Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2011

There are two basic approaches to the ICD-10 transition: (1) a late, mad scramble to get systems converted before the deadline; or (2) an intentional cultivation that uses the transition to improve business processes, documentation, and clinical care. Three organizations offer a picture of the....

Author: Bhuttar, Vijaya Kumar

Source: Journal of AHIMA

Publication Date: June 2011

Payers that are not ready to migrate from legacy systems are looking at tactical solutions for making their existing systems ICD-10 compliant in the near term. Most solutions involve a crosswalk between old and new code sets, created from four basic options.

For a long time, le....

Author: Butler, Rhonda R.; Mills, Ronald E; Averill, Richard F.

Source: Journal of AHIMA

Publication Date: June 2011

Automation is a major help in converting to the ICD-10 code set, but it is not a magical solution. In fact, skipping a human review of converted systems exposes an organization to legal and financial risk.

People who are secondary users of coded medical records-who see only the resul....

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: June 2011

Transcription has always played an important role in HIM, but today it is taking on a new role in supporting the meaningful use program. Organizations are looking to leverage their transcription technology to capture structured data within their electronic health records (EHRs), a requirement....

Author: White, Susan E; Kallem, Crystal; Viola, Allison F.; Bronnert, June

Source: Journal of AHIMA

Publication Date: June 2011

In April the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking for the Medicare Shared Savings Program. The program was mandated by the Affordable Care Act to encourage the development of accountable care organizations (ACOs) in Medicare.

The....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011

ICD-10-CM/PCS will capture a greater level of specificity for nervous system coding. This article highlights some of the new features in coding central and peripheral nervous system cases with ICD-10-CM/PCS.
Nervous System ICD-10-CM Diagnosis Coding

Nervous system diagnosis cod....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2011

With its unprecedented funding to support the effective implementation of health IT and health information exchange (HIE), the American Recovery and Reinvestment Act of 2009 has given new urgency to the need for a national health identifier. Because no unique personal identifier has been establ....

Author: Garrett, Gail S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2011

The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 was signed into law on June 25, 2010. One of its provisions revised the three-day payment policy, or the so-called "three-day DRG window."

This article highlights the changes to the three-da....

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: June 2011

This spring, as the first providers began attesting to their performance in stage 1 of the meaningful use program, the rest of the industry seemed too absorbed with the program's next phase to take much notice.

Through the spring a subgroup of the Health IT Policy Committee was prepa....

Author: Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: June 2011

HIM professionals are most familiar with the data standards mandated through HIPAA. However, the data standard adoption process is also now part of the requirements for EHR technology in the meaningful use program.

Understanding the data standards adoption process under HIPAA and th....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2011

Back in January 2009, when the deadline for ICD-10-CM/PCS was announced, the path to October 1, 2013, seemed straight and reasonably long. Then came ARRA/HITECH (February 2009), soon followed by the Affordable Care Act (March 2010).

Add in other federal and local regulations that nee....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: June 2011

The theme of this month's Journal is very timely on two accounts. First, the process for implementing ICD-10-CM/PCS is heating up as the industry is now six months from what many consider the first national milestone: the January 2012 compliance deadline for the HIPAA 5010 transaction upgrade.....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: June 2011

Now is the time to embrace ICD-10 adoption and plan for your personal success and the future state within your organization. Healthcare organizations are depending on the HIM profession to do the heavy lifting and prepare the industry for ICD-10.

We will never walk this path again. T....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2011

It's a long journey to ICD-10 implementation. Organizations that need directions-or a jumpstart-can use a new checklist to map out 10 milestones for the first leg of the journey.

Healthcare facility staff unsure how to start the conversion to ICD-10 now have a ready-reference road ma....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: May 2011

May 10, 2011


Payers and providers must work their way through the transition to ICD-10-CM/PCS only once, and by the end, few will likely choose to do it again. System vendors and consultants, however, will have been through many, many implementations before it’s all over.

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: May 04, 2011

Since it was planted 30 years ago, the ICD-9 code set has grown roots deep into the healthcare system. Within individual organizations and enterprises, those roots can reach into nearly every department and function.


Upgrading to ICD-10 thus requires....

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2011

For nearly 40 years I have served as an HIM and health IT professional, but for my entire life I have been a healthcare patient. My understanding of the processes that create medical records has helped me identify system and human mistakes in my own records. Consequently, I know well that the....

Author: Bass, Deb

Source: Journal of AHIMA

Publication Date: May 2011

Every health information exchange must determine how it will gain consent from patients to share their information. The Nebraska Health Information Initiative chose opt out and with good communication and management has maintained a high rate of patient participation.

Even afte....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2011

The laws surrounding release of a deceased patient's records can lead to complex and frustrating situations in the HIM department. Just who has access rights depends on federal law, state law, and individual circumstances, illustrated by the two scenarios below.

Last summer the Office....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: May 2011

The Centers for Medicare and Medicaid Services' meaningful use program includes a set of requirements for the exchange of clinical information. The Office of the National Coordinator for Health IT outlined the EHR standards and certification requirements necessary to enable clinical informatio....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: May 2011

Health information exchange continues to evolve as the federal government and states launch initiatives promoting technology, interoperability, standards utilization, and harmonization. One of these, the State Health Information Exchange Cooperative Agreement Program, is the center of a federa....

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: May 2011

Health information exchanges (HIEs) continue to expand across the nation as organizations prepare to meet the stage 1 meaningful use criteria. A 2010 eHealth Initiative survey found that there are currently 73 operational HIE initiatives, up from 57 in 2009.

During this rapid advanc....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2011

Editor's note: This update supplants the November-December 2006 practice brief "Privacy and Security in Health Information Exchange".


The primary function of a health information exchange (HIE) is to permit access to clinical information on demand at the point of care. HIEs enabl....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2011

The field of sleep medicine is rapidly expanding, and its coding and reimbursement are attracting more attention from federal and state governments, public health organizations, scientists, payers, auditors, the transportation industry, and healthcare consumers. Emerging topics in the area of....

Author: Stine, Kevin; Dang, Quynh

Source: Journal of AHIMA

Publication Date: May 2011

Healthcare and health IT professionals are entrusted with protecting the privacy and confidentiality of patient data. To provide this protection, these professionals frequently look to commonly accepted technologies and methodologies to safeguard the data while at rest and in transit. One tech....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2011

The federal government has been actively encouraging health information exchange through direct grants and leadership. However, its challenge now is keeping focused and getting the multiple efforts aligned.

The Office of the National Coordinator for Health IT is attempting to do in a....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: May 2011

Three federal reports released as March ended and April began will dictate the trajectory of HIM and health IT initiatives over the next several years and possibly through the end of the decade. HIM professionals should review the reports, as they will have a major impact on the healthcare ind....

Author: Voigt, Chris; Torzewski, Susan

Source: Journal of AHIMA

Publication Date: May 2011

Some HIEs were surprised when the federal government announced a project to enable direct provider-to-provider information exchange. But CareSpark, an HIE piloting the lightweight exchange method, is seeing the benefits for users and a logical integration into the services it offers....

Author: Winter, Kitt; Hastings, Bob

Source: Journal of AHIMA

Publication Date: May 2011

The Social Security Administration has plenty of reasons to streamline its records request process-more than 15 million reasons each year, in fact. That's why it has been pioneering information exchange projects with the private sector, including use of the Nationwide Health Informa....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2011

Many coding professionals will need to learn new terminology and brush up on their anatomy and physiology (A&P) knowledge to prepare for the ICD-10-CM/PCS transition. Although it is still too early for intense training on the new code sets, now is the time for coding professionals to gain....

Author: Martin, Timothy D

Source: Journal of AHIMA - website

Publication Date: April 2011

The Affordable Care Act of 2010 calls for the Centers for Medicare and Medicaid Services to create a Medicare “shared savings” program, which will encourage the development of accountable care organizations. ACOs will be eligible to receive additional payments if t....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: April 19, 2011

All good plans begin with an assessment of the here-and-now. A first step for any organization mapping its transition to ICD-10-CM/PCS is an assessment of the upgrade’s impact on current systems that use ICD codes. Understanding that impact is the start of all othe....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: April 2011

Apr 18, 2011

ICD-10-CM/PCS offers organizations better data about their patient populations and the services they provide them. The code set’s greater specificity allows coding professionals to more accurately reflect the details of physician documentation.

However, an....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: April 13, 2011

Without a doubt, the transition to ICD-10-CM/PCS will impact patient care and revenue. Whether that impact is positive or negative, however, comes down to the quality of the training that organizations provide their clinical and coding staff.


Omar Ros....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: April 13, 2011

In April 2010 the Georgetown University Consulting Team conducted a series of interviews with six hospital networks that had gotten an early start on their ICD-10 transitions. Researchers asked the hospitals about their approaches, priorities, and early experiences....

Author: Wang, Tiankai; Biedermann, Sue E.

Source: Journal of AHIMA - website

Publication Date: April 04, 2011

In the August 2010 print edition, Tiankai Wang and Sue Biedermann applied the cost-benefit analysis model to EHR adoptions. Here the authors describe the decision tree model, another tool to aid in the complex considerations that come with choosing to implement—or delay implementing&....

Author: Kallem, Crystal; Richesson, Rachel; DuLong, Donna; Sison, Luigi; Van Dyke, Patricia; Mon, Donald T.

Source: Journal of AHIMA

Publication Date: April 2011

Organizations must consider a multitude of data standards and reporting requirements when capturing and aggregating healthcare data. These standards and requirements are vast in scope and complex to implement.

To help address these challenges, healthcare desperately needs clearly de....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: April 2011

The vinyl record is gone from music, and the paper record is exiting healthcare. But the music keeps coming-in fact, more of it, in smaller and smaller pieces. What does the future hold for that touchstone of health information management-the record?

Not that long ago, the music indu....

Author: Haas, Mark

Source: Journal of AHIMA

Publication Date: April 2011

Since 2007 Massachusetts General Hospital has been working toward a do-it-yourself model for records requests. Not only does the organization save time and money when patients fulfill their own requests, the model also aligns with the emerging philosophy of patient-centered care, wher....

Author: Viola, Allison F.; Kallem, Crystal

Source: Journal of AHIMA

Publication Date: April 2011

With the federal government ramping up efforts to further tie healthcare reimbursement to quality of care through initiatives like value-based purchasing and accountable care organizations, quality measurement organizations are gaining more national prominence.

Many different organi....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: April 2011

Ethics can look easy on paper, but the working world offers some complex situations. Three scenarios illustrate how the AHIMA Code of Ethics provides a guide for examining ethical issues.

Anyone who is a member of AHIMA or holds its credentials agrees to abide by its code of ethics.....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: April 2011

HIM's primary ethical obligation is to protect patient privacy and confidential information, which includes oversight of information disclosure; health information systems and health records; and the quality of information. Both paper and electronic health records contain personal and private....

Author: Karban, Karen M

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2011

The final rule for the calendar year 2011 Hospital Outpatient Prospective Payment System (OPPS) was released November 24, 2010. Changes in the rule went into effect with January 1, 2011, outpatient hospital-based services.

The changes to OPPS continue to reflect packaging adjustments....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: April 2011

As in life, change is a constant in the world of HIM. However, the concepts that define the medical record and the HIM profession's responsibilities remain unchanged from the early days of medical record librarians.

In the first edition of Manual for Medical Records Librarians in 194....

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: April 2011

The American Recovery and Reinvestment Act came out with a bang in February 2009. The rules enacting its privacy and security provisions, however, have trickled out over the subsequent two years. Many of the provisions have the potential for significant impact on HIM operations, and the slow p....

Author: Majerowicz, Anita

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2011

Although the ICD-10-CM/PCS implementation deadline is two and a half years away, it is not too early to begin planning coder training. Solid training plans will ensure a smooth transition and minimize the transition's impact on productivity. A well-planned training strategy will ensure that co....

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: April 2011

In the past several years cloud computing has gained substantial recognition. However, it is still a relatively new concept for those in the healthcare industry.

Before adopting cloud-based services or applications, organizations need to understand how cloud computing works, the typ....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: April 2011

Data stewardship is a hot topic. As this issue went to press, the Department of Health and Human Services was expected to publish a notice of proposed rulemaking on accounting of disclosures, an expansion of the HIPAA requirements mandated by the HITECH Act.

Rulemaking was also expe....

Author: Rollins, Genna

Source: Journal of AHIMA - website

Publication Date: April 2011

Despite the rise of health IT, healthcare providers still face daily privacy and security risks of the mundane variety—paper records are misplaced, improperly disclosed, or released without confidential information redacted. No matter the opportunities and risks that technology bring....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: March 2011

Note: this article has been updated to reflect changes implemented through the HITECH Act.

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: March 22, 2011

Pilot projects testing the Direct Project health information exchange protocol remain on track, with project officials estimating wide industry use of Direct in 2012.


But more detail on how the average healthcare provider would use the exchange servic....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: March 2011

This is a true story that occurred recently in Indiana. Failing to collect payment for treatment, a medical group sent a patient to collections. In providing the unpaid bills to the collections attorney, practice staff failed to redact sensitive information. When the attorney filed the bills wi....

Author: Dowling, Alan F.

Source: Journal of AHIMA

Publication Date: March 2011

Social media has had a profound impact on recent events, both political and personal. In healthcare, social media is presenting HIM professionals with a quandary about how best to manage information privacy.

More and more people from all walks of life are using social media outlets s....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2011

Stopping fraud will require health record systems, organizations, and individuals capable of, and committed to, detecting and preventing false claims before they are paid.

Healthcare fraud continues to plague the country, costing the United States billions of dollars per year.
....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: March 2011

The practice of health information is changing dramatically, but the profession's ethical obligations are a constant. HIM professionals should recall these tenets and demonstrate them daily.
A Code of Ethics Refresher

The AHIMA Code of Ethics serves multiple purposes. As it sta....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2011

Lawsuits can hinge on a deposition. And while HIM professionals have long been called on to attest to the production of the paper medical record, electronic health record systems are introducing a whole new set of questions and considerations.

Providing an accurate deposition on an....

Author: Boyle, Ginger; Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2011

Multiple factors contribute to urinary tract infections (UTIs); common causes are aging and medications, especially in combination.

Aging is associated with changes in kidney structure and muscle strength. The kidneys lose their ability to filter waste from the blood. Muscles in the....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: March 2011

The stage 1 meaningful use criteria do not require that eligible providers (EPs) and eligible hospitals (EHs) create patient portals, but portals may be the best option for meeting certain stage 1 patient access and electronic communication-related provisions. Portals may also be mandatory in....

Author: Backman, Cecilia; Dolack, Susan; Dunyak, Denise; Lutz, Laurie J.; Tegen, Anne; Warner, Diana

Source: Journal of AHIMA

Publication Date: March 2011

Social media has become an undeniable force, and its rapid, informal communication style represents both possibility and liability for healthcare organizations. Good policies and training help organizations pursue the benefits and mitigate the risks.

Social media refers br....

Author: Emery, Steven; McDavid, Jan P

Source: Journal of AHIMA

Publication Date: March 2011

Registration for the meaningful use program opened in January, and many HIM professionals and chief information officers are preparing their organizations to meet stage 1 meaningful use criteria. Two of the objectives directly affect an organization's release of information (ROI) process. Part....

Author: Holmes, Casey

Source: Journal of AHIMA

Publication Date: March 2011

Yesterday's problem lists aren't suited for tomorrow's electronic systems. Standardizing the content and use of problem lists will help leverage new tools, and new tools can help improve problem list accuracy.

The problem list, that cheat sheet to patient health, originated with Law....

Part 3: Denials Management

Author: Easterling, Sharon

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2011

The denials management process is the final step in the RAC process and can be the most time-consuming portion, depending on the circumstances of each case. Providers may appeal a RAC decision either through the discussion period or the formal Medicare Appeals Process.

Becoming know....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2011

In early December the President's Council of Advisors on Science and Technology (PCAST) released "Report to the President Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward." The council's path represents some significant departu....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: March 2011

Managing third-party requests for health information is a routine function for every HIM department. HIM professionals regularly receive record requests from third parties for a variety of reasons, such as revenue integrity audits or admission validation reviews.

Historically, fulfi....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: March 01, 2011

This is a true story that occurred recently in Indiana. Failing to collect payment for treatment, a medical group sent a patient to collections. In providing the unpaid bills to the collections attorney, practice staff failed to redact sensitive information. When the attorney filed the bil....

Author:

Source: Journal of AHIMA - website

Publication Date: February 18, 2011

That nudging occurs in several of the measures related to engaging patients and their families in their healthcare. The measures are primarily met by providing patients with easier access to information about their health.


Despite the shifting focus to patient needs, EHR vend....

Author: Steindel, Steven J

Source: Journal of AHIMA - website

Publication Date: February 09, 2011

On October 1, 2013, healthcare providers must begin reporting HIPAA claims using the ICD-10 counterparts to the current ICD-9 code sets. In presenting these code sets two points come to the forefront: the code structure has changed and the number of codes has drastically increased. This ar....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: February 2011

Editor’s note: In the cover story to this month’s print issue, Journal writer Chris Dimick explores the patient-centered measures in the meaningful use EHR incentive program. As experts tells him, the current stage 1 measures are a good start to getting patients more informatio....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: February 05, 2011

Editor’s note: In the cover story to this month’s print issue, Journal writer Chris Dimick explores the patient-centered measures in the meaningful use EHR incentive program. As experts tell him, the current stage 1 measures are a good start to getting patients more information....

Author: Holmes, Casey

Source: Journal of AHIMA

Publication Date: February 2011

The meaningful use program requires that problem lists in the EHR use a common dictionary through coding. It is a good first step in boosting the usefulness of problem lists, but getting to the next level will be a harder challenge-agreeing on standardized content and use.

Last mont....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2011

It is hard to say just what patient-centered care is, but just about everyone agrees that we lack it. The meaningful use program has focused providers, vendors, and consumer advocates around some basic first steps.

This January the meaningful use program began, and with it launched a....

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: February 2011

The second session of the 111th Congress began with the Democrats in firm control of the House and Senate. Working from their position of power enabled the Democrats to pass healthcare reform.

Although Congress was mired in contentious debates, AHIMA still advocated for its public po....

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: February 2011

Healthcare entities collect a vast amount of administrative, clinical, and financial data. Health data analysts play a critical role in helping translate these data into meaningful information that can be used to identify improvement opportunities, recognize trends, and assist in decision maki....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: February 2011

In March 2010 President Obama signed into law the Patient Protection and Affordable Care Act (ACA), which includes many provisions calling for the implementation of quality measurement programs. One program that must be established by January 2012 is the Medicaid Quality Measurement Program, w....

Author: Smith, Gail I.; Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2011

Each year CPT adds codes to reflect new procedures and surgical techniques. For example, new codes were added in the surgical section to identify procedures performed using balloon catheters.

In addition, CPT continues to make editorial changes and add coding guidelines within the t....

Author: Easterling, Sharon

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2011

Healthcare organizations are still struggling to manage the Recovery Audit Contractor (RAC) process implemented last year. This article is the second in a series that discusses the provider portal, the discussion period, and the review results letter. Part 1, published in the January issue, di....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: February 2011

Patient-centered care focuses on delivering healthcare in a manner that works best for patients. In a patient-centered approach, providers partner with patients and their family members to identify and satisfy the full range of patient needs and preferences.

Organizations practicing....

Author: Benson, Sean

Source: Journal of AHIMA

Publication Date: February 2011

Little direct attention has been paid to clinical documentation in the context of meaningful use. Discussion and debate instead focused on electronic health records (EHRs), computerized physician order entry, and other health IT systems.

However, the electronic capture and exchange....

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: February 2011

Every organization approaches the transition to an electronic health record (EHR) differently, and completing the endeavor successfully hinges on multiple factors that include evaluating the organization's existing IT systems and planning for those components to become fully integrated.
....

Author: Carolan, Katie

Source: Journal of AHIMA

Publication Date: February 2011

HIM professionals can help move their organizations' ICD-10-CM/PCS transitions off the back burner by working with their systems' vendors to establish upgrade schedules, training, and transition staffing.

The ramp-up to ICD-10-CM/PCS has been slow...at best. Focused on implement....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: February 2011

With one year of breach reporting on the books this month, theft remains the most common cause of data breach in healthcare. Of the 217 large-scale breaches reported to the Department of Health and Human Services by mid-January 2011, 121 (56 percent) involved theft. Of those, 89 involved a lapt....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: January 2011

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

Author: Herrin, Barry S.; Jones, Frankie T

Source: Journal of AHIMA

Publication Date: January 2011

In 2009 the average cost per incident of a data breach in the United States was $6.75 million.1 Mark Bregman, executive vice president and chief technology officer at Symantec Corporation, cited this statistic during his testimony before the Senate Subcommittee on Consumer Protection, Product....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: January 2011

Today, employers are counting on us to achieve great success in adopting health IT, creating strategy, managing implementations with new workflows, and demonstrating meaningful use while properly planning for the monumental transition to ICD-10.

These are the most revitalizing times....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: January 2011

A 45-year-old man rushes into a Maryland hospital's HIM department requesting the full medical records of both his 70-year-old mother and father. Both had been previously treated by the hospital for complications from Alzheimer's disease.

Some years previously the mother and father e....

Author: Dowling, Alan F.

Source: Journal of AHIMA

Publication Date: January 2011

Welcome to 2011, a year in which opportunities abound!

This is a year in which we are likely to see increased collisions between preconceived notions and innovative concepts, between optimistic projections and implementation realities.

This year many individuals from a var....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2011

It always is helpful to look back at what transpired over the past year in order to prepare for the coming one. Certainly many of the significant initiatives and events coming out of Washington in 2010 will reverberate well into 2011.
A New Congress Convenes

The 2010 midterm ele....

Author: Easterling, Sharon

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2011

Thirteen months after the Recovery Audit Contractor (RAC) process was implemented nationwide, healthcare organizations are still learning how to best manage the audit process. The initial reviews were automated, but since that time RACs have also begun complex coding reviews and medical necess....

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: January 2011

The electronic health record's promise of a paperless environment has been around for decades, but it has proven difficult to keep. Regardless of how an EHR is implemented or the phase of implementation, paper remains a staple of the health record for quite some time after conversion and, in m....

Author: Rollins, Genna

Source: Journal of AHIMA

Publication Date: January 2011

While EHRs offer improvements to patient care, they are not documentation panacea for record keeping. Systems must be properly configured and used to generate solid documentation. When they are not they might not represent what actually occurs in patient care, compromising care and complicatin....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: January 2011

Important differences exist in advance directives. Only some grant access to another person's medical records, and that can change with time.

After 50 years of marriage, Rosa Taylor-Payne noticed even the slightest change in her husband, Marvell Payne. So she started to worry when he....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: January 2011

Seven stories unfolding in 2011 illustrate the sweeping changes under way in what will be an active and sometimes tumultuous year in health information management.
Each year brings change to HIM, whether it is coding modifications, compliance changes, or new technology. But 2011 promises....

Author: Yaniszewski, Linda

Source: Journal of AHIMA

Publication Date: January 2011

We all know the state of the economy. Cutting costs has been a mantra in healthcare for years, but recent pressures have been more demanding than ever.

In HIM, the downward pressures in cost conflict with the upward forces in workload. Additional tasks related to recovery audits, IC....

Author: Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2011

Note: This article has been updated.  The updated version is available here.

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2011

Electronic health record systems offer many opportunities for long-term care (LTC) facilities and their patients, and momentum is building for their widespread adoption across care settings.


Although some federal health IT initiatives benefit long-term care, LTC facilities are not....

Author: Bowman, Sue E; Leon-Chisen, Nelly

Source: Journal of AHIMA

Publication Date: January 2011

The ICD-10-CM/PCS final rule requires HIPAA covered entities adopt the ICD-10-CM and ICD-10-PCS code sets by October 1, 2013. Adoption is not required for noncovered entities such as property and casualty insurance health plans, workers' compensation programs, and disability insurance programs....

Author: Steindel, Steven J

Source: Journal of AHIMA - website

Publication Date: January 01, 2011

On October 1, 2013, healthcare providers will start reporting HIPAA claims using the ICD-10 counterparts to the current ICD-9 code sets. The vastly expanded code space of ICD-10-CM should prove familiar to most ICD-9-CM users and very approachable for new learners. With the exception....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2010

Editor's note: This update replaces the June 2004 practice brief "Homeland Security Act and HIM."
After the terrorist attacks in New York City, Pennsylvania, and Washington, DC, on September 11, 2001, the United States Congress enacted the Patriot Act in 2001 and the Homeland Security Act....

Author: Dowling, Alan F.

Source: Journal of AHIMA

Publication Date: November 2010

Today physician practices have the opportunity to improve information completeness, accuracy, and timeliness and care quality. ARRA incentives and the new regional extension centers have joined the myriad market forces accelerating the push for physicians to trade paper for health IT.

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: November 2010

This fall advocacy took a back seat to the mid-term elections. Candidates from both parties are offering a wide variety of viewpoints on the current issues facing the US.

One of the major issues in the election is how our nation will address the recession while also contending with....