Author: Watson, Monica M

Source: Journal of AHIMA

Publication Date: October 2019

By Monica Watson, RHIA, CPC, CCS, CCS-P, CPMA, CIC, CRC, CDEO


Coding professionals will be relieved to find fewer changes in the fiscal year (FY) 2020 ICD-10-CM code changes, effective October 1, 2019, than the last several years. The trend in decreasing changes for annual updates....

Author: Hernandez, Sandra MSMIS, RHIA, CPHI, CCS, CHC

Source: Journal of AHIMA

Publication Date: October 2019

By Sandra Hernandez, MSMIS, RHIA, CCS, CPHI, CHC


The Centers for Medicare and Medicaid Services (CMS) has continued its efforts to reduce the administrative burden for physicians and “restore the doctor-patient relationship” by easing reimbursement requirements for tel....

Author: Ward, Maria

Source: Journal of AHIMA

Publication Date: October 2019

By Maria N. Ward, M.Ed., RHIA, CCS, CCS-P


There has been an increase in the number of possible codes in ICD-10-PCS every year since its implementation. With the Fiscal Year (FY) 2020 ICD-10-PCS code changes, effective October 1, 2019, the tides have turned. In the Medical and Surg....

Author: Head, Erin

Source: Journal of AHIMA

Publication Date: October 2019

By Erin Head, MBA, RHIA, CHDA, CCS, CHTS-TR


Picture it: No more fax machines by 2020. That means no fax machines by next year.


Ambitious as this timeline may seem, it’s actually the challenge set forth by Centers for Medicare and Medicaid Services (CMS) Adminis....

Author:

Source: Journal of AHIMA

Publication Date: October 2019

By Santosh Mudiraj, MBBS, MPH


Common and unintended errors in today’s healthcare system can create major complications for patients, personnel, and systems. These error-related issues can harm patients, affect quality of care, increase operational costs, impact competition,....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: October 2019

Pushing Paper Aside as eCR Changes HIM’s Quality Practices


By Allison Viola, MBA, RHIA


Public health agencies across the country continue to face new challenges, from surveilling chronic and infectious diseases such as Ebola and Zika, to managing the anticipated &ld....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: October 2019

By Mary Butler


Retail healthcare is having another “moment” with the recent announcements that both Amazon and Walmart are rolling out primary care clinics with consumer convenience in mind.


Amazon’s entry to the market, Amazon Care, is a “vir....

Author:

Source: Journal of AHIMA

Publication Date: October 2019

By Julie M. Wulf Plimpton, MSHI, RHIA, CPHI


As smartphone use continues to grow, these devices are often used to access an individual’s private information. American mobile device users spend, on average, five hours of their day communicating or accessing information on thei....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: October 2019

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


Throughout the year we’ve been talking about AHIMA’s transformation. Our aim with this project has been to keep AHIMA relevant in light of today’s trends and to become an association that better meets the....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: October 2019

Reflecting on a Year to Treasure

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


I cannot pick just one thing that I am most proud of from this year. I am extremely proud to have worked alongside an amazing board of directors, CEO, and AHIMA staff during my year as President and Ch....

Author:

Source: Journal of AHIMA

Publication Date: October 2019

A Report from AHIMA’s Coding Thought Leadership Council


By Anne Zender, MA


What does the future of coding look like? A panel of coding experts and health information management (HIM) professionals met in early June to answer this question and others.


T....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: October 2019

Evaluating Whether EHRs are Meeting the Needs of Value-Based Care


By Mary Butler


The “meaningful use” Electronic Health Record (EHR) Incentive Program successfully brought the vast majority of healthcare providers into the computer age and transitioned the ind....

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: 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: 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: 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: 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: 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: 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: 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: 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

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: 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: Casto, Anne B.

Source: Journal of AHIMA

Publication Date: September 2019

By Anne Casto, RHIA, CCS

The American Hospital Association’s Coding Clinic publishes valuable advice and guidance for coding professionals, but can coding professionals learn even more from this publication? What could coding professionals gain if Coding Clinic ent....

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: September 2019

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

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: 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

Recruitment Best Practices


Create a culture where great employees want to work

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

Consider all candidate streams when recruiting both internally an....

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: 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: 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 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

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 telemedicine encounter to determine her treatment. Later, when c....

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

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 to pay $900,000 to 16 states that had jointly filed suit for violating t....

Author: Campbell, James R.

Source: Journal of AHIMA

Publication Date: August 2019

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 AHIMA Press.


In 2007, the Institute of Medicine set a vision for the....

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: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

By Ken Reiher, MBA









Ken Reiher, MBA




The Danger of Being Connected

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

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 and Medicare reimbursement levels and av....

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: August 2019

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 artificial intelligence in the diagnosis and treatment of....

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: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019

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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2019

By Mary Butler


As text messaging has come to replace telephone calls as the primary means of interpersonal communication, apps such as SwiftKey have popped up to help those with less than nimble thumbs. SwiftKey and other “intelligent keyboards” quickly learn a user&rs....

Author: Carlson, April M; Goldman, Daniel JD; Milnes, Burke MPA; Otte, Kimberly JD; Schacht, Morgan JD

Source: Journal of AHIMA

Publication Date: June 2019

By April Carlson, MBA, HCISSP, CFE; Daniel Goldman, JD; Burke Milnes, MPA; Kimberly Otte, JD; and Morgan Schacht, JD


Hoping to balance the competing demands to share information while also protecting it, Mayo Clinic has developed a process to review disclosures of data that is ris....

Author: Houser, Shannon H.; Wagner, Jodie ; Holland, Christopher O

Source: Journal of AHIMA

Publication Date: June 2019

By Shannon H. Houser, PhD, MPH, RHIA, FAHIMA; Jodie Wagner, CPhT; and Christopher O. Holland, RPH


As technology continues to evolve in medicine the way medical data are handled has also evolved over time. Pharmacy data are a vital component in the electronic health record (EHR) d....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: June 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


I have not coded a medical record in many years, but I love coding. I love to use the codes to examine all aspects of coding processes and disease-related research. In the past, I worked on a team that examined the computer-assisted codin....

Author: Gillespie, Joe D; Lucci, Susan

Source: Journal of AHIMA

Publication Date: June 2019

By Joe Gillespie, MS, RHIA, CHPS, and Susan Lucci, RHIA, CHPS, CHDS, AHDI-F


The Anthem Blue Cross breach made the cybersecurity data breach headlines across the nation in 2015. As the single largest email phishing attack up until that time, impacting nearly 80 million patients, th....

Author: Land, Daniel

Source: Journal of AHIMA

Publication Date: June 2019

By Daniel Land, RHIA, CCS


Marshall McLuhan, the Canadian philosopher who predicted the World Wide Web nearly 30 years before its invention, said that “we shape our tools and thereafter our tools shape us.”1 It is important to keep this in mind in any discussion of computer-assiste....

Author: Mason, Cheryl MSHI

Source: Journal of AHIMA

Publication Date: June 2019

By Cheryl Mason, MSHI


By now, most health information management (HIM) professionals are familiar with national quality measures and the role they play in value-based care. Accuracy in reporting is paramount as the Centers for Medicare and Medicaid Services (CMS) continues to elev....

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

In research findings that should surprise very few health information management (HIM) professionals, attending physicians and the colleagues they conduct morning rounds with think electronic health records (EHRs) aren’t well suited for rounding in patient rooms. Their disdain for this now perv....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: June 2019

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


The phrase “interesting times” suggests both opportunity and anxiety. These are especially “interesting times” for those of us in coding.


On the one hand, one research organization recently forecast that the....

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: Carlson, April M; Goldman, Daniel JD; Milnes, Burke MPA; Schacht, Morgan HCISSP, CFE; Otte, Kimberly JD

Source: Journal of AHIMA

Publication Date: June 2019

Author: Davis, Nancy

Source: Journal of AHIMA

Publication Date: June 2019

By Nancy Davis, MS, RHIA, CHPS


While serving as a system privacy officer for a Wisconsin-based healthcare system, the author of this article met regularly with the organization’s president to review privacy and security compliance. This time was spent reviewing breaches that membe....

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: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2019

By Mary Butler


When you see a list of letters after a health information management (HIM) professional’s last name, it’s sometimes too easy to take for granted all the long, hard hours that went into earning and creating those acronyms. For both the credential earner and the certi....

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....