Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2011

The final rule for the FY 2012 Hospital Inpatient Prospective Payment System was released August 1, 2011. Changes in the rule went into effect with October 1, 2011, inpatient discharges.
MS-DRG Documentation and Coding Adjustment

The Centers for Medicare and Medicaid Services....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2013

Editor’s note: This is the third in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.

The implementation of ICD-10-PCS will challenge the skills of coders-it contains many unique features and provides an opportunity to truly reflect the complexity of....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2012

The transition to ICD-10-CM/PCS will provide coding professionals with the opportunity to enhance and improve their coding skills. However, it will also require coders brush up on their anatomy and physiology knowledge. This is the perfect time to gain a better understanding of the differences....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2010

The final rule for the FY 2011 Hospital Inpatient Prospective Payment System was released July 30, 2010. Changes in the rule went into effect with October 1, 2010, inpatient discharges.

The changes to MS-DRGs and the complication and comorbidity (CC) and major complication and comorb....

Author: DeVault, Kathryn

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

Publication Date: September 2015

The complexity of ICD-10-PCS, as well as the need for a better understanding of anatomy and physiology and the technique of surgical procedures, has been well documented. The coding of cardiovascular procedures in ICD-10-PCS, in particular, requires focus.


Consider these p....

Author: DeVault, Kathryn

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

Publication Date: April 2015

With just six months until the implementation of ICD-10-CM and ICD-10-PCS, now is the time for HIM professionals to re-evaluate the state of their facility’s implementation plan and make any necessary adjustments to ensure a successful transition. Previous delays may have slowed down....

Author: DeVault, Kathryn

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

Publication Date: June 2016

The implementation of ICD-10-PCS has created new challenges in coding surgical procedures. While coding professionals have always been expected to read and interpret all surgical documentation, ICD-10-PCS has increased the level of understanding necessary for accurate code assignment.

Author: DeVault, Kathryn; Easterling, Sharon; Huey, Kim

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

Publication Date: January 2017

In the current era of healthcare transformation, the continuing importance of documentation and coding cannot be overstated. With the multitude of acronyms being added to the healthcare vocabulary, one may wonder where documentation and coding fits in. It’s important to remember that....

Author: DeVault, Kathryn; Sartori, Natalie

Source: Journal of AHIMA

Publication Date: June 2018

By Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, and Natalie Sartori, MEd, RHIA


All coding professionals have been involved in coding audits, in one form or another. Many hear the term “coding audit” and expect it to be a quality....

Author: DeVoe, Megan

Source: Journal of AHIMA

Publication Date: May 2018

By Megan DeVoe, CCS


Editor’s Note: This is the first article in a three-part series on how to master the information available on the Centers for Medicare and Medicaid Services website.


When coding foR outpatient hosp....

Author: DeVoe, Megan

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2018

By Megan DeVoe, CCS


Editor’s Note: This is the final article in a three-part series on how to master the information available on the Centers for Medicare and Medicaid Services website.


Have you ever wondered how a code bec....

Author: DeVoe, Megan

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

Publication Date: June 2017

The Impella® device (2.5 and 5.0) provides percutaneous external ventricular support for high-risk patients who cannot undergo traditional open cardiovascular procedures in the inpatient hospital setting. Like intra-aortic balloon pumps (IABPs) that have been used for decades, these de....

Author: Diamond, Carol; Ricciardi, Lygeia

Source: Journal of AHIMA

Publication Date: November 2006

For nationwide health information exchange to succeed, consumers must trust that their data are being managed responsibly. Regional and other networks that create the nationwide exchange should make consumer trust a priority that is factored into every decision they make. Connecting for....

Author: Diamond, Mark

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: Dickey, John MSHI, RHIA, PMP

Source: Journal of AHIMA

Publication Date: October 2018

By John H. Dickey, MSHI, RHIA, PMP


The road to information governance (IG) varies greatly between healthcare organizations. Some organizations may compare it to a pathway with trampled grass, partially filled with gravel, while others find a freshly paved....

Author: Didear, Kay

Source: Journal of AHIMA

Publication Date: October 1998

Implementing a computer-based patient record (CPR) begins long before the first installment of software is loaded. This process significantly benefits from the skills and expertise health information management professionals bring to the table. But don't assume that your healthcare m....

Author: Dierker, Lynn

Source: Journal of AHIMA

Publication Date: May 2008

Operating between community efforts and a nationwide health data network, statewide public-private partnerships are showing unique potential to advance interoperability and promote effective governance.

The early proliferation of health data-sharing networks produced numerous config....

Author: Dill, Mark W; Lucci, Susan; Walsh, Tom

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2016

As protectors of patient health records, health information management (HIM) professionals are developing a keener understanding of the broad topic of cybersecurity and are becoming actively involved in organizational cybersecurity efforts. Information technology (IT) departments typically are....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2008

Those excited about the electronic health record, welcome to the meeting! Those nervous or stressed, pull up a chair!

That could be a greeting for the Connecticut Health Information Management Association’s (CTHIMA) EHR Roundtables, which occur each quarter around Connecticut.....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2012

Increased quality measurement, better patient access to health information, and greater volume of information exchange is in store for providers and hospitals participating in the federal stage 2 meaningful use incentive program.

On March 7 the Centers for Medicare and Medicaid Servi....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2011

The legal issues healthcare organizations must consider when joining a health information exchange (HIE) go far beyond the standard HIPAA-related concerns.

HIEs are rapidly gaining prominence in healthcare, bolstered by federal initiatives like the meaningful use program, which requ....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: January 2008

Just how complicated is defining the legal electronic record for disclosure? There’s nothing new to the need for a legally sound record of care. HIM professionals have helped meet that requirement with paper-based records for years. But just how new and complex is it to define the content....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: November 2008

Maintaining dual paper and electronic systems is often a necessity in the transition to digital record systems. The challenge in reporting data is keeping track of what data reside where.
The transition from paper to electronic records is occurring in many HIM departments across the coun....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: April 2011

Apr 18, 2011

ICD-10-CM/PCS offers organizations better data about their patient populations and the services they provide them. The code set’s greater specificity allows coding professionals to more accurately reflect the details of physician documentation.

However, an....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: November 2013

Though sometimes used interchangeably, data governance and information governance are two distinct terms with very different meanings. And information technology (IT) governance is something completely different as well. With AHIMA pushing its members and the healthcare industry to embrace information governance as a major tent pole of HIM work, it is important for HIM professionals to understand the difference and interrelation of these governance terms and just what an individual can do to help foster governance initiatives that aim to improve health records and patient care....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2007

A model that segments health IT adoption into stages shows a slow climb for US hospitals.
The Big Bang is more than just a theory on how the universe was created. The term also describes the all-at-once implementation of a complete electronic record system within a healthcare facility.

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2010

In 2008 The National Quality Forum (NQF) created a health IT division that, in part, hopes to simplify what it takes to abstract quality measurement data from electronic health records. HIM professionals are among those serving on the workgroups.

The division was developed in respons....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: August 2010

Chris Dimick


Aug 01, 2010 07:15 am


The regional extension center program might have some people experiencing déjà vu.

Granted, the REC program is an unprecedented attempt by the federal government to transition American healthcare to electronic health record sy....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2012

Electronic health records could soon become more patient-centered, more secure, and more frequently used for treatment improvement-if provisions outlined in the EHR certification proposed rule are widely implemented.

Under the 2009 ARRA economic stimulus package, healthcare providers....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2008

There is a gold rush in personal health records. Or at least on paper.

Over the last two years, a wave of companies not typically associated with health information exchange have rounded up their technological wagons and headed out into the PHR frontier looking for profit and a chanc....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2011

Lawsuits can hinge on a deposition. And while HIM professionals have long been called on to attest to the production of the paper medical record, electronic health record systems are introducing a whole new set of questions and considerations.

Providing an accurate deposition on an....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2012

Step up, or step out of the way-that could be a motivating motto for HIM professionals when it comes to developing, critiquing, and using quality measures.

While HIM professionals have traditionally worked with nurses and other clinicians on quality measures, the move to the d....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2007

For physicians trained to see the medical record as an archive, maximizing EHR potential comes in using it as a tool to improve care.
When it comes to implementing electronic health record (EHR) systems, physicians in small practices have an abundance of deterrents. Cost is one; disrupti....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2007

Any change brings with it uncertainty, doubt, and fear of the unknown.

These are strong emotions, and it takes strong-willed and confident leaders to combat them. An organization is only as good as its leaders-a statement especially true in the fast-changing world of h....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: March 2011

Note: this article has been updated to reflect changes implemented through the HITECH Act.

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: September 2010

Sep 24, 2010

The EHR is a valuable clinical tool for streamlining and improving patient care. But it is complicating and confusing the courts.

As the first cases involving electronic health records make their way into legal proceedings, everyone involved is discovering th....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: August 2008

No matter their specialty, physicians share a common purpose in their work. They aim to improve patients’ quality of life. To do this, physicians are forever learning from their peers and their own experiences with patients. Improving the quality of the care they provide is always a goal....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2008

Change is the constant in coding. And while it is a coding supervisor’s job to stay current and implement these changes, sometimes just getting the day-to-day coding work accomplished is a challenge.

Staying ahead of the changes can be difficult, but it is important that manage....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: August 2011

A coding department reorganizes its career paths from the bottom up, creating a culture of professional development.

Six years ago, a limited promotional structure, high turnover, and low recruitment had knocked a dent in the morale of Denver Health's coding department.

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2009

Washington State’s experiment in consumer-controlled health records has moved into a pilot phase, transforming the health record banking model from theory to testing. In March the Washington State Health Care Authority (HCA) announced the launch of three pilot sites that will try out the....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2007

Tracking what should or shouldn’t be included in a healthcare organization’s legal health record can be a dizzying process without ample organization. The increasing mix of digital information with traditional paper records makes good organization all the more essential.

HIM pr....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2012

In an industry facing several distractions from various government initiatives and regulation changes, ICD-10-CM/PCS became the center of attention from April 16-17 as top experts and interested parties gathered in Baltimore, MD to discuss the ongoing transition to the new code set at the 2012....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: January 2010

Talk is cheap. But learning how to communicate is essential for those working to be leaders within their teams, departments, and organizations.

The HIM profession has never offered more opportunity for leadership than it does right now. EHR implementations have HIM profession....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: April 2008

Last year federally funded research documented the privacy and security barriers to health information exchange. Now HISPC moves into its next phase, seeking common practices that enable confidential, secure, and timely cooperation.

Individualism is a cherished American institution.....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2007

Industry trends are putting HIM professionals in charge of staffs with diverse expertise. Managing staff in non-HIM roles takes some special skills, but the advantages abound.
Information is a thread that weaves together healthcare staff with a wide range of expertis....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2012

Patient-Centric Stage 2 Meaningful Use Measures Considered Treatment for Ailing US Health System



The US healthcare system is ill. Higher costs, sicker patients, and struggling providers are the symptoms of the disease that has sent industry stakeholders scrambling t....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2008

Students often learn about health IT by reading books and looking over someone’s shoulder. Now schools can offer hands-on access to IT programs provided over the Internet.

The scavenger hunt had begun.

Scanning the list of items on her worksheet, Lois Hitchcock carefu....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: November 2007

Varying privacy practices that pose barriers to health information exchange are putting HIM concerns in the national spotlight.
The 35-year-old Minnesota woman’s winter vacation in the neighboring state of Wisconsin was going great, until her ski snapped and the accident happened. B....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: August 2010

Provisions within the HITECH Act require that covered entities notify individuals if their protected health information is breached. However, the current regulation allows an exemption if the risk of harm is slight. Assessing risk can be subjective, and privacy officers have been working to cr....

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: May 2011

May 10, 2011


Payers and providers must work their way through the transition to ICD-10-CM/PCS only once, and by the end, few will likely choose to do it again. System vendors and consultants, however, will have been through many, many implementations before it’s all over.

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2010

Even small departments may never experience complete harmony in their assignment of codes, but they have good motivation for achieving as much consistency as they can. Training, communication, monitoring, and coding reviews help reach that goal, HIM experts say.

Coding manager Julie....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2010

The healthcare forecast for 2010 includes a strong chance of audit. HIM professionals in many organizations will be busy responding to a shower of external record requests and internal compliance checks.

Stormy systems of audit programs, compliance initiatives, and fraud preventi....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2014

Majority of Healthcare Organizations Lack Vital Information Governance Strategy


AHIMA has fired the starting pistol heralding in the urgent race to implement information governance (IG) practices within the healthcare industry. While some organizations were quick off the bloc....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2008

The topic of sensitive health data and how to keep it private in the electronic age is one of the most complex issues facing the development of a nationwide, interoperable health information exchange network.

Physicians need accurate medical records to provide adequate care. Yet pati....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: August 2012

Today's HIM education models must change now to keep up with the rapidly evolving landscape of tomorrow's HIM field.



The health information technology revolution has begun, and as it progresses, the shake-up in health information management departments, processes, a....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: August 2008

The medical home model puts the patient at the center of healthcare. It may also save primary care in the process.

Medicine is fighting to save the primary care physician.

With healthcare increasingly oriented around specialty physicians and large practices, market realitie....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2014

Some in the healthcare industry feel electronic health record (EHR) systems are a miracle cure for what ails a US healthcare system plagued with bloated costs, an inability to communicate, and stunted growth in the use of advanced tools. There are still others who equate some of the promis....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: November 2007

The use of health data for secondary purposes has been increasing, and federal agencies and industry organizations are exploring the need for more guidance.
Data in a health record don’t rest when care is complete and a bill is drawn up. Once treatment and reimbursement ar....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2008

Transitioning to ICD-10-CM may seem like a distant problem. But SSM Integrated Health Technologies began its preparations about three years ago. Its reason is simple: “Something of this magnitude, you don’t want to be scurrying,” says Anne Stuckel, SSM’s manager of clini....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2011

To build up competencies in the new code set, AHIMA-credentialed professionals must add ICD-10-CM/PCS continuing education to their credential maintenance through 2013.

The impending coding classification system change from ICD-9 to ICD-10 is the talk of health information....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2007

Chris Meyers, RHIA, had landed the job of her dreams as an e-HIM® enthusiast. A Phoenix medical network was opening a brand-new hospital and needed someone to help build a complete EHR from the ground up. Meyers jumped at the chance, becoming the administrative director of HIM/patient....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2007

The time had come in the physicians’ meeting to discuss HIM issues, and Wilson was in charge of bringing the room up to speed.

Wilson, then the coding quality manager at Charleston, SC-based Roper St. Francis Healthcare, was new to public speaking and training. For a moment,....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: January 2008

Computer-assisted coding won’t eliminate the profession, but it will change it dramatically.

Mythily Srinivasan thought she was out of a job. Out with human coders, in with computer-generated coding. At first that seemed to be her facility’s master plan.

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2009

Forty-four states require organizations to alert customers and employees when data breaches occur. But ambiguity in the laws requires organizations to be capable of making good decisions on their own.

The laptop was missing.

Previously stationed in the EEG department of Nor....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2012

The HIPAA transaction standards-meant to streamline financial and administrative transactions-have instead devolved into a kind of free-for-all. Now the first operating rules are in hand to standardize use of the standards and gain the efficiencies originally intended.

When it....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2009

For senior HIM students, a professional practice internship offers real-life experience and a firsthand look at future careers. But PPEs require sites that volunteer as hosts and HIM professionals to serve as mentors.

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: November 2009

Although the federal government has stepped in to give healthcare a push into the digital age, some providers remain hesitant, spooked by antiquated and ambiguous state laws that still identify paper records as the legal standard.

Their confusion is delaying their transition to elect....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: April 2010

Lawsuits, lobbying, and legislation are holding up enforcement of the Federal Trade Commission’s identity theft prevention law.

The Red Flags Rule has been all bark and no bite since the federal regulation was published in November 2007. More than two years and four postponements la....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: June 2010

The federal government is creating a stripped-down version of the nationwide health information network to aid the meaningful use program. What does it mean for HIEs?

Simple is not a word typically associated with electronic health information exchange. For years, the act of sending....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2008

When people face a big change, they often call a friend for advice. It’s natural to seek out those who have experienced a similar transition.

Many questions surround the implementation of ICD-10 in the US. Besides the big question of when the classification system will be requir....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: February 2011

It is hard to say just what patient-centered care is, but just about everyone agrees that we lack it. The meaningful use program has focused providers, vendors, and consumer advocates around some basic first steps.

This January the meaningful use program began, and with it launched a....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: August 2009

In California, teasing apart state and federal breach notification laws highlights the challenges organizations everywhere face in determining their responsibilities under ARRA’s new privacy regulations.

Within healthcare organizations, the temptation for some staff can be great: wh....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2008

On the third anniversary of the hurricane, staffing shortages still plague some HIM departments, and many EHR implementations remain on hold.

In a matter of hours, 400,000 medical records were reduced to pulp.

Dorothy Jones, RHIT, health information supervisor at Medical Ce....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2011

After debate, speculation, and anxiety throughout the industry, the first physicians and hospitals have embarked on stage 1 of the meaningful use program. So far… so good.

The first physicians and hospitals have embarked on stage 1 of the meaningful use journey; it has been nin....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2010

Since beginning his career in healthcare, Alan Dowling, PhD, has understood that health information management is at the core of quality care. It is as beneficial in the treatment of patients as a good radiologist or CAT scan machine, he believes.

As AHIMA’s new CEO, Dowling says he....