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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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?
<....

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....

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.....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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,....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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&....

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....

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....

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....

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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,....

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....

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....

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....

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....