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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: November 2012

It’s time for HIM to come out of the basement. I'm not talking about relocating our offices. I’m talking about coming out of the mental bunkers where many of us have hunkered down, hoping the onslaught of changes will blow over.

A Call to Action


I am insp....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2012

AHIMA held its 84th annual Convention and Exhibit September 29-October 4 in Chicago, IL, where the themes of innovation and professional development underscored sessions that helped attendees look toward the future and prepare for the coming year’s challenges in health information managem....

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: November 2012

AHIMA has long advocated for ICD-10, and these advocacy efforts have overcome some stout barriers to ensure the implementation of the modern, more detailed classification system. Even with this recent success and the reassurance that comes with the final ICD-10 implementation date set for....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2012

Injection and infusion coding is a challenging area, thanks to vast instructional notes, hierarchy rules, and payer-specific policies.


Current Procedural Terminology (CPT) defines the terms “injection” and “infusion” as:


Injection—delivers a dosage in one “shot,” r....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: November 2012

The summer of 2012 ended with a bang when the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) issued final regulations outlining requirements for the stage 2 “meaningful use” EHR Incentive Program. The stage 2 final regulation did....

Author: Gemmell, Doris

Source: Journal of AHIMA

Publication Date: November 2012

Seven ICD-10 Myths Confusing Healthcare Today, and the Canadian-Proven Reality

Heads up: ICD-10 is coming. Actually... heads “north.”

American healthcare providers curious about how the pending ICD-10 implementation will impact their processes need only to look to the....

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: Cassidy, Bonnie S.; Gorman-Klug, Catherine; Taylor, Lisa Brooks

Source: Journal of AHIMA

Publication Date: November 2012

A key theme for the healthcare industry in 2012 has been embracing technology, and people have begun practicing what they preach. Computer-assisted coding (CAC)-with natural language processing (NLP) or natural language understanding (NLU) capabilities-will soon be integrated into the coding w....

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....

Author: Dooling, Julie A; Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: November 2012

Innovative approaches in health information management (HIM) led to the University of Wisconsin Hospital and Clinics (UWHC) being selected as the winner of the first AHIMA Grace Award. The award was presented to UWHC leadership on October 2 before thousands of HIM professionals at AHIMA’s 84t....

Author: White, Susan E; Taylor, Lisa Brooks

Source: Journal of AHIMA

Publication Date: November 2012

Value-based purchasing of healthcare is transforming the US healthcare delivery system and payment methodologies. Spurred by commercial pay-for-performance initiatives and the roll out of the Centers for Medicare and Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP), accountable....

Author: Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: November 2012

As I prepared my incoming address for the AHIMA Convention and Exhibit last year, I turned to my family and friends for inspiration on music ideas. Little did I know that the hunt for a song with an upbeat tempo would set in motion a year that challenged us all to “Dream Big”-from AHIMA staff....

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: Rode, Dan

Source: Journal of AHIMA

Publication Date: November 2012

The Centers for Medicare and Medicaid Services (CMS), along with the Office of the National Coordinator for Health IT (ONC), formally released three final rules around the the time of the Labor Day holiday. Appropriately enough, the arrival of these final rules spells out much work ahead for t....

Author: Rose, Angela Dinh

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2012

In August 2012, the Department of Health and Human Services (HHS) announced its much-anticipated final ruling on the implementation deadline for the ICD-10-CM/PCS classification system-October 1, 2014.1 The transition to this highly awaited coding system will require appropriate planning,....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2012

The AHIMA Triumph Awards recognize individuals who make a difference and is a long and cherished tradition of honoring the excellence, dedication, and service of those professionals whose steadfast efforts have enriched the health information management (HIM) field. The awards honor leadershi....

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

Source: Journal of AHIMA

Publication Date: November 2012

Editor’s note: This is the second in a series of three articles 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.

Healthcare quality for elective joint replacem....

Author: Kuhl, Joy

Source: Journal of AHIMA - website

Publication Date: November 2012

Just because information can be exchanged electronically doesn’t mean it can be digitally analyzed. Data needs to be structured using clear electronic standards for HIM professionals and other health IT specialists to analyze and use the data. Much of the data generated in healthcare-like pro....

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: October 2012

New, deleted, and revised ICD-9-CM codes are included every year in the Centers for Medicare and Medicaid Services’ (CMS) annual update to the Inpatient Prospective Payment System (IPPS). But only one new ICD-9-CM code, effective October 1, 2012, has been added to the code set due to the ongo....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2012

We are going through a revolution in healthcare, spurred on by a desire to improve healthcare quality and decrease costs. As we work to make these changes a reality for the US healthcare delivery and payment system, a “patient-centric” model is emerging that increases the involvement of patien....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: October 2012

“Evolution” and “change” are two words that come to my mind when I think about how the move to electronic health records (EHR) has altered the nature of the work we do. AHIMA has been talking about this change for as long as I can remember. But now it’s happen....

Author: Fernandes, Lorraine M.; O'Connor, Michele; Weaver, Victoria

Source: Journal of AHIMA

Publication Date: October 2012

Healthcare is embracing the big data movement, hoping to revolutionize HIM by distilling vast collections of data for specific analysis


One only needs to open a recent conference brochure, read an electronic newsletter, or preview marketing materials to appreciate that "B....

Author: Coffey, Bonnie; Paulson, Justine

Source: Journal of AHIMA

Publication Date: October 2012

Release of Information (ROI) continues to be an integral component of the health information management (HIM) department. Before copiers and fax machines, medical record librarians would create a handwritten abstract of a patient’s medical history and then mail it to the requestor through the....

Author: Reeves, Mary G; Bowen, Rita K.

Source: Journal of AHIMA

Publication Date: October 2012

Many individuals have a high degree of confidence in the validity and integrity of data if it comes from a computer. When they encounter data in this form, the assumption is the data has been vetted, scrubbed, and signed off by a reliable source. In truth, however, this is rarely the case.

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2012

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