Author: Geissler, Kristen; Dion, Joni

Source: Journal of AHIMA

Publication Date: July 2015

Long gone are the days of “grab and go” coding, finding the CC/MCC to push reimbursement to the next level and then moving on to the next record. Today, in addition to reimbursement, clinical data drives quality initiatives, hospital and physician profiles, and medical necessit....

Author: Foley, Margaret M.

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2015

Prior to the October 1, 2015 implementation of ICD-10-CM/PCS, every hospital must examine how the new code set will impact MS-DRG reimbursement. A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimburs....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2015

One of the most famous cases in medical history that led to regulation of the number of hours that resident physicians are allowed to work is also a case study in clinical documentation failures.


In 1984, a college student in New York, NY named Libby Zion was admitted to a....

Author: AHIMA Staff

Source: Journal of AHIMA

Publication Date: July 2015

It is the matchup of the century—the towering hulk of healthcare’s Big Data versus the super computer known as Watson. Will Watson be able to take on this lumbering, untamed mass of information and whip it into submission?


One year ago, the Journal of AHIMA reported on the IBM su....

Author: Arrowood, Danita; Johnson, Laurie M.; Wieczorek, Michelle M.

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2015

Clinical documentation improvement (CDI) programs have proven their worth with over a decade of success and continued role expansion in the inpatient setting. As the healthcare industry prepares for new initiatives such as value-based purchasing, electronic health records (EHRs), and ICD-1....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2015

With its roots in DRGs, the prospective payment system, and value-based purchasing, clinical documentation improvement (CDI) can seem like a practical administrative task. The process of ensuring accurate clinical documentation is—like so many HIM functions—often done in the ba....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 2015

The HIM Problem: The Federal Aviation Administration (FAA) manages the autopsy records of hundreds of pilots killed in accidents every year, but until 2008, health information management (HIM) professionals weren’t leading the efforts.


The HIM Problem Solver: Christy Hileman....

Author: Houlihan, Walter

Source: Journal of AHIMA - website

Publication Date: July 2015

Forget about dual coding? With ICD-10-CM/PCS implementation still months away, that might sound impossible. But that’s the strategy the health information management department at Baystate Health has deployed when it comes to preparing for ICD-10 implementation.


Throughout 20....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: June 2015

Healthcare isn’t the only industry embarking on an information governance (IG) journey—plenty of other industries and organizations are too—and getting started is one of the hardest steps along the way. But developing a project plan for IG should is a powerful first step if done....

Author: Dooling, Julie A

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 17, 2015

In my April post “Quality Data Starts With Us” I discussed the importance of identifying patients correctly the first time. I think of this as Step #1 in capturing quality healthcare data for our patients.


Step #2 is in a race with Step #1, and which comes out ahe....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2015

I’ve written for AHIMA on various subjects, including preservation and spoliation of electronically stored information (ESI). This month, I want to ask you to think about both.


To start, consider this premise: The parties to a civil action agreed to an order “on D....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 10, 2015

With just four months until the big implementation day, you are probably feeling one of two things… Relief that it’s finally here and you can begin putting into practice everything you’ve learned over the past 5-6 years of preparation, or panic because you still have much more to do to pre....

Author: Flewelling, Charles

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: June 2015

With the consistently rising value of highly skilled outpatient coders, numerous HIM departments are moving to a staffing model that employs coding professionals who are well versed in coding both inpatient and outpatient encounters. Coders in the profession today should possess a mastery....

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: June 2015

As it starts to appear likely that ICD-10-CM/PCS will finally be implemented this year, prominent advocates for the transition are striking a more optimistic tune in public statements. Overall, the ICD-10 zeitgeist has steadily swung toward an implementation date of October 1, 2015 after years....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2015

Anyone who has bought a home has inevitably heard at some point along the way that “real estate is always a gamble.” That’s cold comfort for anyone who’s plunked down earnest money on a fixer upper. But smart buyers know that if they’ve done their research and invested in the right places....

Author: Bowen, Rita K.

Source: Journal of AHIMA

Publication Date: June 2015

Fifteen years ago, many individuals accepted the role of the privacy officer with a perception that it would be a role involving the education and training of individuals on HIPAA rules and regulations, developing policy, and responding to reported incidents. The security officer was focu....

Author: Black, Michelle A

Source: Journal of AHIMA

Publication Date: June 2015

If you don't use it, you lose it. This is true for much of what we learn in life, and it’s particularly true when it comes to ICD-10-CM/PCS. Although most organizations initiated ICD-10 coder training in 2013, many decided to cease training and dual coding practice after the second ICD-10....

Author: Kostick, Karen M.; Sanvik, Gina

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: June 2015

All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.

ICD-10-PCS Scope of Work


On October 1, 2015, hospital inpatient pr....

Author: Hinkle-Azzara, Barbara; Carr, Kimberly J

Source: Journal of AHIMA

Publication Date: June 2015

At a US House of Representatives subcommittee hearing on February 11, lawmakers and stakeholders agreed that the implementation of the ICD-10-CM/PCS code sets should not be further delayed. Moreover, in March the House passed legislation that provides a permanent replacement to the Sustain....

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2015

Editor’s Note: This Practice Brief supersedes the October 2012 Practice Brief “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation.”


Improving patient care continues to take center stage in the healthcare industry, as demonstrated by an increa....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: June 2015

Chills run up and down my spine as I write this article, knowing how hard we have worked as a profession, association, and industry to get to this red letter date for ICD-10-CM/PCS.


Just before I wrote this column, I was on the edge of my seat along with the rest of indust....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia

Source: Journal of AHIMA

Publication Date: June 2015

Editor’s Note: This is the third in a series of four articles that discuss the eight Information Governance Principles for Healthcare.


AHIMA’s new Information Governance Principles for Healthcare (IGPHC) provide a framework for healthcare organizations to leverage informati....

Author: Mancilla, Desla; Guyton-Ringbloom, Carolyn; Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: June 2015

Jobs in the health information management (HIM) profession are becoming increasingly advanced in the need for both technical expertise and leadership skills. This shift is particularly important to recognize as HIM professionals navigate new career opportunities and changes ahead. Strong l....

Author: DuBravec, Daniel A; Daigle, Matt

Source: Journal of AHIMA

Publication Date: June 2015

With student safety and privacy an increasing parental concern, school administrators nationwide are sitting on a powder keg of potential backlash because of a gray area of student privacy protections that Julia Lear, senior advisor for the Center of Health and Health Care in Schools at G....

Author: Orlova, Anna

Source: Journal of AHIMA

Publication Date: June 2015

With the growing adoption of health information technology (HIT), interoperability—or the sharing of data between systems—has become a topic that everybody in healthcare is talking about. Interoperability impacts every stakeholder in healthcare with each individual party involv....

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: June 2015

Niall Brennan, director of the Office of Enterprise Data and Analytics and the first chief data officer at the Centers for Medicare and Medicaid Services (CMS), recognizes the pivotal role that data and information should play in transforming healthcare.


Before Brennan took....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: June 2015

What a difference a year makes.


A year ago, the HIM industry was reeling from an unexpected delay to the implementation of ICD-10. The change was brought on at the last minute, slipped into legislation and passed within a couple of days. The result was a one-year delay of ICD....

Author: Quick, Tara; Hickman, Stephani

Source: Journal of AHIMA

Publication Date: June 2015

As facilities approach the final laps in the race towards implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), they should heed the yellow caution flag warning of basic challenges with the vast differences between inpatient and....

Author: Eramo, Lisa A

Source: Journal of AHIMA - website

Publication Date: June 2015

Ask any coder about the ICD-10 transition, and he or she will likely tell you that it hasn’t been easy. Coders working in physician practices have had a tough time. Many of these coders have more responsibilities than their inpatient coder counterparts. Physician practice coders may even b....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: May 2015

The HIM Problem


The legislative and regulatory delays for the go-live date for ICD-10-CM/PCS have left some hospitals and physician practices skittish about investing in training and education programs. While a “boy who cried wolf” syndrome exists in some corners of healthcare, fo....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: May 20, 2015

As the costs associated with data storage and storage infrastructure continue to shrink—thanks to innovations such as cloud computing—individuals who manage records for a living must accept a new reality: destroying information and setting retention schedules will soon b....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 14, 2015

Social media is ubiquitous. Almost assuredly everyone reading this blog is employed by or a member of a healthcare organization that has a social media presence. That presence can be beneficial to you and your organization. However, that presence might be harmful. Let’s explore certain asp....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 13, 2015

There are only seven approach values in ICD-10-PCS, so one would think that selecting the correct approach value would be simple, but it’s not! Let’s take a closer look at these seven approaches and then walk through some challenging cases.


Open (0)


....

Author: Voltz, Donald M

Source: Journal of AHIMA

Publication Date: May 2015

According to data published on HealthIT.gov, 173 health IT vendors are supplying certified electronic health record (EHR) products to more than 4,500 hospitals. Despite wide penetration of EHRs in hospitals, clinics, and physician offices, a lack of access to patient information between sy....

Author: Keeton, Priscilla; Pierson, Patricia

Source: Journal of AHIMA

Publication Date: May 2015

The rapid evolution of health information management (HIM) has created enormous opportunity for those individuals who are up for the challenge and prepared for the work. With the emergence of electronic health records (EHRs) and supporting technologies, the roles of HIM specialists are un....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: May 2015

Watch and learn. For clinical informaticist Nathan Patrick Taylor, MPH, MS, CHDA, and others like him, watching patient-physician encounters and learning from them is just as important as knowing how to query data in a health IT system. Because as technical as informatics can get, at its....

Author: Desai, Anna

Source: Journal of AHIMA

Publication Date: May 2015

Today’s healthcare environment is driven by various economic and regulatory forces and technological advancements that bring both opportunities and challenges. Healthcare organizations need the right information at the right time to make accurate decisions regarding patient care and....

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: May 2015

“We need it—and we are ready!” That was the main message from speakers who voiced support for making the ICD-10-CM/PCS transition at a briefing by the Coalition for ICD-10 in February.


The following are interviews with several speakers at the briefing on why....

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: May 2015

Unless they know exactly what to look for, most Internet users wouldn’t know that a “Dark Web” exists or what it is—let alone the potential for harm that can be done with it.


But the dark side of the web is out there, and its proprietors want your medical information.

....

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: May 2015

The implications of ICD-10-CM/PCS for healthcare reimbursement is a topic at the top of everyone’s mind in the healthcare industry these days. As healthcare organizations continue to prepare for the transition to ICD-10-CM/PCS on October 1, 2015, an essential and important element of a su....

Author: Drake, Suzanne P

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: May 2015

The organizations health information management professionals serve are reliant on their understanding of outpatient coding and reporting conventions to ensure that the reimbursement received by facilities is accurate and not subject to improper payment audits.


The National....

Author: DeMasters, Dana

Source: Journal of AHIMA

Publication Date: May 2015

A police officer arrives in the emergency department of a hospital at 2 a.m. seeking information about a patient who was recently admitted following a motor vehicle accident. The officer suspects the patient was intoxicated while driving and assertively asks the nurse to tell him the resul....

Author: Regard, Dan; Hedges, Ron

Source: Journal of AHIMA

Publication Date: May 2015

As the healthcare industry moves into an electronic health record (EHR)-only environment, practitioners increasingly have to “search” electronically stored information (ESI). They may need to do this to find, for example, the date on which a patient was given a specific drug and the dosag....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: May 2015

WHEN I DECIDED to pursue my graduate education in health information management (HIM) and informatics seven years ago, adoption rates for advanced electronic health record (EHR) systems were evolving, data was siloed, and interoperability was far from reality. Organizations were up to the....

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2015

Editor’s Note: This Practice Brief supersedes the March 2007 [and March 2013] Practice Brief “Assessing and Improving EHR Data Quality.”


The United States-based Institute of Medicine (IOM) reported in 1999 that “at least 44,000 people, and perhaps as many a....

Author: Orlova, Anna

Source: Journal of AHIMA

Publication Date: May 2015

In 1898 Yale University graduate Charles Dudley, PhD, looked for a solution to the seemingly intractable problem of building a consensus on standards for industrial materials used on the Pennsylvania Railroad. To sooth the antagonistic attitudes that marred relationships between the Penns....

Author: Kowalski, Christine

Source: Journal of AHIMA

Publication Date: May 2015

Just as the world is held together and shaped by a delicate and intricate global ecosystem, the US healthcare system’s community of connected components, surviving and thriving when working together toward common goals, represents its own sort of ecosystem. As healthcare moves toward an i....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: May 2015

Informatics is one of the pillars of AHIMA’s strategy. And many people agree that it’s a critical part of the profession. But when we’re in the middle of doing our daily work, it’s easy to think of informatics as something that’s done by somebody else.

Author: Dolezel, Diane

Source: Journal of AHIMA

Publication Date: May 2015

The digital era of Big Data has generated a growing need for more electronic health information management (e-HIM) professionals who can assume the emerging role of data analyst.1 This new role requires learning how to analyze data and perform statistical calculations to support informed d....

Author: Wang, Tiankai; Moczygemba, Jackie

Source: Journal of AHIMA - website

Publication Date: May 2015

Risk management is defined as “the act or practice of dealing with risk, which includes planning for risk, assessing, identifying and analyzing risk areas, developing risk-handling options, monitoring risks to determine how risks have changed, and documenting the overall risk managem....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: April 2015

The HIM Problem


As HIM becomes increasingly data-centric, knowledge of informatics is becoming an essential tool.


Today, it’s hard to identify even one aspect of health information management (HIM) as a profession that isn’t profoundly affected by the use,....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: April 2015

In the privacy and security world, whenever a big health data breach makes the news, HIPAA experts warn that it’s only the beginning and the news will only get worse. Over the last year that has certainly been the case as the size and scope of breaches has climbed.....

Author: Dooling, Julie A

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 15, 2015

This monthly column will highlight and discuss emerging trends and challenges related to healthcare data and its ever changing life cycle.



Identifying patients correctly the first time is where data quality begins. Think of yourself as a patient for a moment.....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 09, 2015

Legal consequences flow from the use or abuse of EHR. This monthly column presents examples of what those consequences can be.


Last month I wrote about the possible consequences for a healthcare provider which violated HIPAA when it produced personal health information (PHI)....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: April 2015

This is the second installment of the Journal of AHIMA’s special series for Privacy and Security Month at AHIMA. Click here to read the first installment.



Last year was a banner year for healthcare privacy breaches, according to an annual report that....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 08, 2015

Journal of AHIMA's monthly online coding column where AHIMA’s coding experts address challenging areas and documentation opportunities for ICD-10-CM/PCS.

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: April 2015

The lack of interoperable health information systems and IT has long been a barrier to achieving a learning health system (LHS) in the US. As the Institute of Medicine defines it, a LHS is a system in which “progress in science, informatics, and care culture align to generate new knowledge as a....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: April 2015

In movies and on television lately, Hollywood has made encryption and decryption look exciting, glamorous, and world-saving. The film The Imitation Game and the BBC show The Bletchley Circle chronicle how British code breakers decrypted military strategy codes from the Nazi encryption tool....

Author: Thomas, Jeane

Source: Journal of AHIMA

Publication Date: April 2015

Imagine your organization is involved in a lawsuit or government investigation and needs to access documents or information located outside the United States. If you think you can just demand that they be sent to the US because they are relevant or maybe even necessary for the legal matte....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: April 2015

With just six months until the implementation of ICD-10-CM and ICD-10-PCS, now is the time for HIM professionals to re-evaluate the state of their facility’s implementation plan and make any necessary adjustments to ensure a successful transition. Previous delays may have slowed down....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: April 2015

The spiders of time have been hard at work on the US healthcare privacy and security rules, to the point that their place in health IT interoperability has become fogged and is inhibiting their proper role in the meaningful exchange of health information, according to Lucia Savage, JD, th....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: April 2015

Determining what to do with one’s life is a daunting task. Even once you’ve chosen the field of HIM, the sky is the limit in terms of the roles in which you can serve. As HIM evolves commensurate with the electronic health record (EHR), the options only continue to grow—a....

Author: Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: April 2015

The call for HIM professionals to develop measures and metrics that guide HIM efforts is not entirely new. Linda Kloss, MA, RHIA, FAHIMA, president of Kloss Strategic Advisors and former chief executive officer at AHIMA, discussed the importance of these measures in a Journal of AHIMA art....

Author: Lewis, Sharon; McDonald, Kevin B

Source: Journal of AHIMA

Publication Date: April 2015

As data is made more readily available through a growing number of public and private channels, understanding the risks is critical. Patients expect organizations to take the steps required to protect their sensitive and personal information as it is being produced, processed, shared, and....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: April 2015

From the year 2009 through 2014, nearly 42 million people had their protected health information (PHI) compromised, according to data from the Department of Health and Human Services’ Office for Civil Rights (OCR). Each passing year brings into sharper focus the challenges associated with....

Author: Baldwin, Kevin; Burton, Benjamin W; Cothran, Carey L.; DeMasters, Dana; Grady, Reginald; Halpert, Aviva M.; Hofman, Judi; Kadlec, Lesley; O'Dell, Rosann M; Pearson, Sandra; Deanna, Peterson; Rode, Dan; Rose, Angela Dinh; Schmidt, Peg

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2015

The advancement of technology has changed the practice of medicine. It has evolved the physician-patient relationship from solely a face-to-face interaction into real-time online encounters, from e-mails to virtual appointments. Patient portals represent such a technological advancement, leadi....

Author: Gillis, Grant

Source: Journal of AHIMA

Publication Date: April 2015

In the large community of standards development organizations (SDOs) that are focused on healthcare and health informatics, the International Organization for Standardization (ISO) Technical Committee (TC) 215 Health Informatics (ISO/TC 215) is one of the leading forums. As mandated by ISO....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia

Source: Journal of AHIMA

Publication Date: April 2015

Editor’s note: This is the second in a series of four articles that discuss the eight Information Governance Principles for Healthcare.


AHIMA’s new Information Governance Principles for Healthcare (IGPHC) provides a framework for healthcare organizations to enhance their ab....

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: April 2015

Buried deep within the 700-page “cromnibus”—the massive spending bill passed by both chambers of Congress last December—are various provisions that could affect HIM professionals directly. The following offers an explanation of the cromnibus and some of its most relevant provisions.
<....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: April 2015

Looking for some help around the house? Proponents of what has become known as the “Internet of Things” have been developing products that will do just that. For instance, the winners of the 2014 Internet of Things Awards represent a tempting array of Internet-connected product....

Author: Zeiour, Collette; Twiggs, Mariela

Source: Journal of AHIMA

Publication Date: April 2015

With more than 1,000 large breaches of protected health information (PHI) on record, it’s not surprising that PHI disclosure management is currently top of mind for healthcare leaders.1 Many of these breaches have cost organizations between $1 million and $5 million in penalties, not to m....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: April 2015

As health information management (HIM) professionals find themselves constantly inundated with more data, they will need to update their skills to stay on top of it. And one of the best ways to do just that is by earning AHIMA’s Certified Health Data Analyst (CHDA) credential.

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: April 2015

When former Vice President Dick Cheney revealed in 2013 that his heart surgeons modified the settings on his pacemaker to reduce the chances the device could be hacked by terrorists, the headlines were predictably alarmist. Fans of the Showtime hit “Homeland” immediately recognized th....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: March 2015

For the uninitiated, information governance can be a somewhat abstract concept to explain and visualize. To help health information management (HIM) professionals grasp the importance of information governance—a set of principles designated to better organize and protect healthcare da....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: March 2015

The HIM Problem


Trying to find the best way to advocate for the ICD-10-CM/PCS transition with physicians and legislators.


The HIM Problem Solvers


Dr. Paul Isaacs, MD, CDIP, senior director of health solutions, FTI Consulting; and Linda Renn, RHIT, CCS,....

Author: Dooling, Julie A

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 18, 2015

When “Data Revolution” was suggested for the title of this monthly column, I instantly thought of The Beatles (some of my favorite musicians) and their song “Revolution.”


You say you want a revolution

Well, you know

We all want to change the world
<....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 12, 2015

Legal consequences flow from the use or abuse of EHR. This monthly column presents examples of what those consequences can be.



Healthcare providers receive and respond to subpoenas on a regular basis. Providers routinely produce personal health information (PHI) when doing so....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 11, 2015

Saint Patrick’s Day is both a cultural and religious celebration that includes displays of the color green, eating and drinking, and parades. One of the greatest places to celebrate this day, outside of Ireland, is the city of Chicago, where the people go all out for Saint Patrick’s D....

Author: Maimone, Carol

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: March 2015

The Centers for Medicare and Medicaid Services (CMS) released a final rule providing required adjustments to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year (CY) 2015 on October 31, 2014.....

Author: AHIMA Staff

Source: Journal of AHIMA

Publication Date: March 2015

Health Information Management (HIM) professionals have a notoriously hard time getting folks in the C-suite to take on new health IT projects. But in one area, at least, that's beginning to change. Telehealth (or telemedicine) may have reached the tipping point in seeing a return on investment,....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: March 2015

Accounts of mistaken identity, anecdotally at least, seem to happen to everyone at least once in the healthcare realm with both paper and electronic records. But in an increasingly electronic world employing electronic health record (EHR) systems and other health IT where patients ar....

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: March 2015

AHIMA's Information Governance Principles for Healthcare (IGPHC), published in late 2014, can be seen as a set of best practices for litigation. Attorneys and litigation support personnel would do well to keep the activities outlined in these principles in mind when responding to litigati....

Author: Beckett, Barb; Downing, Kathy; Gillespie, Joe D; Waugh, Traci

Source: Journal of AHIMA

Publication Date: March 2015

Since its initial adoption the HIPAA Privacy Rule has granted individuals the right to request restrictions on the use or disclosure of their protected health information (PHI) for treatment, payment, and healthcare operations (TPO), as well as for disclosures to family members and certai....

Author: Ward, Maria

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: March 2015

On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Medicare Physician Fee Schedule (PFS) Final Rule. Because of section 101 of the Protecting Access to Medicare Act (PAMA) of 2014, no changes to the fee schedule will occur until April 1, 2015. At t....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: March 2015

Despite the fact that "strides have been made in the sharing of information across technology systems and information platforms," according to Karen DeSalvo, MD, MPH, MSc, national coordinator for health IT, I believe that our work has only just begun when it comes to developing a seamles....

Author: Liebner, Carole S; Lowery, Amanda L; Maccariella-Hafey, Patricia C; Usher, Joan L; Ward, Maria; Young, Carol

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2015

Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident's clinical conditions.


ICD-10-CM facilitates the collection and....

Author: Backman, Cecilia; Kadlec, Lesley; Kirby, Annessa; Leonard, Mary Ann; Ward, Maria; Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: March 2015

Health Information Management's (HIM) role in care coordination involves much more than ensuring records are collected and disseminated for reporting purposes. HIM ensures that patient needs are met through availability of patient information along the continuum of care.


H....

Author: Sandefer, Ryan; Karl, Ellen Shakespeare

Source: Journal of AHIMA

Publication Date: March 2015

In January 2014, the AHIMA Council for Excellence in Education (CEE) released updated curricular competencies for all accredited academic programs, including those at the associate, baccalaureate, and graduate levels. The curricular competencies were intended to better align education with....

Author: Rogers, Anne M

Source: Journal of AHIMA

Publication Date: March 2015

HIPAA-HITECH regulations have imposed many important compliance requirements on US healthcare organizations, large and small. However, the reality is that many small- and medium-sized healthcare organizations, private practitioners, and non-profit clinics often struggle to comply with the....

Author: Orlova, Anna

Source: Journal of AHIMA

Publication Date: March 2015

Health IT Standardization is the process of agreeing on standards that allow electronic exchange of data, information, and knowledge between disparate data systems. The goals of standardization are to achieve comparability, compatibility, and interoperability between independent systems; t....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: March 2015

At AHIMA's 2014 Annual Convention and Exhibit, held in San Diego, CA, National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, announced that the Office of the National Coordinator for Health IT (ONC) was in the process of refreshing its federal health IT strategic plan for the next....

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: March 2015

OIG's 90-page work plan for fiscal year 2015 (FY15) offers a high-level view of the office's continued monitoring of various HHS programs and initiatives, particularly those designed to ensure the appropriateness of Medicare and Medicaid payments. The work plan also outlines many of the government's activities in FY15 designed to ensure care quality and safety in hospitals and other healthcare settings.

Author: Crump, Dawn; Hennum, Jeannie

Source: Journal of AHIMA - website

Publication Date: March 2015

The Affordable Care Act (ACA) has a dramatic ripple effect on the healthcare industry—and will continue to create seismic shifts for many years to come. One important change for health information management (HIM) professionals to understand is the impact of ACA on health plan audits. Alre....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: February 2015

The HIM Problem


To improve the efficiency and productivity of its clinical documentation improvement (CDI) program, Baystate Health decided to train CDI specialists to work from home.


The HIM Problem Solvers


Walter Houlihan MBA, RHIA, FAHIMA, direc....

Author: Orlova, Anna; Warner, Diana

Source: Journal of AHIMA - website

Publication Date: February 2015

In the effort to advance secure and interoperable health information exchanges, the US Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) has released Connecting Health and Care for the Nation: A Shared Nationwide Intero....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 11, 2015

The coding of heart procedures is done very differently in ICD-9-CM versus ICD-10-PCS. In honor of American Heart Month, this month’s Code Cracker explores the guidelines for coding heart procedures.


There are a few specific guidelines associated with procedures don....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: February 2015

When Sherry Doggett decided to retire in 2013 after a 30-year career in HIM, the first thing she did was try to figure out how she was going to spend her time. Doggett, who spent her last year of work as the corporate director of transcription at the University of Cincinnati (UC) Academic....

Author: Don, Hardwick; Twiggs, Mariela; Braden, James H

Source: Journal of AHIMA

Publication Date: February 2015

A mere two decades ago, healthcare providers didn’t face significant penalties for improperly disclosing protected health information (PHI). Since then, regulations surrounding the privacy and security of PHI have evolved to include strict requirements and corresponding steep financial pe....

Author: Karff, Diana

Source: Journal of AHIMA

Publication Date: February 2015

Inpatient and outpatient coders enter the HIM workforce only after they have taken medical terminology, procedural terminology, pharmacology, structural anatomy and physiology, disease and treatment, and all requisite coding courses. These required courses earn academic credit in a classr....

Author: Buttner, Patty

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: February 2015

On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....