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Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement

Author: Whittle, Kelly

Source: Journal of AHIMA

Publication Date: September 2016



It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....

Reviewing for Inpatient Quality

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 25, 2016



The Hospital Value-Based Purchasing (HVBP) Program has heightened hospital awareness of quality outcomes. Under this program, payments made under the Inpatient Prospective Payment System (IPPS) are based on the quality of care that was provided. Quality of care is recognized through the cl....

DSM-5 vs. ICD-10-CM

Author: Foley, Dianna

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 10, 2016




The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) both present ways to classify diseases. In the case of DSM-5, it is strictly for mental dis....

Making the Call for Patient Experience: Using Health IT to Address Gaps in Patient Data-Sharing, Communication, and Interoperability

Author: Labow, Kim

Source: Journal of AHIMA

Publication Date: August 2016



Interoperability and integration within the health IT landscape remain high priorities for providers, patients, and technology firms. Interoperability in health IT holds the promise of more satisfied patients, providers, and health information management (HIM) professionals. But approachi....

Solving the Health IT Interoperability Quagmire

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: August 2016



As the sun begins to set on the Obama administration, Vice President Joe Biden has been leveraging the weight of his office to speak out on the health IT interoperability quagmire in which the nation currently finds itself. During a speech at the industry’s Health Datapalooza in May,....

Bringing HIM to Every Corner of Healthcare

Author: Martin, Melissa

Source: Journal of AHIMA

Publication Date: August 2016



Remember our association’s theme from last year: HIM without walls?


In June I accepted a new professional role as the assistant vice president of the Heart and Vascular Institute at West Virginia University Medicine, which has been an amazing opportunity.


Sh....

Improving Coding and Documentation Quality Through Real-Time Collaboration: Nurses and Coding Professionals Team Up to Tackle Documentation Issues

Author: Horn, Kelli; Younger, Adrienne; Snow, Trevor

Source: Journal of AHIMA

Publication Date: August 2016



While working through the recent implementation of ICD-10, leaders at Ardent Health Services began to focus on the re-bill process and what it would look like in the months following use of the new code set. Re-billing means submitting a corrected bill to the payer after it has been rejec....

Taking Up the Interoperability Mantle

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: August 2016



In May the Office of the National Coordinator for Health IT (ONC) released a Data Brief describing the state of interoperability among non-federal acute care hospitals in 2015.1 The report looks specifically at four “domains” of interoperability: the ability for health systems....

Managing a Part-Time Remote CDI Team

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 29, 2016




As clinical documentation improvement (CDI) programs become more popular, providers are still struggling with implementing CDI programs for several different reasons, including: geographical location; a shortage of outpatient coders and CDI specialists; or even the lack of physi....

Seventh Character Application for Injuries in the Principal Diagnosis and the Impact to Data Quality

Author: Wall, Kathleen E.

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 25, 2016



By now, we’ve all had practice assigning 7th characters for injuries. And, by now, we all know that in theory the guidance seems very clear—but the application of this new concept is not clear at all. Why is there so much confusion and why does it matter? What are the short- and long-term....

What It Means to Be Deposed

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 22, 2016




In this blog I talk about legal consequences. I usually provide current examples of what those consequences might be under a specific set of facts. Here, instead, I want to highlight a litigation-related event that readers might experience in the future—or perhaps already have: a depo....

CDI: A Cog in the Wheel of Information Governance

Author: Downing, Katherine

Source: Journal of AHIMA

Publication Date: July 2016



Information governance (IG) is an emerging discipline in healthcare that focuses on how an organization ensures information is complete, accurate, trustworthy, and usable. The goal of information governance is to enable organizations to utilize a valuable strategic asset—information&....

CDI is about Relationships

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2016



“Alone we can do so little; together we can do so much,” said Helen Keller. This quote was part of Keller’s vaudeville circuit speech, but the sentiment holds true for those of us in the spotlight of HIM.


Our goal is to tell the patient’s story accurat....

Planning Ahead for 2017 and Beyond

Author: Martin, Melissa

Source: Journal of AHIMA

Publication Date: July 2016



Since I am halfway through my term as AHIMA’s President, I wanted to take some time this month to reflect on the work AHIMA’s Board of Directors has done thus far.


We hit the ground running in January at our first board meeting of the year, where we discussed our 2016 quar....

Can Data Save a Life?

Author: James, Wendy

Source: Journal of AHIMA - website

Publication Date: June 15, 2016



The technological advances that have taken place over the past 25 years have been nothing short of phenomenal. When I reflect on the things I have experienced, not only in my professional career, but the technological advances I have seen over the course of my life  across the board i....

'Patient First' Should Be Our Mission

Author: Martin, Melissa

Source: Journal of AHIMA

Publication Date: June 2016



During my many years working in healthcare I have received several forms of training regarding mission statements and putting our patients first.


When I first joined the health information management (HIM) profession, I did not fully understand the trials and tribulations....

HIM's Role in Health Data Analysis

Author: Kadlec, Lesley

Source: Journal of AHIMA

Publication Date: June 2016



In today’s healthcare environment, data abounds. From the time of admission through the patient care episode, discharge, and aftercare, the volume of clinical data in healthcare continues to grow and expand. Regardless of whether the data results from a patient office visit, the lab,....

What to Expect When Phase 2 HIPAA Audits Begin

Author: Rose, Angela Dinh

Source: Journal of AHIMA

Publication Date: June 2016



The HITECH Omnibus Rule mandated that the US Department of Health and Human Services (HHS) conduct periodic audits on the privacy and security compliance of covered entities and business associates. It was during the Office for Civil Rights (OCR) update session on March 21, 2016 at the 20....

Analyzing Eight Months of ICD-10

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2016



Teachers know there are two kinds of students. Student A studies and does their assigned reading throughout the whole semester, earning extra credit where they can. When the final exam rolls up, they’re anxious but prepared—they did their homework. Student B, on the other hand, has the sa....

Unlocking the Benefits of ICD-10 through Data Analytics

Author: Ewing, Crystal

Source: Journal of AHIMA

Publication Date: June 2016



The reality of the ICD-10-CM/PCS implementation and the fact that it was, by all measures, a success, is the payoff of years of hard work. It’s the product of lessons learned from the implementation of 5010 and the outcome of diligence on the part of healthcare professionals, providers, a....

Semantic Content in EHR Systems

Author: Bhattacharyya, S. B; Warner, Diana

Source: Journal of AHIMA

Publication Date: June 2016



An electronic health record (EHR) can greatly help the timely delivery of efficient healthcare if the information it contains is adequate, accurate, and accessible in a timely manner. An EHR is a longitudinal record of an individual’s health journey made up of electronic documents from va....

HIM Enjoying its ICD-10 Moment

Author:

Source: Journal of AHIMA

Publication Date: June 2016



Remember the Y2K bug? Not so long ago, there was a widely spread concern that the change from the year 1999 to 2000 would play havoc with computer systems everywhere. Technology experts set about repairing programs; “preppers” recommended we all stock up on Spam and bottled wat....

Guidelines for Achieving a Compliant ICD-10-PCS Query

Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2016



Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.




The complex and highly specific nature of ICD-10-PCS has changed....

Role of Standards in IG

Author: Warner, Diana

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 13, 2016




The use of health information technology (HIT) in the clinical setting brings both opportunities and challenges for health information management (HIM) professionals regarding data capture and exchange; data storage, use and reuse; record ownership and access; e-discovery and e-forens....

Preparing HIM for the Changes Ahead

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: May 2016



As we focus on education and workforce issues, there’s good news and bad news.


The good news is: The employment outlook for HIM professionals is bright. According to AHIMA’s 2016 Environmental Scan report, “The Bureau of Labor Statistics estimates that the H....

Recognizing the Characteristics of Quality Documentation

Author: Combs, Tammy

Source: Journal of AHIMA

Publication Date: May 2016



When we take a bite of our favorite food we can easily determine the quality by relying on what our senses tell us. The look, smell, and taste are all clues to the quality that was put into preparing the meal. If it looks undercooked or has mold on it, smells foul or tastes bitter, we kno....

Information Governance for Offsite Data Security

Author: Saharia, Devendra

Source: Journal of AHIMA

Publication Date: April 2016



Disruptive technology can turn any industry on its head—virtually overnight. Just five years ago, summoning a taxi was an inefficient, time-consuming effort that often involved dialing up a dispatcher, who contacted a driver, who would then make their way to your location, perhaps in an h....

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