod....

Coming Soon to Your Healthcare Facility: Information Governance. A Look at Healthcare Information Governance Trends through Practical Case Studies

Author: Kadlec, Lesley

Source: Journal of AHIMA

Publication Date: August 2014



The growing momentum of information governance (IG) initiatives in healthcare provider organizations raises many questions. What are the goals of information governance? Why have some organizations decided they need formal IG programs? How do healthcare organizations expect to benefit from....

HIM Must Shoot for the Moon

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: August 2014



ONE OF MY father’s favorite sayings was: “Shoot for the moon. If you only get to the stars, it’s better than never having gone at all.”


It’s a saying that kept coming back to me as I was getting ready to write this column for the Journal issue o....

Leveraging the Leader-Member Exchange Theory in HIM

Author: Hunt, T J

Source: Journal of AHIMA

Publication Date: August 2014



Editor’s note: This article is an excerpt from “Leader-Member Exchange Relationships in Health Information Management,” published in the Spring 2014 issue of AHIMA’s scholarly research journal Perspectives in Health Information Management.


Following the leader-member excha....

How to Lead Your Organization in Compliance, Ethics, and Customer Service: Health Information Management Professionals Can Help Organizations Create a Culture of Compliance

Author: Burton, Ben

Source: Journal of AHIMA

Publication Date: August 2014



Today’s healthcare organizations must field a constant bombardment of both new and evolving regulations that dictate how, when, or where patients may receive care. The changing regulatory landscape—combined with the fact that the government is recovering $16 for every dollar spent to comb....

Practical Implications of Informatics

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 2014





For decades, most consumers relied on one physician for all of their healthcare needs—their primary care physician—and that one physician knew the patient’s entire health history and documented it in one place. This paradigm is starting to change, says Anupam Goel, MD, MBA, an in....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: July 2014



Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....

HIPAA Breach Enforcement Roundup

Author: Cacciatore, Victoria; Downing, Katherine

Source: Journal of AHIMA

Publication Date: July 2014



Criminal attacks on healthcare systems have risen 100 percent since 2010, according to a recent Ponemon study.1 This makes it obvious that the privacy and security of patient health information is vulnerable and highly susceptible to data breach. The HIPAA Breach Notification Rule became e....

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.”

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