Author: Aschettino, Lucia; Birnbaum, Cassi L; Crocker, Janice; Grebner, Leah A.; McNicholas, Faith C.

Source: Journal of AHIMA

Publication Date: May 2013

Health information management (HIM) best practices state that it is important for HIM professionals to focus not just on the information but also on internal and external customers. Customers have varied, and ever-changing, needs that must be met by HIM professionals. Both internal and ext....

Author: Huey, Kim

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2013

Though it may seem contrary to popular opinion, electronic health record (EHR) products will make providers' coders more necessary and valuable than ever. Physicians who trust only EHR and computer-assisted coding software to choose the codes they bill, without any training or oversight, a....

Author: AHIMA Staff

Source: Journal of AHIMA - website

Publication Date: May 01, 2013

In February 2013, the practice brief on “Guidance on a Compliant Query” was published in the Journal of AHIMA. The intent of this practice brief is to maintain the integrity of the coded healthcare data. The purpose of the query process outlined is to ensure appropriate....

Author: Kirkpatrick, Joseph

Source: Journal of AHIMA - website

Publication Date: April 17, 2013

It seems that everyone wants to know about Britain’s royal family. The media are obsessed with the most mundane private details from their lives because that information is marketable to the public. While the relentless pursuit of their private information is excep....

Author: McMillan, Mac

Source: Journal of AHIMA - website

Publication Date: April 12, 2013

The Health Insurance Portability and Accountability Act (HIPAA) has ushered in a new era in healthcare that has transformed the way information is managed and used to deliver care. While we often say we still have a long way to go before achieving compliance with HIPAA,....

Author: Hofman, Judi

Source: Journal of AHIMA

Publication Date: April 2013

Due to new HIPAA rules, HIM must strike an appropriate privacy balance when releasing decedent records

Author: Galterio, Louis

Source: Journal of AHIMA

Publication Date: April 2013

Anyone unfamiliar with quality measurement and reporting might find the journey of self-education daunting. There are numerous organizations that develop, use, and require sets or collections of measures for reporting, and many address different measurement goals. There are varying areas o....

Author: Solove, Daniel J

Source: Journal of AHIMA

Publication Date: April 2013

Ten years ago after countless years of germination and many twists and turns, the HIPAA Privacy Rule finally became effective. It would soon be followed by the HIPAA Security Rule-which was published in 2003 and became effective in 2005-and eventually by the HIPAA Enforcement Rule and the....

Author: Taylor, Lisa Brooks

Source: Journal of AHIMA

Publication Date: April 2013

Each year the AHIMA national convention ends with an inspirational speaker. In 2012, in a personal and well-received chat, comedian Joy Behar shared in her emblematic, witty, and straight forward style a three-step life motto that led to her success:


Show up

Warm....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: April 2013

THIS YEAR MARKS the 10th anniversary of the implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.


As I write, the industry is currently deciphering the implications of a new law-the changes to the rule wrought by the Health Informati....

Author: Frawley, Kathleen A.

Source: Journal of AHIMA

Publication Date: April 2013

AHIMA celebrates its 85th anniversary this year. Many current healthcare associations were founded after the Joint Commission was founded in 1951. AHIMA, however, was founded in 1928 when 35 members of the Club of Record Clerks met at the Hospital Standardization Conference sponsored by th....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: April 2013

The Office for Civil Rights (OCR) has published the long-awaited final omnibus rules covering many HITECH Act requirements in the January 25, 2013 Federal Register (78FR5566). The rule is officially titled “Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notific....

Author: Scott, Karen S.

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2013

ICD-10-PCS will bring about many changes and challenges for coding professionals. It is important for those involved in coding to start preparing today for the many unique features of the coding system. One of the keys to understanding ICD-10-PCS is the many new definitions and description....

Author: Lardiere, Michael R

Source: Journal of AHIMA

Publication Date: April 2013

Sharing behavioral health and physical health information is a growing concern for the US healthcare system. Sharing the history and status of patients’ symptoms and progress-or lack of progress-between and among physical health and behavioral health providers is essential for assist....

Author: White, Susan E

Source: Journal of AHIMA

Publication Date: April 2013

One of the newest buzz words in data analytics is “Big Data,” and the data created through the healthcare industry is some of the “biggest” around. The widespread implementation of electronic health records (EHRs) and the need to share data to measure quality and ma....

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: April 2013

The HITECH Act’s omnibus HIPAA modification final rule, released January 25, 2013, finalized sweeping changes to privacy and security regulations. Though much of the proposed rule was adopted, the omnibus rule included major changes made to the “harm threshold” standard i....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: April 2013

Healthcare claims auditors have inundated release of information staff and vendors this year with record requests, in part due to the aggressive Centers for Medicare and Medicaid Services’ (CMS) Recovery Audit Contractor (RAC) initiative. RACs review provider bills and medical records to....

Author: Sheide, Amy; Wilson, Patricia S

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2013

What do coders need to know about Logical Observation Identifiers Names and Codes (LOINC)? A health records coder is unlikely to come across a LOINC code when looking for the correct ICD-9-CM code to reflect the documentation provided. A compliance officer may not see a LOINC code when eva....

Author: Solove, Daniel J

Source: Journal of AHIMA

Publication Date: April 2013

How HIPAA has performed overall as a privacy law is open to interpretation, but most agree it has had a wide-reaching impact on the healthcare industry. In comparison to the dozens of federal privacy laws for various industries, HIPAA is one of the most comprehensive and detailed. 

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2013

The Occupational Safety and Health Administration (OSHA) defines an “occupational medical record” as an occupation-related, chronological, cumulative record, regardless of the form or process by which it is maintained (i.e., paper document, microfiche, microfilm, or automatic data processing me....

Author: Bowen, Rita K.

Source: Journal of AHIMA - website

Publication Date: April 2013

The HIPAA Omnibus Rule, the new Final Rule modifying HIPAA, was published in the Federal Register on January 25, 2013. The amended rule went into effect on March 26 and full compliance is expected by September 23. For HIM professionals, the most far-reaching of the changes to HIPAA is that....

Author: Journal of AHIMA Staff

Source: Journal of AHIMA - website

Publication Date: April 2013

The term “standard” has a number of definitions in health information management. The healthcare media groups frequently include this word in tandem with other familiar buzz words, including interoperability, standardization, standards development organizations, harmonization, “meaningful....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: April 2013

Patients retain the right to keep their medical records private even after death. The laws surrounding just who has a legal right to view those records can lead to confusing and frustrating situations.


But new rules implemented through the HITECH Act’s HIPAA moficiation final....

Author: Perlman, Marc

Source: Journal of AHIMA - website

Publication Date: March 2013

Information is the future of healthcare, and the industry is developing an almost unquenchable thirst for it. The good news is that healthcare organizations are amassing data at an unprecedented pace. Rapid adoption of electronic health records (EHRs) in the wake o....

Author: Frawley, Kathleen A.

Source: Journal of AHIMA

Publication Date: March 2013

The health information management (HIM) profession will continue to see constant and increasing change in 2013. While HIM professionals continue to work to define and evolve their roles and career pathways, AHIMA has been working on the best ways to support and lead the change. As part of....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: March 2013

Remember when you had no choice but to do your banking with a teller at your local branch? Now we can bank from anywhere in the world.


If the industry’s efforts with health information exchange (HIE)-the topic of this month’s Journal-are a success, perhaps one da....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2013

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

Author: Wiedemann, Lou Ann; Dooling, Julie A

Source: Journal of AHIMA

Publication Date: March 2013

The Nationwide Health Information Network (NwHIN) was originally defined as a “set of standards, services, and policies” by the Office of the National Coordinator for Health IT (ONC) in 2007. Further changes were established in February 2009 as a part of the Health Information....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: March 2013

Do your printed health records have that tired, bored look that went out with the leisure suit? If so, the Office of the National Coordinator for Health IT (ONC) is offering a medical record makeover that can turn your files from drab to fab.


Hoping to make printed....

Author: Mitchell, Glenn

Source: Journal of AHIMA

Publication Date: March 2013

With ICD-10-CM/PCS, there is good news and there is bad news. First, the bad news-the implementation of ICD-10 in any healthcare facility will take ample staff time, financial resources, and strategic planning. But the good news-whether you are a C-suite leader, clinician, or worker bee, t....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013

As 2012 drew to a close, US healthcare facilities began the daunting task of reviewing the Centers for Medicare and Medicaid Services’ (CMS) hospital outpatient prospective payment system (OPPS) update to ensure their chargemaster and systems were up-to-date with the 2013 changes. Th....

Author: Deakle, Mary S; DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013

Several changes to the prospective payment system went into effect at the start of 2013, including coding changes affecting the M1024 Rule.


Reimbursement for home healthcare agencies (HHA) was converted to a prospective payment system by the Centers for Medicare and Medicaid....

Author: Romeo, Jim

Source: Journal of AHIMA

Publication Date: March 2013

Establishing a health information exchange (HIE) and building an infrastructure to support it internally and externally is a daunting task. Whether funded by federal and state grants or launched as a private sector initiative, launching a HIE often means blazing new territory and making de....

Author: Berry, Kate

Source: Journal of AHIMA

Publication Date: March 2013

Health information exchange (HIE) has great potential to improve healthcare quality while containing costs, something the US health system is under increasing pressure from providers and the federal government to achieve. Benefits of HIE include better care coordination, assurance that pat....

Author: Robb, Deborah; Owens, Lori

Source: Journal of AHIMA

Publication Date: March 2013

According to the Centers for Medicare and Medicaid Services, evaluation and management (E/M) services accounted for $28 billion in Medicare Part B payments during a one-year period.1 And of these, 8.4 percent were billed at the wrong level-either too high or too low. Chasing these potentia....

Author: Townsend, Hilary

Source: Journal of AHIMA

Publication Date: March 2013

The emergence of electronic health records (EHRs) has necessitated the use of innovative technologies to facilitate the transition from paper-based records for healthcare providers. Natural language processing (NLP) is one technology providers are turning to for improving clinical outcomes....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2013

The US healthcare industry is now a mere six months from the point in time that the Centers for Medicare and Medicaid Services has suggested for ICD-10-CM/PCS readiness testing to begin. Many health plans have said they are already prepared-or will be ready when the time comes-to test transact....

Author: Dimick, Chris

Source: AHIMA regulation analysis | Journal of AHIMA

Publication Date: March 2013

At 138 fine-print pages, the final rule detailing the HITECH Act’s modifications to HIPAA privacy and security requirements is not a quick or easy read. But it is an important read since the content of the Federal Register post drastically impacts HIM professionals and their business....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA - website

Publication Date: March 2013

Today’s HIM and coding professionals are faced with multiple challenges to increase documentation accuracy and specificity due to new rules and regulations. They also face financial pressure to accelerate billing processes, which can lead to errors and fraudulent c....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: February 2013

Health information technology systems have supported the administrative functions of healthcare for more than a decade. Historically, these healthcare administrative systems primarily focused on performing fiscal transactions or supporting key ancillary departments. Widespread use of elect....

Author: McGinness, Doris; Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank

Source: Journal of AHIMA

Publication Date: February 2013

RxNorm is a public domain drug vocabulary maintained by the National Library of Medicine (NLM) on behalf of the United States. The purpose of RxNorm is to facilitate the sharing of electronic drug information between hospitals, pharmacies, and healthcare professionals. The scope of RxNorm....

Author: Frawley, Kathleen A.

Source: Journal of AHIMA

Publication Date: February 2013

As HIM professionals, one of our key responsibilities is to provide patients with access to their health information. A poll conducted by Wolters Kluwer Health in November 2012 focused on the consumerization of healthcare. The poll asked whether consumers really want more control of their....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2013

Updates have been released for the 2013 ICD-10-CM code set, approved by the ICD-9-CM Coordination and Maintenance Committee, as well as the 2013 ICD-10-CM/PCS updates maintained by the Centers for Medicare and Medicaid Services (CMS). There were minimal changes to the draft code sets in li....

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: February 2013

[dih-fahy-ning] [helth] [in-fer-mat-iks]


adjective, noun, noun


1. An educator’s in-depth look at what informatics is and what it can do for HIM professionals



In the movie Annie Hall, Woody Allen finds himself in a movie theater line in....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: February 2013

Members of the AHIMA staff and ICD-10 Implementation Coalition recently met with the incoming House of Representatives Energy and Commerce Committee and Health Subcommittee Vice Chairman, Michael Burgess, MD. Discussion included considerations for how to reach out to those physician groups....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: February 2013

What a difference a decade makes.


This year marks the 10-year anniversary of the publication of AHIMA’s landmark report, “A Vision of the e-HIM Future.” Back then, AHIMA convened a group of industry, academic, and government representatives to identify what....

Author: Coleman, Johnathan

Source: Journal of AHIMA

Publication Date: February 2013

Not all protected health information (PHI) is created equally. Some health data requires special handling according to law, organizational policies, or patient preferences. For appropriate sharing of health information to occur, a patient must trust that a provider organization will proper....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2013

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

Author: Duckert, Jane; Rose, Angela Dinh

Source: Journal of AHIMA

Publication Date: February 2013

The University of Wisconsin Hospital and Clinics’ (UWHC) motto of “great information, great care” has been the underlying force behind their health information technology (IT) adoption achievements since 2008. Besides attaining the highest level of the Healthcare Informat....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: February 2013

Health information management is a global profession, with individuals in various countries working to ensure quality care through quality information. While opportunities and challenges do vary from country to country, there is much the world’s HIM professionals can learn from each other....

Author: Pilato, Jeff

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2013

While the transition to ICD-10-CM/PCS has the potential to put revenue at risk, adding staff to the revenue cycle is rarely an option in today’s cost-cutting environment. There are no extra hands to review charges, double-check bills, or safeguard claims. To mitigate risk, preventive....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: February 2013

Patient portals are becoming commonplace in healthcare facilities, which have installed the technology to provide patients and physicians immediate online access to electronic medical records. Adoption of patient portals will continue to increase, driven in part by stage 2 “meaningfu....

Author: Derr, John F.; O’Malley, Terrence A

Source: Journal of AHIMA

Publication Date: February 2013

Editor’s note: This is the third and final installment of a series reviewing the current and desired state of longitudinal care, as well as the steps healthcare stakeholders need to take to embrace this emerging quality measurement process.



E-quality measures....

Author: AHIMA Staff

Source: Journal of AHIMA - website

Publication Date: February 01, 2013

A query can be a powerful communication tool used to clarify documentation in the health record and achieve accurate code assignments. This Practice Brief In Addition provides examples of the different forms of queries available to HIM professionals.

....

Author: Galterio, Louis

Source: Journal of AHIMA

Publication Date: January 2013

Healthcare facilities are cutting out the middle man-the post office-by sending audit-requested medical records directly to the federal government using the Electronic Submission of Medical Documentation (esMD) program.



The esMD program has been growing at a fast ra....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2013

As AHIMA welcomes the new year, the association continues to work on several ongoing developments in the HIM profession-as well as the additional opportunities and challenges that 2013 presents the US healthcare industry. Though the work is not yet done, HIM professionals and AHIMA staff h....

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: January 2013

In October 2012, AHIMA's Grace Whiting Myers Award was presented to the University of Wisconsin Hospital and Clinics in recognition of excellence in health information management (HIM). This inaugural award focused on organizations who have demonstrated effective and innovative approaches....

Author: Rollins, Genna

Source: Journal of AHIMA

Publication Date: January 2013

The preparation for any great journey usually begins with reflection on lessons learned and research on just how those lessons can be utilized down the unpredictable road. The paradigm shift of electronic health records has caused HIM professionals to steer their work and career into promi....

Author: Luthi-Terry, Stephanie

Source: Journal of AHIMA

Publication Date: January 2013

Healthcare system Allina Health is leveraging their groundbreaking electronic health record system to revamp the health information management (HIM) department and its various functions. The goal is to make HIM more effective and efficient in the digital age, which they are accomplishing i....

Author: Bowe, Robin

Source: Journal of AHIMA

Publication Date: January 2013

Copyright © 2012 by Kern Medical Center, County of Kern, CA. All rights reserved. Printed with permission.


Medical identity theft is a growing concern for healthcare providers and healthcare consumers. Defined under the Fair and Accurate Credit Transaction Act of 2003 as....

Author: Frawley, Kathleen A.

Source: Journal of AHIMA

Publication Date: January 2013

During the past year Patty Thierry Sheridan, AHIMA’s past president, spoke eloquently about the power of dreaming big dreams. I am going to build on those ideas this year by talking about the importance of believing.


It is important that you believe in yourself, believe....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: January 2013

Starting a new year is like starting a long journey. Before I set out, I want to make sure I have a plan. What’s the destination? Where’s the map? What provisions will we need? How will we get started?


Similar questions came to mind as I read this month’s co....

Author: Alonso, Paula; Love, Tammy R.

Source: Journal of AHIMA

Publication Date: January 2013

Accurately coded data does more than just provide the mechanism for appropriate reimbursement. It also tells the story of the patient, the complexity of the patient’s case, and reflects the care provided to the patient. This growing trend of “holistic coding” seems to be....

Author: Miller, Jackie

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013

The CPT code set has undergone extensive revisions for 2013, with codes, guidelines, and modifiers being revamped and updated. HIM coding professionals should download and review the CPT 2013 errata on the AMA website before starting to use the new codes. This download can be accessed at w....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2013

The health information exchange (HIE) landscape has changed dramatically since HIE and the Nationwide Health Information Network (NwHIN) was first conceptualized in 2001. The National Committee on Vital and Health Statistics (NCVHS) published recommendations in 2001 on nationwide electronic hea....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: January 2013

Experience working with electronic health record (EHR) systems is growing in demand, and healthcare facilities in some areas of the country are having a tough time finding employees qualified to fill open EHR-focused positions, according to recruiting and business intelligence organization Want....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2013

Clinical documentation is the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has been an ongoing challenge to health informati....

Author: Ruhl, Jennifer L; Zumar, Wendy

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013

When ICD-10-CM is officially implemented, its code set will not only be used for primary care purposes but also as an invaluable secondary data source used by many types of healthcare registries in the US. A registry can be defined as “an organized system that uses observational stud....

Author: Gattadahalli, Satish

Source: Journal of AHIMA - website

Publication Date: January 2013

Healthcare and health information technology (health IT) are undergoing transformative change at an unprecedented pace. Strategic planning has become a major discussion point among CIOs, CTOs, CMIOs, and IT Directors. Whether it is implementing enterprise-wide elec....

Author: AHIMA Staff

Source: Journal of AHIMA - website

Publication Date: January 01, 2013

Accurate patient identification and successful linking of electronic records is highly dependent on the accuracy of key demographic data. There are three different events that must occur in order to maintain patient identity data integrity.




....

Author: Zender, Anne

Source: Journal of AHIMA - website

Publication Date: November 2012

Today, healthcare organizations are investing in information technology (IT) at unprecedented rates. And IT is generating more data-of all kinds-than ever before. What’s needed now, says Linda Kloss, RHIA, FAHIMA, is for healthcare organizations to invest in ways to manage, control, and under....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2012

An analysis of the “physician coder” anatomy would reveal a cornucopia of responsibilities nestled under this one succinct title.

They are equal parts clinical documentation improvement specialist, office manager, patient counselor, physician process tracker, coder... the list goes....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2012

With the push to develop and deploy electronic health records (EHRs) and the need for more detailed documentation, there is a growing concern in the medical community regarding the time expended to capture information-electronic or otherwise. The time providers spend during a patient visit capt....

Author: McKnight, Wanda G; Madden, Angie

Source: Journal of AHIMA

Publication Date: November 2012

Tennessee HIM professionals have worked for years to build positive relationships with physicians. ICD-10 offers another chance for collaboration.



Healthcare is inherently a stressful, fast-paced, and diverse industry. Naturally there will be times where different heal....

Author: Butterfield, Blair

Source: Journal of AHIMA

Publication Date: November 2012

Physician practices have made great strides in the last several years toward adopting EHRs, but even in the era of the HITECH Act and the “meaningful use” EHR Incentive Program, a large percentage of practices continue to drag their feet. Cost is certainly a factor for many practices, as is t....