AHIMA BoK: Search for

Source: Journal of AHIMA

Publication Date: March 2004

As I think about all that the HIM profession aims to accomplish, I realize that we are faced with the challenge of reinventing ourselves. This seems daunting, but ours is not the only profession faced with this challenge.
Change Can Make Us Stronger

Consider the challenges fac....

E-HIM: Mobilizing for Impact

Source: Journal of AHIMA

Publication Date: September 2004

What an exciting time for healthcare and our profession. Tremendous strides have been made toward transitioning healthcare from paper to an electronic environment. Many AHIMA staff and members have participated in key collaborations during the last two years to advance the implementation....

Visions of Future, Global Initiatives Focus for 2004

Source: Journal of AHIMA

Publication Date: January 2004

Our 75th diamond anniversary, year-long celebration was quite a success. We celebrated our rich history and the important contributions AHIMA has made to the field of HIM. We also confirmed that the work we do has never been more important. We are thriving as an association, with some 46,000-p....

Developing an Experienced HIM Work Force

Source: Journal of AHIMA

Publication Date: July 2004

HIM practitioners have a long history of contributing to education by serving as site preceptors. Today, however, increased work demands and changing practice patterns limit time to train new graduates onsite. These factors are raising the demand for graduates with higher levels of experience....

Gaining a Global Perspective on HIM

Source: Journal of AHIMA

Publication Date: October 2004

In February this column focused on an AHIMA Board of Directors strategic initiative for HIM outreach—increasing consumer and industry awareness of HIM professionals and practice at home and abroad. This month, efforts related to the international portion of the initiative will be realized as....

Advancing the Globalization of HIM

Source: Journal of AHIMA

Publication Date: February 2004

One of the strategic initiatives set by the AHIMA Board of Directors for 2004 focuses on HIM outreach; that is, engaging in activities designed to increase consumer and industry awareness of HIM professionals and practices at home and abroad. My message this month focuses on the “abroad&....

Becoming a Lifelong Learner

Source: Journal of AHIMA

Publication Date: June 2004

As I reflect on what AHIMA has accomplished over the last 10 years and where the HIM profession is currently headed, I realize that we have a very eventful future ahead of us, a future that requires transitioning from one knowledge and skill level to another. The challenge is to remain litera....

Progress Toward Implementing the HIT and HIA Curriculum Models

Source: Journal of AHIMA

Publication Date: October 1997

Strategic Planning: a Winning Play

Source: Journal of AHIMA

Publication Date: April 2004

In April we look back at AHIMA’s own form of college basketball’s “March Madness”—Team Talks. The communication, collaboration, and networking of these meetings make all who attended national champs. The information shared at Team Talks is essential for achieving the A....

Looking Back on a Successful 2004

Source: Journal of AHIMA

Publication Date: November 2004

As 2004 draws to a close, I would like to thank all who have helped to make the year a success. Our success this year stems from the collective work of our members, state leaders, volunteers, board members, and AHIMA staff who worked to further our goal of moving health information management....

HIM Work Force: Where We Are and Where We're Going

Source: Journal of AHIMA

Publication Date: May 2004

Where are the jobs? We hear this question in discussions about offshoring of jobs and in presidential debates on the future of the US economy and its work force. I am pleased to say we now know where the jobs are in HIM as a result of the AHIMA work force study initiated in 2002.
AHIMA....

Status of Graduate Education Programs in Health Information Management

Author: Brodnik, Melanie S.; Bean, Betty; Hickey, Christie; Massey, Olivia; Ritchie, Carissa

Source: Journal of AHIMA

Publication Date: July 1998

The growing complexity of information needs in the delivery of quality healthcare at low cost has contributed to educational reform in health information management (HIM) and the need for advanced professional preparation of HIM practitioners. In 1997, AHIMA published curriculum mode....

Taking The Doctoral Challenge: Educators Push HIM Professionals to Add PhD to Credentials

Author: Brodnik, Melanie S.; Valerius, Joanne D; Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: August 2013

The push toward graduate education in health information management (HIM) is becoming a reality as more universities and colleges develop or explore launching HIM and informatics graduate curricula. Fundamental to offering these programs is the need for doctorally prepared HIM-credentialed....

Preparing for the CAC Transition

Author: Bronnert, June

Publication Date: July 2011

One of the biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the "use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare p....

Coding Chronic Kidney Disease

Author: Bronnert, June

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

Publication Date: June 2007

by June Bronnert, RHIA, CCS, CCS-P

Chronic kidney disease (CKD) affects 20 million Americans, or one in every nine adults, and another 20 million Americans are at risk of developing CKD, according to the National Kidney Foundation. With this prevalence, it is important for coding professio....

Coding Pregnancy

Author: Bronnert, June

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

Publication Date: October 2006

While science and research have shed light on the various stages of fetal development, the process is still fascinating. This article details each month of a fetus’s development and reviews common delivery complications and where related information may be documented in the record.
....

Necessary Coding Skills: What Employers Are Looking for in Coding Professionals

Author: Bronnert, June

Publication Date: June 2005

The employment market for coders is expected to increase 36 percent or more between 2002 and 2012, according to the Bureau of Labor Statistics.1 Even now we are experiencing a shortage of qualified coders. Ask a coding manager to name the biggest challenges of the job, and recruitment and ret....

Assigning E Codes: Two New Sections Go into Effect October 1

Author: Bronnert, June

Publication Date: September 2009

Two new E code sections go into effect October 1—E000, External Cause Status, and E001–E030, Activity. The sections will facilitate prevention strategies developed by epidemiologists and injury prevention specialists and bring ICD-9-CM E codes more in line with ICD-10-CM external c....

Determining Surgical Complications

Author: Bronnert, June

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

Publication Date: July 2006

All surgical procedures involve potential risks, which is why patients are asked to sign an informed consent. Conditions that arise after a procedure may be considered complications. Coding professionals must be able to determine if a condition is a complication per ICD-9-CM guidelines.

Coding in Long-Term Care Hospitals: How Medicare Distinguishes LTCHs from Other Providers

Author: Bronnert, June

Publication Date: April 2008

The term “long-term care hospital” (LTCH) can leave some in a quandary—do these facilities provide acute care or long-term care? Many people associate them with skilled nursing facilities.

However, LTCHs are not synonymous with skilled nursing facilities; each has....

Therapy Coding in Long-Term Care Facilities

Author: Bronnert, June

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

Publication Date: September 2006

Patients or residents are admitted to long-term care (LTC) facilities for a variety of reasons. While there, many receive some type of therapy, from physical to speech, during their stay. This article reviews the various procedures that may be provided to a resident at an LTC facility as well....

Codes and Treatments for Drug and Alcohol Conditions

Author: Bronnert, June

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

Publication Date: May 2006

In 2003 61 percent of adults drank alcohol, according to the National Center for Health Statistics.1 Illicit drug use for that same year is reported at 8 percent, with 6 percent using marijuana.2 With those statistics, it’s a safe bet that coding professionals will encounter records repo....

Coding Ethically

Author: Bronnert, June

Publication Date: October 2005

With the many reimbursement issues and regulatory requirements surrounding coding, it is sometimes necessary for coders to refamiliarize themselves with what it means to code ethically. AHIMA’s Coding Policy and Strategy Committee developed the Standards of Ethical Coding, which were app....

Assigning Secondary Codes from the History and Physical

Author: Bronnert, June

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

Publication Date: March 2006

To code or not to code can be one of the toughest questions a coder faces on a day-to-day basis. Assigning the appropriate secondary diagnoses can be a challenge. This article describes appropriate coding of secondary diagnoses by reviewing documentation of a history and physical.

Un....

Optimizing Data Representation Through the Use of SNOMED CT

Author: Bronnert, June; Daube, Julie L; Jopp, Gretchen; Peterson, Kathleen; Rihanek, Theresa; Scichilone, Rita A; Tucker, Vanna

Source: Journal of AHIMA

Publication Date: March 2014

Electronic health records (EHR) have changed the landscape for data representation. For many years health information management (HIM) professionals have relied on classifications for data representation and the support of clinical documentation. SNOMED CT is a data standard frequently used in electronic systems and has been included in the requirements for the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR Incentive Program. SNOMED CT is maintained and distributed by the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED CT is recognized throughout the world, and the terminology is available at no cost. The National Library of Medicine (NLM) serves as the US release center and the IHTSDO member country representative.

Problem-Centered Care Delivery: How Interface Terminology Makes Standardized Health Information Possible

Author: Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank; Rose, Eric; Aldin, Greg

Source: Journal of AHIMA

Publication Date: July 2012

Terminologies ensure that the 'languages of medicine' can be understood by both humans and machines.

Electronic health records (EHRs) are the industry standard for documenting patient care. Industry initiatives and government legislation have facilitated EHR i....

Testing ICD-10-PCS

Author: Brooks, Patricia E.

Source: Journal of AHIMA

Publication Date: May 1998

HCFA conducted a formal test of ICD-10-PCS (procedure coding system) in order to determine if it would be a practical replacement for the current ICD-9-CM, Procedures. This coding system was developed after an open competition contract was awarded to 3M/HIS. In order to avoid any con....

Speaker: SNOMED Promises to Change HIM Practice

Author: Brouch, Kathy L.

Source: Journal of AHIMA

Publication Date: January 2004

How will SNOMED CT change the way health information is managed? An educational session captured the basic concepts that HIM professionals need to know.

It’s important to understand the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) because it is increasingly being....

Coding Worldwide: Gain a Global Perspective with IFHRO

Author: Brouch, Kathy L.

Publication Date: May 2002

Many HIM professionals may not know that there is an international health records organization, but the International Federation of Health Records Organizations (IFHRO) has been in existence since 1968.

The Federation presents great opportunities for AHIMA members who wish to b....

Where to Find Answers to Your Coding Questions

Author: Brouch, Kathy L.

Publication Date: January 2003

For more information on physician queries, see the "Developing a Physician Query Process" practice brief in the October 2001 Journal of AHIMA and in the FORE Library: HIM Body of Knowledge in the Communities of Practice at www.ahima.org.
Is obtaining an answer to a coding question a daunting t....

Where in the World Is ICD-10?

Author: Brouch, Kathy L.

Source: Journal of AHIMA

Publication Date: September 2000

Where and how is ICD-10 being used? Learn how countries all over the world have adapted to the newest version of this coding system and how coders in the US can prepare for an eventual transition.

Are you ready for ICD-10? If you're a coder in the United State....

AHIMA Project Offers Insights into SNOMED, ICD-9-CM Mapping Process

Author: Brouch, Kathy L.

Source: Journal of AHIMA

Publication Date: July 2003

AHIMA’s Cinical Vocabulary and Terminology Expedition

In 1999, AHIMA appointed the Coding Futures Task Force to study the likely futures in the domain of coding practice. The group’s conclusions, summarized in the January 2000 (vol. 71, no. 1) Journal of AHIMA article “....

Compliance is Everything, Everything is Compliance

Author: Brow, Julie A.

Source: Journal of AHIMA

Publication Date: May 2001

Everything, when reduced to its basic components, is a compliance issue," says Dorothy Wagg, JD, RHIA, vice president of HIM/compliance at Applied Management Systems in Burlington, MA. "It may seem pernicious to be thinking all the time, `how will this look under the microscope?' but....

Winning Joint Commission Jeopardy: Tips for Success

Author: Brow, Julie A.

Source: Journal of AHIMA

Publication Date: April 2001

Organization, preparedness, and quality are three familiar words to those managing hospital and clinic health information. At no time is it more important to be organized, prepared, and quality-minded than when surveyors from the Joint Commission on Accreditation of Healthcare Organi....

Making the Most of External Coding Audits: From Preparation to Recommendations

Author: Brownfield, Cathy; Didier, Donna M.

Source: Journal of AHIMA

Publication Date: July 2009

Getting a full return on an external audit requires that HIM directors commit to the process from start to finish—preparing, managing, and following up.

Is your coding good, bad, or great? Not knowing for certain creates risk and stress. Audits offer visibility into department....

Safeguarding ePHI from Fire the Dry Way

Author: Brown, Karen

Source: Journal of AHIMA

Publication Date: March 2005

With HIPAA’s security rule compliance date right around the corner, many HIM professionals are still trying to determine if they have adequate safeguards in place to ensure the confidentiality, integrity, and availability of electronic protected health information (ePHI).

Many....

HIPAA Security: Don't Disband the Committee Just Yet

Author: Brown, Stephen C.

Source: Journal of AHIMA

Publication Date: May 2005

By now, every healthcare organization has faced the initial security compliance responsibilities associated with HIPAA. However, the compliance road has not yet been fully traveled. The nature of the rule makes compliance a recursive effort of reassessment, continual auditing, regular educatio....

2019 ICD-10-PCS Coding Updates

Author: Bruce, Tina MHIM, MHI, RHIA, CCS, CDIP

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

Publication Date: November 2018

By Tina Bruce, MHIM, MHI, RHIA, CCS, CDIP

Healthcare practices, clinical documentation improvement specialists, auditors, and coding professionals are on the edge of their seats anxiously awaiting the annual release of coding updates by the....

Patient Empowerment -- A Trend that Matters

Author: Bruegel, Robert B.

Source: Journal of AHIMA

Publication Date: September 1998

Increased patient empowerment will generate an extensive shift in fundamental roles and procedures in healthcare, including the roles of HIM professionals. Here's a look at factors influencing patient empowerment and a forecast of how patient and provider communications are likely to be affec....

Ensuring Compliant Malnutrition Coding

Publication Date: October 2011

Coding malnutrition has always been a challenge, especially since MS-DRGs were implemented. However, with Recovery Audit Contractors and other regulatory auditing being initiated across the country, providers and HIM professionals must be proactive rather than reactive when coding this conditi....

AHIMA’s Revised Standards of Ethical Coding Available

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 10, 2017

The American Health Information Management Association Standards of Ethical Coding includes new and updated information and guidance as of December 2016. This is a must-have resource for any health information management coding professional.

The standards now include definiti....

Engaging Physicians in ICD-10 Planning: The Documentation Link

Publication Date: May 2012

There is much to do before we reach ICD-10 go-live in our organizations-including engaging the medical staff. Physician engagement is important in all healthcare settings and initiatives, but it will be essential in an organization's successful transition to ICD-10.

Obtaining engage....

CMS Bans Use of Physician Signature Stamps

Source: Journal of AHIMA

Publication Date: November 2008

Question: What is the new Centers for Medicare and Medicaid Services ruling on use of signature stamps?

Answer: The Centers for Medicare and Medicaid Services (CMS) has made it clear that it will only accept signatures that are handwritten, electronic, or facsimiles of original wri....

Compliance Efforts Get Some PEPP

Source: Journal of AHIMA

Publication Date: September 1999

Earlier this year, the Office of the Inspector General (OIG) informed the Health Care Financing Administration (HCFA) that "the DRG system is vulnerable to abuse by providers who wish to increase reimbursement inappropriately through upcoding, particularly so within certain DRGs.&....

Ensuring Proper Wound Care Service Coding: OIG Highlights Need for Organizations to Assess Wound Care Coding Practices

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

Publication Date: November 2007

This year the Office of Inspector General (OIG) issued two reports relating to wound care services and Medicare payments. As the OIG has included wound care services as part of its 2007 work plan, coding and HIM professionals should review each report and re-assess their organization̵....

Clarifying Patient Status Code

Publication Date: June 2008

The patient status code reflects the level of care a patient was discharged or transferred to when leaving an acute care hospital as an inpatient or outpatient (i.e., emergency department or emergency room). A recent Centers for Medicare and Medicaid Services MLN Matters publication provides a....

Auditing and Monitoring--Elements of HIM Compliance

Source: Journal of AHIMA

Publication Date: January 1999

Auditing and monitoring are two important components of a compliance plan. The author answers the most frequently asked questions about audits. In addition, find out how to get started—and what to do with the results.
Compliance—it's more than a buzzword. Establis....

Catching Up with PEPP

Author: Bryant, Gloryanne H.; Fletcher, Robin

Source: Journal of AHIMA

Publication Date: September 2000

A year ago, the Journal of AHIMA reported on the newly created Payment Error Prevention Program (PEPP), which went into effect in August 1999. What has happened since then?
Best Billing Practices

PEPP was created to reduce Medicare prospective payment system (PPS) ....

Closer Look at Cardiac Function and Resynchronization

Author: Bryant, Gloryanne H.; Gold, Robert S.

Publication Date: February 2002

by Gloryanne Bryant, RHIT, CCS, and Robert Gold, MD

Coding cardiac conditions and treatments can be difficult for coders, due both to the intricacies of the muscle and its workings and the lack of specificity and documentation in the medical record. This article reviews common cardiac....

New Anemia Codes Address Chronic Illness

Author: Bryant, Gloryanne H.; Gold, Robert S.

Publication Date: July 2001

As of October 2000, there were three new codes for the assignment of Anemia of Chronic Disease. These codes are 285.21, Anemia in end-stage renal disease, 285.22, Anemia in neoplastic disease, and 285.29, Anemia of other chronic illness.

These three codes will help to better describe....

CDI Tips Developed to Maximize ICD-10-CM/PCS

Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi

Source: Journal of AHIMA - website

Publication Date: December 2014

Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of det....

CDI Tips Developed to Maximize ICD-10-CM/PCS

Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi

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

Publication Date: January 2015

Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of detail....

Simple API: Will it solve healthcare’s interoperability problems?

Author: Bryson, Casey

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 22, 2017

You can’t throw a rock in healthcare today without hitting someone claiming to solve “the problem of interoperability.” Those claims come from interface engines, private or public collaboratives like the Sequoia Project and Commonwell, government entities like the Office of the Nation....

Coding for Mammography Services

Author: Buck, Stacie L

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

Publication Date: July 2007

You’re diligently auditing outpatient diagnostic services when you find an order in the medical record for a screening mammogram. However, a diagnostic mammogram was performed, not a screening mammogram.

The business office and the patient request that you change the diagno....

Deciphering Dialysis Access Maintenance Coding

Author: Buck, Stacie L

Publication Date: May 2008

One year after the introduction of two new HCPCS codes for dialysis declotting procedures, confusion remains as to when to report these codes and how to report them in conjunction with other interventions performed during dialysis access maintenance. This article discusses the many facets of d....

Coding in the Coming Decade: Three Initiatives That Will Drive the Profession’s Evolution

Author: Buck, Stacie L