Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: September 2019

By Lisa A. Eramo, MA


The more we know about patients, the easier it is to match them. Or at least that’s the theory. Clinical data, patient-generated data, biometrics, social determinants of health: all of this should make patient matching in health information exchanges (HI....

Author: Olenik, Keith

Source: Journal of AHIMA

Publication Date: September 2019

By Keith Olenik, MA, RHIA, CHP


As healthcare services migrate toward outpatient settings, hospitals and health systems are struggling to ensure coding accuracy and quality for owned practices and clinics. With the steady increase in outpatient services, revenue integrity chal....

Author:

Source: Journal of AHIMA

Publication Date: September 2019

Article citation:

.
"Evaluating Clinical Scenarios in Coding Clinic with Data Analytics"
Journal of AHIMA
90, no.9
(September 2019):
36-37, 42.


....

Author: Youmans, Karen

Source: Journal of AHIMA

Publication Date: September 2019

By Karen Youmans, MPA, RHIA, CCS, and Vanessa Youmans, MA, RHIA, CCS, CPC


As healthcare organizations strive for continuous efficiency and sustainability, mergers and acquisitions (M&A)among diverse medical facilities provides organizations new opportunities to reduce costs an....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

By Karen Starling Greenhalgh, HCISPP, CHC, CHPC


Privacy is often seen as a barrier to electronic health information exchange (HIE). To help address those concerns and meld core privacy principles with proven oversight and accountability mechanisms, the National Institute of Standa....

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: September 2019

By Gail L. Gottehrer, JD, and Ronald J. Hedges, JD


A recently filed class action highlights the risk that the proliferation of health-related smartphone apps, fitness trackers, and the data these programs collect, may enable the re-identification of purportedly de-identified elect....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

Editor’s Note: This Practice Brief is based on an excerpt from the AHIMA Press publication Clinical Documentation Improvement for Outpatient Care: Design and Implementation by Pamela Carroll Hess, MA, RHIA, CCS, CDIP, CPC.


The AHIMA Foundation has established compe....

Author: Fahy, Kristi

Source: Journal of AHIMA

Publication Date: September 2019

By Kristi Fahy, RHIA


Technology is the segue to the future. It is the very thing that will transform the landscape of today’s world into one with endless possibilities. In healthcare, that transformation is being accelerated by the transition to electronic health records (EH....

Author: Clack, Lesley

Source: Journal of AHIMA

Publication Date: September 2019

By Lesley Clack, ScD, MS, CPH


Telehealth, which refers to healthcare services facilitated remotely through electronic information and telecommunications technology, is on the rise. In 2010, 35 percent of hospitals had partially or fully implemented computerized telehealth systems,....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


HIM professionals are well aware of the work involved in matching patients to their unique records. Mismatched records can cost us time, lead to frustration, and cause headaches and dissatisfaction for patients and provide....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


Over the summer I was fortunate to participate in several conferences. I was both honored to be involved and enthralled at the expertise of all of the individuals who participated and presented.


Data is powerful. Data litera....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: September 2019

By Mary Butler


In the film The Farewell, Chinese-American actress and comedian Awkwafina plays a woman torn between two cultural approaches to death and dying when her character, Billi, learns that her grandmother has terminal lung cancer. Billi's grief is compounded when she....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: September 2019

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

Appendix A: Key Points in Developing a CDI Program



Recruitment Best Practices




Create a culture where great employees want to work

Consider the candidate’s cultural compatibility, leadership skills, communication skills, and intellectual abi....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

An annual plan for ongoing education can be developed and started at the beginning of each calendar or fiscal year, or with the annual employee evaluation. The manager of the CDI team or designee can be required to ensure each education topic is offered to the employee during the year. It is im....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

Orientation for new clinical documentation professionals should include the nuances involved in diagnosis, procedure, inpatient prospective payment systems (IPPS), and outpatient prospective payment systems (OPPS) capture. Some of these topics include concepts such as major diagnostic categorie....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

Productivity expectations can be both qualitative and quantitative. Qualitative productivity is measuring the quality of the work being performed. This is typically measured by performing audits of the CDI professional’s work and then assigning a numeric value so it can be measured (see e....

Author: Zak, Cindy

Source: Journal of AHIMA

Publication Date: August 2019

By Cindy Zak, MS, RHIA, PMP, FAHIMA


Yale New Haven Health (YNHH) began implementing the electronic health record (EHR) across four delivery networks in 2012. As the system moved to the electronic world, it became evident that YNHH needed to address the issue of defining the organi....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


I am so inspired by our leaders all across the country. At last year’s CSA Leadership Symposium it was agreed that AHIMA was in a state of decline and that change was needed. It was an amazing moment—one I will never forget an....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


September is a time of new starts. At AHIMA, it’s our busiest time of year as we prepare for our annual conference and a host of other fall and winter activities. It’s also a time to look back on the year: two-....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: August 2019

In Search of the EHR’s Designated Record Set


By Mary Butler


When Rita Bowen, MA, RHIA, CHPS, CHPC, SSGB, broke her elbow while attending an AHIMA event in Baltimore threeyears ago, she soldiered on through the event but summoned her primary care physician for a tele....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

Historic State AG HIPAA Filing: An Important Case to Understand


By Iliana L. Peters, JD, LLM, CISSP, and Pasha Sternberg, JD


ON MAY 30, 2019, Medical Informatics Engineering, Inc. and its subsidiaries (collectively referred to in this article as “MIE”), agreed....

Author: Campbell, James R.

Source: Journal of AHIMA

Publication Date: August 2019

Data Mapping of Clinical Terminologies, Classifications, and Ontologies


By James R. Campbell, MD, FACP, FACMI


Editor’s Note: This article is an excerpt from Chapter 17 of Healthcare Code Sets, Terminologies, and Classification Systems, Fourth Edition, published by A....

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: August 2019

Lost Data and Its Implications for Litigation


By Ron Hedges, JD


Healthcare providers deal with electronic information on a daily basis. Providers must expect that volumes and varieties of electronic information will increase exponentially with, for example, the rise of ar....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

The Danger of Being Connected


By Ty Greenhalgh, HCISPP


In 2014, the American Recovery and Reinvestment Act required and incented hospitals to demonstrate “meaningful use” of an electronic health record (EHR). Hospitals, desiring to maintain existing Medicaid a....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

By Ken Reiher, MBA









Ken Reiher, MBA




Data Analytics: The Straight-Lined Labyrinth that Entrapped the HIM Profession

Author: Sandefer, Ryan

Source: Journal of AHIMA

Publication Date: August 2019

By Ryan Sandefer, PhD, and David Marc, PhD, CHDA


Skills in data analytics are critical to the future of health information management (HIM), yet there has been considerable confusion regarding how to articulate what data analytics means for the profession. In a survey of more than....

Author: William, Fiala C

Source: Journal of AHIMA

Publication Date: August 2019

By William C. Fiala, BS, MA, CCS-P, CPC, RMA


Capturing socioeconomic data, also referred to as social determinants of health (SDOH), is rapidly becoming a necessary element of documentation. SDOH “are among the most influential factors that determine health outcomes of indiv....

Author: Monga, Kapila; Singh, Harpreet

Source: Journal of AHIMA

Publication Date: August 2019

By Kapila Monga and Harpreet Singh


In the United States, five percent of the world’s population consumes about 80 percent of the world’s opioids,1 a statistic that merits the status of a public health crisis in which the demand and supply side of the issue deserve equa....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

Editor’s Note: This Practice Brief supersedes the July 2013 Practice Brief titled “Recruitment, Selection, and Orientation for CDI Specialists.”


The goal of a strong clinical documentation improvement (CDI) program is to validate that the documentation supports t....

Author: Campbell, James R.

Source: Journal of AHIMA

Publication Date: August 2019

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2019

By Mary Butler


On the most widely used job search websites, listings for clinical documentation improvement (CDI) specialists typically look something like this:



Description: The clinical documentation improvement specialist provides support of clinical docume....

Author: Fee, James P; Trepina, Sonia; Boles, Jennifer; Sparks, Joel

Source: Journal of AHIMA

Publication Date: July 2019

By James P. Fee, MD, CCS, CCDS; Sonia Trepina, MPA; Jennifer Boles, CPC, CRC; and Joel Sparks, PMP


Cost containment. It’s a concept that accountable care organizations (ACOs) cite frequently as they strive for shared savings. This makes sense because expenditures drive cost thresh....

Author: Mills, Lorie B.; Sweeney, Susan; Laura, Little; Goyal, Abhinav

Source: Journal of AHIMA

Publication Date: July 2019

By Lorie B. Mills, RHIT, CCS; Susan Sweeney, RN, BSN, CCDS, CCS; Laura Little, RHIT, CCS; and Abhinav Goyal, MD, MHS, FACC, FAHA


As many HIM professionals know, there are substantial “red flag” terms related to coding myocardial infarctions (MIs) and non-MI troponin elevation, whi....

Author: Dean, A. Andrews

Source: Journal of AHIMA

Publication Date: July 2019

By A. Andrews Dean, CPHIMS, CHDA, CPHI, CPPM, CPC


The Centers for Medicare and Medicaid Services (CMS) turned many healthcare information technology consultants’ heads in March 2018 when they announced the new MyHealthEData initiative—intended to continue CMS’s goal of digitizing....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: July 2019

By Lisa A. Eramo, MA


Telling an accurate and complete patient story through clinical documentation is a goal that transcends cultures and geographic boundaries. It’s also the primary theme at the 2019 AHIMA World Congress (AWC) Healthcare Information Summit that will take pla....

Author:

Source: Journal of AHIMA

Publication Date: July 2019

By Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, and Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA


There are multiple benefits of an effective coding compliance program. An article published in the January 2019 issue of the Journal of AHIMA titled “Components of an Effective O....

Author: Mason, Cheryl MSHI

Source: Journal of AHIMA

Publication Date: July 2019

By Cheryl Mason, MHSI


The scope of healthcare’s Big Data imperative is growing by the day. For instance, one study reveals that the doubling time of medical data in 1950 was 50 years; in 1980, seven years; and in 2010, three and a half years. In 2020 it is projected to be 0.2 year....

Author: Beidler, Aurae

Source: Journal of AHIMA

Publication Date: July 2019

By Aurae Beidler, MHA, RHIA, CHC, CHPS


In December 2018, the Office for Civil Rights (OCR), the entity that enforces HIPAA, requested public input on ways to modify HIPAA Rules to “facilitate efficient care coordination and/or case management and to promote the transformation to v....

Author: Evers, Teresa

Source: Journal of AHIMA

Publication Date: July 2019

By Teresa Evers, RN, RHIA, CDIP, CCS


Healthcare professionals have all been subjected to mountains of information urging them to amplify quality care and patient safety. Everyone who works in healthcare, including health information management (HIM) professionals, must strive to a....

Author: Mogbo, Chinedum; Yuen, Anny Pang

Source: Journal of AHIMA

Publication Date: July 2019

By Chinedum Mogbo, MBBS, MsHIM, RHIA, CCDS, CDIP, CCS, and Anny Pang Yuen, RHIA, CCS, CCDS


Employees are requesting more flexibility and organizations are now finding that by offering remote capabilities, they are getting some of the best talent that may not reside in their same t....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: July 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


The Journal’s clinical documentation improvement (CDI) issue gives me an opportunity to provide an update on some of the important work AHIMA has been doing in 2019.


As you know, we’ve been undertaking what w....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2019

A couple years ago, Saturday Night Live spoofed how senior citizens use automated home assistant products such as Amazon’s Echo by imagining a fictional product called Amazon Echo Silver—a device designed to help forgetful, hard of hearing seniors manage activities like turning up the thermosta....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2019

The problem list was first defined and created by Lawrence Weed in the 1960s at a time when care continuity was its primary purpose. Problem lists have become more widely used as a basis for problem-oriented charting, a methodology for clinical documentation embraced by many in the medical esta....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: June 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


Dr. Amal Alzu’bi, a graduate of the doctoral program at University of Pittsburgh, just had part of her dissertation published in AHIMA’s online scholarly journal Perspectives in Health Information Management under the title “Genetic Varia....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: June 2019

By Lisa A. Eramo, MA


While clinical documentation hasn’t exactly been a strength in many of today’s financially strapped skilled nursing facilities (SNFs), this may soon change as SNFs shift to a new payment methodology—the Patient-Driven Payment Model (PDPM)—in which these facili....

Author: Leisch, Monica RHIA, CDIP, CCS

Source: Journal of AHIMA

Publication Date: June 2019

By Monica Leisch, RHIA, CDIP, CCS


Consider the following scenario: a patient is admitted through the emergency department (ED) with acute shortness of breath. The ED notes and history and physical document acute respiratory failure. Blood gases show an oxygen level of 75, pCO2 lev....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2019

The goal of this Practice Brief is to provide an explanation of the complication/comorbid condition and major complication/comorbid condition (CC/MCC) capture rate, review the calculation, and introduce the uses of this key performance indicator (KPI) by different functions of the mid-revenue c....

Author: Lower, Christi L

Source: Journal of AHIMA

Publication Date: May 2019

How the New HIM Curricula Will Change Education, Future Employees


By Christi Lower, PhD, RHIA, FAHIMA


The health information management (HIM) professional’s career pathway has changed as technology continues to impact providers’ ability to acquire, harness, and harvest he....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: May 2019

By Lisa A. Eramo, MA


When Mary B. Parks, JD, RHIA, CCS, director of health information at St. Joseph’s/Candler in Savannah, GA was charged with replacing inpatient contract coders with in-house staff, she did what most directors do. She dove into a candidate search in the hope of....

Author: Humbert, Sarah

Source: Journal of AHIMA

Publication Date: May 2019

By Sarah Humbert, RHIA


As the volume of coding denials steadily increases, providers need a proactive approach to manage and prevent denials rather than accepting them and writing them off. According to the Advisory Board, about two-thirds of denials are recoverable and 90 percen....

Author: Lower, Christi L

Source: Journal of AHIMA

Publication Date: May 2019

How the New HIM Curricula Will Change Education, Future Employees


By Christi Lower, PhD, RHIA, FAHIMA


The health information management (HIM) professional’s career pathway has changed as technology continues to impact providers’ ability to acquire, harness, and harvest he....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2019

If medicine is also an art and not just a science—as physicians who argue that each patient requires a different approach assert—then it’s hard to understand the rationale that led a California hospital to deliver end-of-life treatment plans via telemedicine “robots.”1


As several....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: May 2019

By Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA


What do population health, disease management, predictive modeling, and surgical case indices have in common? They are all a part of bridging coded data to real-time data analytics. Coding professionals have a long history of tran....

Author: DeMasters, Dana

Source: Journal of AHIMA

Publication Date: May 2019

By Dana DeMasters, MN, RN, CHPS


Covered entities are sharing vast amounts of electronic protected health information (ePHI) with business associates (BAs)—from outsourcing entire information technology and patient billing departments to participating in health information ex....

Author: Humbert, Sarah

Source: Journal of AHIMA

Publication Date: May 2019

By Sarah Humbert, RHIA


As the volume of coding denials steadily increases, providers need a proactive approach to manage and prevent denials rather than accepting them and writing them off. According to the Advisory Board, about two-thirds of denials are recoverable and 90 percen....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: May 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


In a recent article in the New Yorker, historian Jill Lepore puts predictions about the future of work—and how it may be changed by automation and artificial intelligence—into perspective. While stoking these fears can con....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2019

Editor’s Note: This Practice Brief supersedes the November-December 2013 “E-Discovery Litigation and Regulatory Investigation Response Planning: Crucial Components of Your Organization’s Information and Data Governance Processes” and October 2005 “Legal Process and Electronic Health Record....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: May 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


Soft skills—empathy, communication, critical thinking, creative thinking, problem solving, interpersonal awareness, and more—are of vital importance in the HIM workforce. This consensus is one I have encountered over and over again, from....

Author: Woebkenberg, Jami; Hernandez, Sandra MSMIS, RHIA, CPHI, CCS, CHC; Dean, A. Andrews

Source: Journal of AHIMA

Publication Date: May 2019

By Jami Woebkenberg, MHIM, RHIA, CPHI, FAHIMA; Sandra Hernandez, MSMIS, RHIA, CPHI, CCS, CHC; and A. Andrews Dean, CPHIMS, CHDA, CPHI, CPPM, CPC


Technology is a major part of our lives and healthcare is certainly not exempt from its influence. Under the 2009 HITECH Act, eligible....

Author: Primeau, Debra

Source: Journal of AHIMA

Publication Date: May 2019

By Debi Primeau, MA, RHIA, FAHIMA


These days, digital information is gold. This is especially true in healthcare, where organizations use health information strategically to improve efficiency, reduce costs, and enhance the safety and quality of patient care. Health information ma....

Author: Mautino, Heather

Source: Journal of AHIMA

Publication Date: May 2019

By Heather Mautino, MS, RHIA


College students across the country recently started their 2019 spring semester Professional Practice Experiences (PPE), with educators and health information management (HIM) professionals now turning to preparations for summer semester PPEs. Such is....

Author: Crabb, Stephanie

Source: Journal of AHIMA

Publication Date: May 2019

By Stephanie Crabb, MA


The age of digital transformation across many industry sectors is in full swing. While healthcare often paces behind others when it comes to technology innovation and adoption, this is not the case with digital health—start-ups in this sector raised a record....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2019

Author: Rose, Angela Dinh

Source: Journal of AHIMA

Publication Date: April 2019

By Angela Rose, MHA, RHIA, CHPS, FAHIMA


The outsourcing of health information management (HIM) functions is not a new concept in the healthcare industry. Coding, clinical documentation improvement (CDI), transcription, electronic heath record (EHR) systems, and release of inf....

Author: McElroy, Kyle; Zak, Cindy

Source: Journal of AHIMA

Publication Date: April 2019

By Mark Diamond


Health information management (HIM) professionals need to ask themselves if their records retention schedule is helping or hurting their records retention program.


Traditional records retention schedules largely assume that most information is paper-....

Author: Humbert, Sarah

Source: Journal of AHIMA

Publication Date: April 2019

By Sarah Humbert, RHIA


According to the Association of American Medical Colleges (AAMC), 44 states and the District of Columbia have accredited medical schools and teaching hospitals.1 Numbering nearly 120, these academic medical centers provide critical services not available el....

Author: Kraft, Kristine N; William, Fiala C

Source: Journal of AHIMA

Publication Date: April 2019

By William C. Fiala, MA, CCS-P, CPC, RMA, and Kristine N. Kraft, DC, RMA


Complication coding is “considered to be one of the more challenging aspects of coding,” as an article in ICD10monitor once put it.1 The reporting of complication codes brings with it certain risks to pr....

Author: Combs, Tammy

Source: Journal of AHIMA

Publication Date: April 2019

Analysis of AHIMA’s New Clinical Documentation Improvement Industry Survey


By Tammy Combs, RN, MSN, CCS, CDIP, CCDS


The AHIMA Clinical Documentation Improvement Practice Council (CDIPC) is a group of clinical documentation improvement (CDI) experts that meet once a....

Author: Dolezel, Diane

Source: Journal of AHIMA

Publication Date: April 2019

By Diane Dolezel, EdD, RHIA, CHDA


Healthcare organizations are at risk for data breaches as the number of healthcare data breaches continues to rise annually despite efforts to slow the upward trend. Since 2009, there were over 2,000 data breaches reported to the Department of Hea....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: April 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


As leaders in the HIM profession, we must strive to reimagine our future and embrace the change that will accompany it. Looking back over the HIM Reimagined (HIMR) recommendations, I see areas where we have already made progress—and other....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: April 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


We’re seeing a powerful case for the profession to keep privacy and security high on its priority list as we drive forward to a more modernized HIM practice. It’s an area that continues to evolve and challenge us.