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Taking a Second Look at Joint Commission Standards

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: January 2002


HIM professionals are well aware of the challenge of meeting Joint Commission standards. Now, however, a recently established review committee has the opportunity to recommend changes to the standards—and may even be able to reduce the burden of compliance.


That’s the....

Mastering the Information Management Standards

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: February 2000


For HIM professionals working at organizations surveyed by the Joint Commission on Accreditation of Healthcare Organizations, the information management standards are critical. Here's an overview of the key points and top issues surveyors look for.
Whether you work in acute, long term, h....

Adapting Enterprise Workflow for ICD-10-CM/PCS

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: June 2013



During her speech at the 2013 HIMSS Annual Conference, the Centers for Medicare and Medicaid Services’ Acting Administrator Marilyn Tavenner said the healthcare industry should proceed full steam ahead on preparing to implement ICD-10-CM/PCS. The message conveyed is that CMS is 100 p....

Using Document Imaging to Strengthen Revenue Cycle

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: April 2009


For many organizations, document imaging is the first step toward implementing a fully electronic health record. Document imaging allows staff members across an organization to access electronic documents simultaneously. Three practitioners share their experiences on how this accessibility can....

To Sign or Not to Sign Verbal Orders

Author: Clark, Susan

Source: Journal of AHIMA

Publication Date: May 1998


The value of obtaining physician signatures on verbal orders after the patient's discharge from care is a concept that has been debated for several years. Typically, state regulations require that verbal orders be signed or authenticated. In some states a specific time frame—such....

Structured Text: Documentation Meets Technology

Author: Colburn, Charlotte

Source: Journal of AHIMA

Publication Date: February 1997

Background

Documentation of patient encounters through dictation and transcription processing has advanced dramatically over the past century, and current technology offers still greater opportunities for efficiency, timeliness, and completeness. Sixty years ago, the "transcriptionist" o....

Risk Management 101

Author: Collins, Patricia

Source: Journal of AHIMA

Publication Date: October 1999


The decision to implement a computer-based patient record (CPR) system is a substantial commitment of time and resources. Making it a reality in your organization requires a number of steps, not the least of which is risk assessment. Assessing the risks associated with the CPR should ....

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....

Measuring CDI Productivity

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 23, 2016



When calculating the productivity guidelines for a clinical documentation improvement (CDI) program it is important to remember both quantitative and qualitative perspectives. Sometimes it is very easy to focus solely on the quantity of reviews that are performed. If the quality of those r....

Understanding CDI Metrics

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 24, 2016


Understanding clinical documentation improvement (CDI) metrics can be confusing, especially when you first start reviewing them.


Let’s dive a little deeper into the topic and take a closer look at some frequently reported CDI metrics and evaluate how these measures can reflect the....

The State of CDI

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....

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....

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....

Impact of Physician Engagement on Clinical Documentation Improvement Programs (AHIMA Practice Brief)

Author: Combs, Tammy; Endicott, Melanie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2017


Physician engagement seems to be the buzzword in healthcare these days. Hospital administrators charged with various clinical improvement initiatives have come to realize that physician engagement is an essential element of success. While physician engagement in clinical documentation improveme....

Coding Open Fractures in ICD-10-CM

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2012


Fractures are a common medical malady, and coders encounter them often. But the differences between coding fractures in ICD-9-CM and ICD-10-CM are vast.

Upon implementation of ICD-10-CM the code system currently in place for fractures within ICD-9-CM will cease to exist, and a new,....

Ensuring Remote Coding Compliance

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012


More and more HIM department managers are turning to remote coding. However, before implementing this staffing model, managers must answer several questions regarding the privacy and security of patient information, including:
What are the compliance risks?
How will privacy and secu....

CY 2013 OPPS Update

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013



As 2012 drew to a close, US healthcare facilities began the daunting task of reviewing the Centers for Medicare and Medicaid Services’ (CMS) hospital outpatient prospective payment system (OPPS) update to ensure their chargemaster and systems were up-to-date with the 2013 changes. Th....

CY 2018 CPT Updates

Author: Comfort, Angie

Source: Journal of AHIMA

Publication Date: February 2018

By Angie Comfort, RHIA, CDIP, CCS, CCS-P

The holidays have come and gone. Now, we must focus our professional attention on what did not “go” with the ringing in of the new year: those 2018 Current Procedural Terminology (CPT) code updates. As is customary for every January 1st,....

CY 2017 OPPS Update

Author: Comfort, Angie

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

Publication Date: February 2017



As last year drew to a close, facilities began the looming task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule to ensure their chargemaster and systems were up-to-date with the 2017 changes. The final rule for calendar year (CY) 2017 was released on Novem....

Privacy Architecture and e-Consent

Author: Connor, Kathleen

Source: Journal of AHIMA

Publication Date: June 2007


As the US prepares to implement a nationwide health information network (NHIN), one issue that repeatedly surfaces is how to appropriately protect the privacy and security of electronic health information. Of particular concern is how such a system can accommodate the various legal restriction....

HIM’s Expanding Role in Clinical Data Analysis and Mapping

Author: Cook, Jane

Source: Journal of AHIMA

Publication Date: September 2012


As the healthcare community works to meet the requirements of the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR incentive program and other initiatives, new opportunities are forming for the health information management (HIM) professional. Roles in both clinical data....

Understanding National Coverage Policies: Navigating the Maze of HACs, Serious Reportable Events, and Wrong Surgical Sites

Author: Cook, Jane; D'Amato, Cheryl; Garrett, Gail S.; Ruhnau-Gee, Becky; Hyde, Linda A.; Novak, Natalie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


Present on admission indicators, hospital-acquired conditions, serious reportable events, and “wrong” surgical events are each hot topics. However, they also can be a hot topic together, because a number of these reporting requirements are interrelated. HIM professionals must under....

Universal Adapters: Terminology Standards Enable Meaningful Data Exchange

Author: Cook, Jane; Foley, Margaret M.; Giannangelo, Kathy; Paterno, Marilyn D.; Scichilone, Rita A; Schwarz, Kathleen M.

Source: Journal of AHIMA

Publication Date: January 2009


Standardized clinical terminologies are critical connectors that allow systems to exchange health information.

In the winter of 1904 a major fire broke out in Baltimore, MD. The resulting damage—an entire swath of the downtown destroyed—was blamed largely on a lack of uni....

Updated Toolkit for Security Strategies

Author: Cooper, Ted

Source: Journal of AHIMA

Publication Date: July 2004


The first version of the Computer-based Patient Record Institute (CPRI) toolkit “Managing Information Security in Health Care” was published on the Web in May 1999 in response to the proposed HIPAA security and electronic signature standard of October 1998. The toolkit is intended....

Certified Meaningful

Author: Costa, Kerry F

Source: Journal of AHIMA

Publication Date: August 2010


This month providers will begin seeing the first EHR products approved for use in the "meaningful use" incentive program. Another piece of the ARRA puzzle is falling into place.

In March 2010 the Office of the National Coordinator (ONC) proposed two programs to test and approve EHR p....

Medicare Data Study Spotlights Coding Errors

Author: Cottrell, Carlton

Source: Journal of AHIMA

Publication Date: September 2000



Coding quality for Medicare claims is an area of constant concern. Coding errors can have far-reaching effects in the healthcare universe, and coders are experiencing increased scrutiny from both regulators and hospitals looking to control costs. As a follow-up to results of a Medica....

Digital Health: Promise, Perils, and Perspective

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....

Making Data Smart: Practical Informatics is Helping Transform Data into Health Intelligence, and Now Moving into Day-to-day HIM Work

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: February 2014



Health informatics is often considered to be an advanced level of health information management (HIM). It’s also in high demand—in addition to handling, storing, and retrieving health data more HIM professionals are getting involved in the decision-making process regarding what types of i....

Declassifying Doctors' Notes

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: May 2013



"Open Notes" Project Gives Patients Simple, Affordable, and Resoundingly Effective Access to Clinician Notes



Exactly who owns a patient's health record-answer, the patient-was once an unknown to many patients and non-HIM staff in healthcare. While HIM professionals have....

Physician Practice Check-Up: Assessing a Practice’s Readiness for Electronic Health Records


Author: Crocker, Janice; Fahrenholz, Cheryl Gregg; Johnson, Wanda; Levinson, Stephen R; Washington, Lydia

Source: Journal of AHIMA

Publication Date: August 2009




Federal incentives will take some of the pain out of transitioning a practice to an electronic health record system, but the transformation will be monumental, nonetheless. For practices that take the leap, focusing initial efforts on a readiness assessment lays a solid foundation for....

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