4020 results.
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Information Governance Road Map: Mile Marker 3—Travel to America’s Most Prized Treasures
Author: Reeves, Mary G
Source: Journal of AHIMA
Publication Date: September 2016
Editor’s Note: This article is the sixth in a series that provides a road map for implementing an information governance (IG) program in any organization. Each month a set of concepts will be discussed that tie to the IG Road Map Infographic developed by AHIMA. Any organization can t....
Copy and Paste Run Amok—EHRs and Malpractice
Author: Journal of AHIMA Staff
Source: Journal of AHIMA
Publication Date: September 2016
As if physicians needed another reason to be wary of electronic health records (EHRs), a new study finds that malpractice claims related to EHR use have risen in accordance with increased EHR adoption.
The study, which was conducted by The Doctors Company, a malpractice insurance....
Do You Want Fries With That? Decoding All the 'Extras' in Physician Visits
Author: Davies, Sharon
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: September 2016
Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the p....
Bridging the HIM Present and Future
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: September 2016
“What does the future of HIM look like?” We have been asking this question as long as our association has existed. In recent memory, our work to answer this question unfolds from “Vision 2006” to “Reality 2016.” The latest iteration is “HIM Reimagi....
Release of Information: When to Call a Healthcare Compliance Attorney
Author: Herrin, Barry S.
Source: Journal of AHIMA
Publication Date: September 2016
The HIPAA-HITECH modifications to the Privacy and Security Rules have made the management of the release of information function even more complex for providers. Add in state law and other protections, and it can be difficult for health information management (HIM) professionals to know ju....
Don't Leave Money on the Table: Mastering MACRA, PQRS, and Value-Based Purchasing: How Quality Coding Impacts Quality Reporting
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: September 2016
Whenever there’s a flashy new piece of consumer technology, there are always holdouts who insist on sticking with the old, more comfortable way of doing things. Consider a grammarian who rejects online dictionaries for a cumbersome hard-bound book. Or the road tripper who prefers their an....
Understanding Information in EHR Systems: Paving the Road for Semantic Interoperability through Standards
Author: Orlova, Anna; Salyards, Kenneth
Source: Journal of AHIMA
Publication Date: September 2016
Today, both clinicians and health information management (HIM) professionals have been experiencing overwhelming challenges with the usability of electronic health record (EHR) systems due to shortcomings in supporting user needs.1,2,3,4 A five-year study recently published by the US Nati....
Pain at the Printer: How To Stop HIM's Addiction To Printing Records From The EHR
Author: Carey, Susan; Beahan, Sally
Source: Journal of AHIMA
Publication Date: September 2016
Historically, health information management (HIM) staff has provided paper copies of medical records in response to authorized requests. No specialty patient education was needed because the paper record was essentially self-explanatory.
But with the ongoing industry trans....
Seat at the Table: Testimony to NCVHS
Author: Martin, Melissa
Source: Journal of AHIMA
Publication Date: September 2016
Back in June I had the opportunity to represent both AHIMA members and the HIM profession while testifying at a National Committee on Vital and Health Statistics (NCVHS) hearing on the need for a better definition of the minimum necessary standards. I would like to share with you some hig....
Study Analyzes Causes and Consequences of Patient Overlay Errors
Author: Landsbach, Grant
Source: Journal of AHIMA
Publication Date: September 2016
For years, many in the health information management (HIM) industry have been aware of the dangerous patient misidentification problem known as an “overlay.”
This situation occurs when the incorrect patient is registered/admitted/documented on another patient&rsq....
OCR Continues to Define Patient Access Guidelines
Author: Bowen, Rita K.; Hofman, Judi; Lucci, Susan; McLendon, Kelly
Source: Journal of AHIMA
Publication Date: September 2016
The Office for Civil Rights (OCR) has made it abundantly clear through numerous communications that providing individuals easy access to their own health information is one of OCR’s most important mandates. Giving patients and their personal representatives access to their own information....
Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement
Author: Whittle, Kelly
Source: Journal of AHIMA
Publication Date: September 2016
It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....
Five Tips to Develop and Share Your HIM 'Elevator Speech'
Author: Eramo, Lisa A
Source: Journal of AHIMA - website
Publication Date: September 01, 2016
As a health information management (HIM) professional, you know just how difficult it is to explain your profession to others. So many acronyms, so little time. How can you capture all of the nuances of HIM in a way that others will understand while also keeping their attention?
<....
Reviewing for Inpatient Quality
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 25, 2016
The Hospital Value-Based Purchasing (HVBP) Program has heightened hospital awareness of quality outcomes. Under this program, payments made under the Inpatient Prospective Payment System (IPPS) are based on the quality of care that was provided. Quality of care is recognized through the cl....
On the Yellow Brick Road to IG: part 3
Author: Goodell, Suzanne
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 24, 2016
In early 2016, Suzanne Goodell, co-chair of AHIMA’s Information Governance Practice Council and director of meaningful use in a large regional health system, invited our blog readers to accompany her on her IG Journey. This is the third blog post describing how the journey is going.....
Solving the Documentation Puzzle with Data Analytics
Author: Monga, Kapila
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 17, 2016
“It’s a beautiful day to save lives. Let’s have some fun,” so says Dr. Derek Shepherd (of “Grey’s Anatomy” fame) and with a smile on his face, gets on with his day’s activities—to help patients heal. I haven’t seen many doctors work, except in “Grey’s Anatomy,” but I have interacted w....
Primer on Avoiding Sanctions for the Loss of Electronically Stored Information
Author: Hedges, Ron
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 16, 2016
Several of my posts have addressed sanctions for the loss of electronically stored information (ESI) through AHIMA’s Information Governance Principles for Health CareTM (IGPHC). I have also referred on several occasions to the December 1, 2015 amendments to the Federal Rules of Civil....
On the Yellow Brick Road to IG: Part 2
Author: Goodell, Suzanne
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 11, 2016
In early 2016, Suzanne Goodell, co-chair of AHIMA’s Information Governance Practice Council and director of meaningful use in a large regional health system, invited our blog readers to accompany her on her IG journey. At that time, she stated, “I feel like I am Dorothy taking the f....
DSM-5 vs. ICD-10-CM
Author: Foley, Dianna
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: August 10, 2016
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) both present ways to classify diseases. In the case of DSM-5, it is strictly for mental dis....
Commentary: The ICD-10 Saga—Lost Years and Hard Lessons
Author: Averill, Richard F.
Source: Journal of AHIMA - website
Publication Date: August 09, 2016
The August issue of the Journal of AHIMA features an article by Sue Bowman that chronicles the dire predictions of negative consequences that would ensue if the antiquated 30-year-old ICD-9-CM coding system was replaced with the modern and up-to-date ICD-10 coding system. This r....
Stopping Thieves in Their Tracks: What HIM Professionals can do to Mitigate Medical Identity Theft
Author: Eramo, Lisa A
Source: Journal of AHIMA
Publication Date: August 2016
The clues are subtle but critical: Perhaps you get a bill for urgent care services you never received. Or upon reviewing your medical record through a patient portal, you see a diagnosis of back pain and multiple prescriptions for narcotic pain relievers.
Though not definiti....
Improving Coding and Documentation Quality Through Real-Time Collaboration: Nurses and Coding Professionals Team Up to Tackle Documentation Issues
Author: Horn, Kelli; Younger, Adrienne; Snow, Trevor
Source: Journal of AHIMA
Publication Date: August 2016
While working through the recent implementation of ICD-10, leaders at Ardent Health Services began to focus on the re-bill process and what it would look like in the months following use of the new code set. Re-billing means submitting a corrected bill to the payer after it has been rejec....
Taking Up the Interoperability Mantle
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: August 2016
In May the Office of the National Coordinator for Health IT (ONC) released a Data Brief describing the state of interoperability among non-federal acute care hospitals in 2015.1 The report looks specifically at four “domains” of interoperability: the ability for health systems....
When Doctors and Patients Troll Each Other, PHI Protection Suffers
Author: Journal of AHIMA Staff
Source: Journal of AHIMA
Publication Date: August 2016
A lot of good things are happening in healthcare in the name of transparency. Rating systems, usually in the form of a designated number of stars, are now being assigned by the public to hospitals, physicians, and nursing homes. And it’s become easier for consumers to comparison shop when they....
ICD-10 Coding Productivity Study Highlights Emerging Standards
Author: Watzlaf, Valerie J.M.; Nemchik, Scot; Hoerner, Mike; Sheridan, Patty Thierry
Source: Journal of AHIMA
Publication Date: August 2016
The implementation of ICD-10 has been compared to Y2K, with industry analysts noting that October 1, 2015 came and went with little fanfare. This commentary speaks volumes to the significant preparation that occurred in the months and years leading up to ICD-10. If you were in the trenches....
Health Records All Access Pass
Author: Payne, Thomas H.; Beahan, Sally; Fellner, Jane; Martin, Dan; Elmore, Joann G
Source: Journal of AHIMA
Publication Date: August 2016
Patient Portals that allow viewing of clinical notes and hospital discharge summaries: the University of Washington OpenNotes implementation experience
Many healthcare organizations are striving to improve patient engagement by facilitating patient access to clin....
Making the Call for Patient Experience: Using Health IT to Address Gaps in Patient Data-Sharing, Communication, and Interoperability
Author: Labow, Kim
Source: Journal of AHIMA
Publication Date: August 2016
Interoperability and integration within the health IT landscape remain high priorities for providers, patients, and technology firms. Interoperability in health IT holds the promise of more satisfied patients, providers, and health information management (HIM) professionals. But approachi....
Look Back on the ICD-10 Transition: Crisis Averted or Imaginary?
Author: Bowman, Sue E
Source: Journal of AHIMA
Publication Date: August 2016
The transition to ICD-10-CM/PCS (ICD-10) was an update to the antiquated 30-year-old ICD-9-CM coding system that was made to reflect changes in the practice of medicine that have occurred over the past three decades. It is a next-generation coding system that modernizes and expands the ca....
Bringing HIM to Every Corner of Healthcare
Author: Martin, Melissa
Source: Journal of AHIMA
Publication Date: August 2016
Remember our association’s theme from last year: HIM without walls?
In June I accepted a new professional role as the assistant vice president of the Heart and Vascular Institute at West Virginia University Medicine, which has been an amazing opportunity.
Sh....
Solving the Health IT Interoperability Quagmire
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: August 2016
As the sun begins to set on the Obama administration, Vice President Joe Biden has been leveraging the weight of his office to speak out on the health IT interoperability quagmire in which the nation currently finds itself. During a speech at the industry’s Health Datapalooza in May,....
HIM's Role in Value-Based Reimbursement: Three Leaders Weigh In on Impact
Author: Czahor, Amy; Evans, Ginna; Friedman, Beth; Head, Erin
Source: Journal of AHIMA - website
Publication Date: August 01, 2016
The healthcare industry’s move from paper to electronic health records (EHRs) has spanned two decades. The implementation of ICD-10 took four years. Now the shift from fee-for-service to value-based reimbursement is upon us. Like most large healthcare initiatives, full realization of....
Making HIPAA Work for You: Discussing Record Access (and More) for Consumers
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: August 01, 2016
The US Department of Health and Human Services (HHS) has taken many steps to try and clear up consumer confusion regarding the more consumer-centric aspects of HIPAA’s Privacy Rule and Security Rule. The most recent efforts include the Office of the National Coordinator’s Patien....
Managing a Part-Time Remote CDI Team
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: July 29, 2016
As clinical documentation improvement (CDI) programs become more popular, providers are still struggling with implementing CDI programs for several different reasons, including: geographical location; a shortage of outpatient coders and CDI specialists; or even the lack of physi....
Create a Learning Environment for Information Governance
Author: Reeves, Mary G
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 28, 2016
To get information governance (IG) off the ground, there must be a leader who is willing to step up and make the case for IG by clearly identifying its benefits—the IG Value Proposition. As a first step in building the value proposition, leaders can create an IG learning environment w....
How Do CDI Programs Impact the Patient
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 27, 2016
We talk a lot about the impact of clinical documentation improvement (CDI) on healthcare organizations and physicians. We look at ways to reflect appropriate reimbursement and accurate quality scores, both of which are very important. But do we take the time to look at the true extent of t....
Seventh Character Application for Injuries in the Principal Diagnosis and the Impact to Data Quality
Author: Wall, Kathleen E.
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 25, 2016
By now, we’ve all had practice assigning 7th characters for injuries. And, by now, we all know that in theory the guidance seems very clear—but the application of this new concept is not clear at all. Why is there so much confusion and why does it matter? What are the short- and long-term....
What It Means to Be Deposed
Author: Hedges, Ron
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 22, 2016
In this blog I talk about legal consequences. I usually provide current examples of what those consequences might be under a specific set of facts. Here, instead, I want to highlight a litigation-related event that readers might experience in the future—or perhaps already have: a depo....
Pokémon Go Poses Privacy and Security Concern for Healthcare Providers
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: July 21, 2016
The mobile app game that has thousand of players roaming streets, parks, and even workplaces—healthcare providers included—has health privacy experts concerned.
Pokémon Go is a smartphone app that uses a phone’s GPS and camera to help players search for virtual chara....
Developing Productivity Standards through Analytics [sponsored article]
Author: Pitsikoulis, John; Doty, Laura
Source: Journal of AHIMA - website
Publication Date: July 15, 2016
“Productivity” is defined as the effectiveness of productive effort, measured in terms of the rate of output per unit of input, easily defined and applicable in many manufacturing scenarios. For the line worker in a manufacturing plant, output is basically the number of widgets or com....
HIM Can Propel IG to Where It Needs to Be
Author: Seargeant, Lori
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 14, 2016
The more I learn, the more I realize how much I do not know.
-Einstein
Information governance (IG) is a growing discipline in many industries, yet we are finding it just taking hold in healthcare with the robust momentum it merits. Recognizing the many comp....
Get Ready: Code Downpour On Its Way
Author: Sanvik, Gina
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 13, 2016
Although many HIM professionals and coding professionals were just starting to get comfortable with ICD-10-CM/PCS, it is time to prepare for the thousands of new ICD-10 changes coming soon.
The upcoming ICD-10 updates for the Fiscal Year (FY) 2017 will also represe....
Planning Ahead for 2017 and Beyond
Author: Martin, Melissa
Source: Journal of AHIMA
Publication Date: July 2016
Since I am halfway through my term as AHIMA’s President, I wanted to take some time this month to reflect on the work AHIMA’s Board of Directors has done thus far.
We hit the ground running in January at our first board meeting of the year, where we discussed our 2016 quar....
CDI: A Cog in the Wheel of Information Governance
Author: Downing, Katherine
Source: Journal of AHIMA
Publication Date: July 2016
Information governance (IG) is an emerging discipline in healthcare that focuses on how an organization ensures information is complete, accurate, trustworthy, and usable. The goal of information governance is to enable organizations to utilize a valuable strategic asset—information&....
Querying Through the Chaos: How to Get Docs' Attention Amidst the Digital Healthcare Haze
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: July 2016
It wasn’t that long ago that online dating—and resultant marriages—carried a stigma. There was a sharp divide between the people who believed in meeting their loves the old fashioned way, and those who felt that online dating was a natural extension of their already Internet-centric profe....
Avoiding a High-Wire Act: Balancing Cash Optimization with Patient Satisfaction
Author: Saharia, Devendra
Source: Journal of AHIMA
Publication Date: July 2016
Think back to the last time you went out for dinner and had a dreadful experience. Did you rush home and write a negative online review of the restaurant? If so, you’re not alone. More and more, restaurant patrons, home improvement customers and, yes, even patients are taking to the Inter....
Impact of Clinical Documentation Improvement on the International Stage
Author: Combs, Tammy
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2016
Illness doesn’t care what country or region a person lives in, and it doesn’t care the race or origin of a person. Since illness is found everywhere around the globe it only stands to reason that providers should also look beyond the boundaries of one country or patient population when re....
Transitioning from Coding to CDI Offers New Career Opportunities
Author: Endicott, Melanie
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2016
The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper repo....
Considerations for Contracting with Cybersecurity Firms
Author: Glondys, Barbara
Source: Journal of AHIMA
Publication Date: July 2016
On March 28, 2016, the information systems at 10 MedStar Health hospital locations were attacked by a virus that prevented certain users from logging in to the organization’s information systems. The organization immediately moved to back-up systems using paper transactions. All facilitie....
Clinical Documentation for Value-based Reimbursement: Why It Takes a Village to Ensure Success
Author: Fee, James P; Clesi, Wendy
Source: Journal of AHIMA
Publication Date: July 2016
Like it or not, the transition to value-based healthcare is well underway. In January 2015, the Department of Health and Human Services (HHS) announced its Better, Smarter, Healthier campaign with clear goals and a timeline for shifting Medicare reimbursement from volume to value. Through....
Cross-walking Health Content Standards Using the ISO/IEC 11179 Metadata Registries Standard
Author: Warzel, Denise B; Reeves, Dianne M
Source: Journal of AHIMA
Publication Date: July 2016
Key challenges in clinical and translational biomedical research and personalized medicine include the need to integrate multidisciplinary, heterogeneous data sets. This requires both reusable data elements and content standards that unambiguously describe data within and across diverse da....
Clinical Validation: The Next Level of CDI
Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2016
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Information Governance Road Map: Mile Marker 2—Updates from the Journey
Author: Meehan, Ann M.
Source: Journal of AHIMA
Publication Date: July 2016
Editor’s Note: This article is the fifth in a series that provides a road map for implementing an information governance (IG) program in any organization. Each month a set of concepts will be discussed that tie to the IG Road Map Infographic developed by AHIMA. Any organization can t....
Study: Tele-dermatologists Only Scratch the Surface
Author: Journal of AHIMA Staff
Source: Journal of AHIMA
Publication Date: July 2016
Every Internet hypochondriac can agree on one thing: No good can ever come from Google image searching one’s own dermatologic irregularities. Spider bite or skin cancer? Only a doctor can know for sure… or can they?
Ideally, every person who wonders about a skin condition can gai....
CDI is about Relationships
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: July 2016
“Alone we can do so little; together we can do so much,” said Helen Keller. This quote was part of Keller’s vaudeville circuit speech, but the sentiment holds true for those of us in the spotlight of HIM.
Our goal is to tell the patient’s story accurat....
Reinventing HIM as Enterprise Content Management
Author: McCann, Linda F; Henciak, William A; Durand, Elizabeth
Source: Journal of AHIMA
Publication Date: July 2016
The University of Maryland Baltimore Washington Medical Center (UM BWMC) installed a new electronic health record (EHR) approximately three and a half years ago. As a result, significant challenges were experienced throughout the organization, but especially in the health information manag....
Information Release to Patient Families and Caregivers: What Does HITECH/HIPAA Actually Say?
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: July 01, 2016
One of the most important objectives of the HIPAA Privacy Rule—and the HITECH Act in particular—was to ensure that consumers have easy and affordable access to their own protected health information. The regulations also clarified how and when medical information about a patien....
CDI is Expanding as Need for Quality Documentation Grows
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: June 23, 2016
Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as healthcare doesn’t stop when a patient is discharged, health problems begin....
IG is Critical for Our World of Growing Health-Related Data
Author: Meehan, Ann M.
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: June 23, 2016
In this world of growing health-related data, information governance is not only needed but is crucial to ensure that healthcare organizations can quickly and efficiently manage the data being produced, resulting in information being used effectively for patient care. The latest numbers on....
What Were They Thinking? Film Crew in ER Brings Lawsuit to Hospital
Author: Hedges, Ron
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: June 2016
As this blog is about legal consequences, I try to provide current examples of what those consequences might be using a specific set of facts. This month’s example comes from the filming of a documentary television series in New York and Presbyterian Hospital (NYP), one which left me with....
Can Data Save a Life?
Author: James, Wendy
Source: Journal of AHIMA - website
Publication Date: June 15, 2016
The technological advances that have taken place over the past 25 years have been nothing short of phenomenal. When I reflect on the things I have experienced, not only in my professional career, but the technological advances I have seen over the course of my life across the board i....
Survey: Coding Productivity Dipped After ICD-10 Implementation
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: June 13, 2016
The implementation of ICD-10 did result in a perceived loss of coding productivity, with a minimal dip in coding accuracy, according to a recent coding productivity and accuracy survey. The survey was conducted by the AHIMA Foundation in the first three weeks of May, and was released today....
Aligning Information Governance Initiatives with Organizational Change
Author: Washington, Lydia
Source: Journal of AHIMA - website
Publication Date: June 09, 2016
How do I start an information governance (IG) program or initiative? The question is a popular one in today’s healthcare organizations. But perhaps the better question is, “WHEN do I start an IG program or initiative?” Timing can be everything. If an IG initiative is started at the right t....
Differentiating Fracture Coding with Osteoporosis Present
Author: Sanvik, Gina
Source: Journal of AHIMA - website
Publication Date: June 08, 2016
While working on the team for AHIMA’s Code-CheckTM Coding Question Service, I’ve noticed several questions related to providing clarification in ICD-10-CM for a fracture in a patient with known osteoporosis.
ICD-10-CM expands the code selection to more than 150 pa....
'Patient First' Should Be Our Mission
Author: Martin, Melissa
Source: Journal of AHIMA
Publication Date: June 2016
During my many years working in healthcare I have received several forms of training regarding mission statements and putting our patients first.
When I first joined the health information management (HIM) profession, I did not fully understand the trials and tribulations....
HIM's Role in Health Data Analysis
Author: Kadlec, Lesley
Source: Journal of AHIMA
Publication Date: June 2016
In today’s healthcare environment, data abounds. From the time of admission through the patient care episode, discharge, and aftercare, the volume of clinical data in healthcare continues to grow and expand. Regardless of whether the data results from a patient office visit, the lab,....
What to Expect When Phase 2 HIPAA Audits Begin
Author: Rose, Angela Dinh
Source: Journal of AHIMA
Publication Date: June 2016
The HITECH Omnibus Rule mandated that the US Department of Health and Human Services (HHS) conduct periodic audits on the privacy and security compliance of covered entities and business associates. It was during the Office for Civil Rights (OCR) update session on March 21, 2016 at the 20....
Analyzing Eight Months of ICD-10
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: June 2016
Teachers know there are two kinds of students. Student A studies and does their assigned reading throughout the whole semester, earning extra credit where they can. When the final exam rolls up, they’re anxious but prepared—they did their homework. Student B, on the other hand, has the sa....
Quality Queries for Quality ICD-10-PCS Codes
Author: Maimone, Carol
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2016
Physician queries have historically been an effective communication tool used by health information management (HIM) coding professionals to clarify documentation in the health record for accurate code assignment. The goal for any coding professional is to have all final coded diagnoses an....
Coding Audits Evolve with ICD-10: Industry Experts Define New Benchmarks and Best Practices
Author: Boomershine, Julie
Source: Journal of AHIMA
Publication Date: June 2016
From privacy and security risk assessments to perennial health plan record reviews, HIM departments are inundated with audits. The move to ICD-10-CM/PCS adds another layer of audit complexity and requirements as hospital and health systems step up their coding quality review processes, pr....
Unlocking the Benefits of ICD-10 through Data Analytics
Author: Ewing, Crystal
Source: Journal of AHIMA
Publication Date: June 2016
The reality of the ICD-10-CM/PCS implementation and the fact that it was, by all measures, a success, is the payoff of years of hard work. It’s the product of lessons learned from the implementation of 5010 and the outcome of diligence on the part of healthcare professionals, providers, a....
Semantic Content in EHR Systems
Author: Bhattacharyya, S. B; Warner, Diana
Source: Journal of AHIMA
Publication Date: June 2016
An electronic health record (EHR) can greatly help the timely delivery of efficient healthcare if the information it contains is adequate, accurate, and accessible in a timely manner. An EHR is a longitudinal record of an individual’s health journey made up of electronic documents from va....
Information Governance Road Map Mile Marker 2—Travel My Way, Take the Highway That's Best
Author: Reeves, Mary G
Source: Journal of AHIMA
Publication Date: June 2016
Editor’s Note: This article is the fourth in a series that provides a road map for implementing an information governance (IG) program in any organization. Each month a set of concepts will be discussed that tie to the IG Road Map Infographic developed by AHIMA. Any organization can....
Dissecting the Operative Report for Accurate ICD-10-PCS Code Assignment
Author: DeVault, Kathryn
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2016
The implementation of ICD-10-PCS has created new challenges in coding surgical procedures. While coding professionals have always been expected to read and interpret all surgical documentation, ICD-10-PCS has increased the level of understanding necessary for accurate code assignment.
Identity Crisis: Patient ID Errors More Dangerous Than Many Clinical Mistakes, Report Says
Author: Journal of AHIMA Staff
Source: Journal of AHIMA
Publication Date: June 2016
If you’ve undergone a major or even a minor medical procedure lately, you may have been asked to say, spell, and confirm your name and birthdate no fewer than five times after you walk in the door. Your providers aren’t forgetful or dense—they’re simply following proven protocols for ensuring y....
HIM Enjoying its ICD-10 Moment
Author:
Source: Journal of AHIMA
Publication Date: June 2016
Remember the Y2K bug? Not so long ago, there was a widely spread concern that the change from the year 1999 to 2000 would play havoc with computer systems everywhere. Technology experts set about repairing programs; “preppers” recommended we all stock up on Spam and bottled wat....
Guidelines for Achieving a Compliant ICD-10-PCS Query
Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2016
Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.
The complex and highly specific nature of ICD-10-PCS has changed....
MACRA, MIPS, and Advanced APMs: Time to Prepare
Author: Marron-Stearns, Michael
Source: Journal of AHIMA - website
Publication Date: June 02, 2016
On April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule titled “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment....
Strategies for Navigating the Approaching Wave of New ICD-10 Codes
Author: Tully, Melinda
Source: Journal of AHIMA - website
Publication Date: May 31, 2016
Before many health information management (HIM) professionals feel fully confident that they have the new ICD-10 codes under control, they should know that there are more on the way. More than 5,500 new procedure and diagnosis codes will go into effect beginning in October 2016, follo....
Developing Coding Professionals That Can Code Any Claim
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: May 31, 2016
Prior to the implementation of ICD-10-CM/PCS, Chloe Phillips, MHA, RHIA, director, HIM and clinical revenue at Brookwood Baptist Health, and her team had a decision to make. Would her organization continue using CPT codes on outpatient and physician claims, or would they dual code them usi....
Benefits and Barriers for Outpatient CDI Programs
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 27, 2016
Many hospitals that have implemented clinical documentation improvement (CDI) programs have seen a reduction of claim denials and an improvement in appropriate reimbursement payments and accurate quality scores. For these reasons, CDI programs have become very....
Importance of Data Stewards in Information Governance
Author: Downing, Kathy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 26, 2016
Data governance (DG) is the sub-domain of information governance (IG) that provides for the design and execution of data needs planning and data quality assurance in concert with the strategic information needs of the organization. Data governance includes data modeling, data mapping, data....
Having Confidence, Seeking Common Ground Are Keys to Launching IG
Author: Butler, Mary
Source: Journal of AHIMA - website
Publication Date: May 25, 2016
In the closing keynote of the 2016 Managing Electronic Records Conference Wednesday in Chicago, speaker Randolph Kahn, Esq., acknowledged that after two days of presentations about information governance (IG), attendees would likely go home feeling overwhelmed. This is doubly so for attend....
Leveraging Analytics to Reduce Readmissions
Author: Monga, Kapila
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 19, 2016
Hospital readmissions cost significant money to our healthcare system every year. According to a report from the Healthcare Cost and Utilization Project and Agency for Healthcare Research and Quality, the total cost of the 3.3 million adult 30-day all-cause readmissions in the US was $41.3....
Healthcare Providers and Their Contractors: What Could Go Wrong?
Author: Hedges, Ron
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 18, 2016
Healthcare providers often enter into agreements with third party contractors to provide services dealing with electronic information. There are various reasons to do so, such as leveraging the contractor’s expertise. Unfortunately, there may be times when the relationship....
Role of Standards in IG
Author: Warner, Diana
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 13, 2016
The use of health information technology (HIT) in the clinical setting brings both opportunities and challenges for health information management (HIM) professionals regarding data capture and exchange; data storage, use and reuse; record ownership and access; e-discovery and e-forens....
Combating our Fear of Change and Creating a Holistic Approach to HIM Education [Sponsored article]
Author: Berkeley Research Group
Source: Journal of AHIMA - website
Publication Date: May 13, 2016
Knowledge is at the core of everything we do. It is behind the mechanics and strategy of coding and the ease of understanding the final outcome(s), and it plays an integral part in the acceptance of change when faced with industry-wide transformation.
Last year, the health in....
Coding Diabetes Mellitus with Associated Conditions
Author: Sanvik, Gina
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 11, 2016
There has been some confusion among coding professionals regarding interpretation of the coding guideline of “with.” An area that contains many instances of using this guideline in ICD-10-CM is coding Diabetes Mellitus with associated conditions. There are 53 instances of....
Deadline for ICD-10 Specificity Draws Renewed Attention to Physicians’ Role [Sponsored article]
Author: Elsevier
Source: Journal of AHIMA - website
Publication Date: May 06, 2016
On October 1, 2016, the Centers for Medicare and Medicaid Services (CMS) will require greater specificity for claims filed in ICD-10-CM/PCS, and payers will either follow suit or, as some already are doing, lead the way. This has put focus back on physicians and the critical role they play....
It Takes a Village of Virtual Experts to Fight Child Abuse
Author: Journal of AHIMA Staff
Source: Journal of AHIMA
Publication Date: May 2016
The consequences of failing to correctly diagnose child abuse are enormous—and a burden to any pediatric provider. Rural healthcare providers, who regularly treat suspected victims of abuse in emergency rooms and clinics, often lack access to the tools and experts that can help them make more i....
Understanding Disclosures for Firearm Background Checks
Author: Davis, Nancy; Glondys, Barbara
Source: Journal of AHIMA
Publication Date: May 2016
Federal law prohibits the sale of firearms to certain individuals with a history of mental illness. Recent mass shootings have focused attention on the fact that the individuals perpetrating these crimes often had a documented history of mental illness which went undetected despite state a....
Redefining HIM for a Quickly Changing Healthcare Industry
Author: Martin, Melissa
Source: Journal of AHIMA
Publication Date: May 2016
At West Virginia University Medicine, we have eight hospitals, three institutes, and more than 800 physicians and specialists all moving onto a common electronic health record (EHR) over the course of 18 to 24 months. As part of this process, my role has changed to the associate vice pres....
Information Governance Roadmap: Mile Marker 1—Engaging IG Leadership and Celebrating Quick Wins
Author: Meehan, Ann M.
Source: Journal of AHIMA
Publication Date: May 2016
Editor’s Note: This article is the third in a series that provides a road map for implementing an information governance (IG) program in any organization. Each month a set of concepts will be discussed that tie to the IG Road Map Infographic developed by AHIMA. Any organization can t....
ICD-10-CM Coding for Injury Resulting from Terrorism
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2016
On October 1, 2015, the ICD-10-CM coding classification was implemented in the United States. This article provides a coding update on how to report injuries resulting from terrorism, which is now classifiable under ICD-10-CM. In the US, ICD-10 (mortality coding) and ICD-10-CM (morbidity c....
Lessons Learned from Training an International Workforce
Author: Strafer, Paul; Milligan, Cassie
Source: Journal of AHIMA
Publication Date: May 2016
In an increasingly interconnected world, offshore coding has piqued the interest of many health information management (HIM) directors hoping to cut costs, alleviate staffing shortages, and tap into a new pool of talented individuals. Coding companies have worked earnestly to train overse....
Preparing HIM for the Changes Ahead
Author: Gordon, Lynne Thomas
Source: Journal of AHIMA
Publication Date: May 2016
As we focus on education and workforce issues, there’s good news and bad news.
The good news is: The employment outlook for HIM professionals is bright. According to AHIMA’s 2016 Environmental Scan report, “The Bureau of Labor Statistics estimates that the H....
HIM's Professional Shake-Up Wake-Up: Moving Beyond Reality 2016 and 'Reimagining' HIM for a Quickly Changing Healthcare Industry
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: May 2016
Health information management (HIM) and coding professionals intent on keeping their jobs and their skills relevant would do well to study the career prospects of medical transcriptionists, their healthcare documentation brethren. As providers started transitioning to electronic health rec....
Continuing on the Intriguing ICD-10 Journey
Author: Bielby, Judy A
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: May 2016
In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States wo....
Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016
Author: Bonner, Dari; Fancher, Karen M
Source: Journal of AHIMA
Publication Date: May 2016
Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI s....
New International Standard for Health Information Privacy Workforce Education
Author: Lee, Mee Jeong; Kim, Yeaeun; Kim, Ok-nam
Source: Journal of AHIMA
Publication Date: May 2016
Maintaining the privacy of personal health information (PHI) is important whenever information is gathered, be it for the primary purpose of delivering healthcare, or secondary uses such as clinical research and population health. According to the International Organization for Standardiza....
Recognizing the Characteristics of Quality Documentation
Author: Combs, Tammy
Source: Journal of AHIMA
Publication Date: May 2016
When we take a bite of our favorite food we can easily determine the quality by relying on what our senses tell us. The look, smell, and taste are all clues to the quality that was put into preparing the meal. If it looks undercooked or has mold on it, smells foul or tastes bitter, we kno....
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