Author: Bechtel, Christine

Source: Journal of AHIMA

Publication Date: September 2005

CMS’s new scope of work sends QIOs to physician offices, hospitals, and home health agencies to provide free assistance implementing health information technology.
Achieving the goal of widely adopted, interoperable health information technology (HIT) rests on the ability of HIM an....

Author: Beck, Catherine A.

Source: Journal of AHIMA

Publication Date: June 2000

One of the newest ways to store medical records isn't available to most HIM departments. For military personnel, the Personal Information Carrier (PIC) or "digital dog tag" is a computer storage medium that can hold some or all of a service member's medical record. Roughly th....

Author: Becker, Joanne

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2003

Sometimes starting small can mean big results. A few months ago, I joined Iowa’s regional HIPAA Strategic National Implementation Process (SNIP) workgroup. The goal of local and regional SNIP workgroups is to create as much collaboration as possible to ensure compliance by all covered ent....

Author: Beckett, Barb; Downing, Kathy; Gillespie, Joe D; Waugh, Traci

Source: Journal of AHIMA

Publication Date: March 2015

Since its initial adoption the HIPAA Privacy Rule has granted individuals the right to request restrictions on the use or disclosure of their protected health information (PHI) for treatment, payment, and healthcare operations (TPO), as well as for disclosures to family members and certai....

Author: Bedrosian, Dan; McCoy, Michael J.

Source: Journal of AHIMA

Publication Date: May 2006

The RFP is a time-honored rite of vendor selection. But it has its drawbacks, and alternative strategies can offer advantages.
In the fast-changing world of health IT, vendor selection would seem to be a rare well-established procedure. But the traditional selection process has its pitfa....

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2001

Among the needs the CPT-5 Project addresses are changes to enhance the use of CPT by practicing physicians, managed care and other payer organizations, and researchers. The project has made recommendations for improvements in the structure and processes of the CPT codes with deliberate emphasi....

Author: Beebe, Michael

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003

In 1998, the American Medical Association (AMA) initiated the CPT-5 Project. This project was a broad-based and comprehensive effort to make needed and practical enhancements to the CPT code set that would address challenges presented by emerging user needs and HIPAA. One of the initiatives tha....

Author: Beguelin, Joan

Source: Journal of AHIMA

Publication Date: May 2003

Does your job lack challenges or underuse your skills? Taking a closer look at the barriers to your success will reveal the first steps to overcoming them.
Increasing HIM professionals’ visibility and credibility in healthcare organizations is a common concern as we try to showcase....

Author: Beidler, Aurae

Source: Journal of AHIMA

Publication Date: May 2018

By Aurae Beidler, MHA, RHIA, CHC, CHPS; Carlyn Doyle, MSHI, RHIA, CHPS, HCISPP; and Elisa R. Gorton, MAHSM, RHIA, CHPS, CHC


After thirty years without a substantive change, the Substance Abuse and Mental Health Service Administration (SAMHSA) has issued two final rules to “update....

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: Beinborn, Julie

Source: Journal of AHIMA

Publication Date: July 1999

Automated coding technology may be key to the evolution of the coding and billing processes. How do these systems work, and how will they change the role of the coder? The author offers a preview.
Technology is changing many aspects of healthcare, and coding is no exception.

R....

Author: Belanger, Mark

Source: Journal of AHIMA

Publication Date: March 2016

The world of health information exchange remains busy in Massachusetts as the Mass HIway, the statewide health information exchange (HIE), enters its fourth year of rolling out Direct messaging statewide. Overall, Mass HIway officials feel things are going very well, with more than 580 or....

Author: Bellenghi, G. Michael

Source: Journal of AHIMA

Publication Date: April 2005

Governed by state and federal regulations, release of information (ROI) is a time-consuming and sensitive process. Failure to fulfill requests accurately and on time can have painful ramifications, affecting quality of patient care and prompting irate phone calls and legal action or fines. Not....

Author: Bellile, Susan K.

Source: Journal of AHIMA

Publication Date: June 1998

A battle for control of medical management is now being waged among hospitals, managed care plans, insurers, employers, physician groups, and researchers—a battle in which data is the weapon of choice. Cumulative and comparative healthcare information is being used to eva....

Author: Bennet, Anna; Kennedy, Estelle; Looney, Peggy

Source: Journal of AHIMA

Publication Date: November 1998

In 1994, Calvary Hospital—a 200-bed acute care facility—transformed its performance improvement initiative: from quality assurance to quality assessment and improvement, and ultimately to a facility-wide organizational performance improvement program. At the same time, it....

Author: Bennett-Woods, Deb

Source: Journal of AHIMA

Publication Date: January 1997

Corporate downsizing and restructuring continue to reduce the number of managers and increase their scopes of authority. As a result of organizational flattening, healthcare organizations increasingly turn to self-directed teams (teams within a department) and cross-functional teams (teams ac....

Author: Benson, Christine L.

Source: Journal of AHIMA

Publication Date: May 2000

Medical records have traditionally housed a patient's health history, but they also hold the statistical information that enables healthcare facilities to determine patient care trends and guides administrators to project future demand of services. As a result, the need for more information,....

Author: Benson, Sean

Source: Journal of AHIMA

Publication Date: February 2011

Little direct attention has been paid to clinical documentation in the context of meaningful use. Discussion and debate instead focused on electronic health records (EHRs), computerized physician order entry, and other health IT systems.

However, the electronic capture and exchange....

Author: Berkeley Research Group

Source: Journal of AHIMA - website

Publication Date: March 2016

This article is published in sponsorship with Berkeley Research Group (BRG).


As a recent initiative, a growing number of healthcare organizations are turning to OpenNotes as a strategy for addressing patient engagement shortcomings in the US healthcare system. Originally pion....

Author: Berkeley Research Group

Source: Journal of AHIMA - website

Publication Date: May 13, 2016

Knowledge is at the core of everything we do. It is behind the mechanics and strategy of coding and the ease of understanding the final outcome(s), and it plays an integral part in the acceptance of change when faced with industry-wide transformation.


Last year, the health in....

Author: Berkey, Tim

Source: Journal of AHIMA

Publication Date: November 1998

As HIM professionals look for ways to become more competitive and achieve the best results, the importance of discovering best practices becomes more apparent. Here's how one team used a benchmarking project to provide specific best practices that reduced accounts receivable....

Author: Bernstein, William

Source: Journal of AHIMA

Publication Date: July 2008

Providing consumers access to their health information seems like a simple concept. In reality, it is fraught with challenges. Records are still largely in paper form, and gaining access to them means contacting multiple parties and paying significant fees. Even when records are in electronic....

Author: Berry, Kate

Source: Journal of AHIMA

Publication Date: March 2013

Health information exchange (HIE) has great potential to improve healthcare quality while containing costs, something the US health system is under increasing pressure from providers and the federal government to achieve. Benefits of HIE include better care coordination, assurance that pat....

Author: Berry, Michael

Source: Journal of AHIMA

Publication Date: April 2008

The potential benefits of health information exchange (HIE) are well documented, as are the privacy concerns of data sharing. In this new environment, patients are seeking increased control and transparency regarding how, with whom, and under what circumstances their electronic records are sha....

Author: Berry, Shamsi Daneshvari PhD, MS, CPHI; Flanigan, Jill

Source: Journal of AHIMA

Publication Date: January 2019

By Shamsi Daneshvari Berry, PhD, MS, CPHI, and Jill Flanigan, MLS, MS, RHIT


The European Union (EU) protects the personal information of EU citizens through the General Data Protection Regulation (GDPR),1 which went into effect on May 25, 2018 and replaced the Data Protection Dire....

Author: Berry, Tracy Bennett

Source: Journal of AHIMA

Publication Date: November 1998

Successful benchmarking can create opportunities to improve performance through discovering best practices. The author offers an overview of benchmarking and best practices and how they apply to HIM—and ways to get started on your own.
Are you looking for a way to jump....

Author: Berthelsen, Cheryl L.

Source: Journal of AHIMA

Publication Date: October 2001

With everyone from executives to college students using personal digital assistants (PDAs), it was only a matter of time before the devices invaded healthcare. Physicians are embracing PDAs to order prescriptions, make progress notes, and order tests faster and more easily. What’s the down sid....

Author: Bettendorf, Jim

Source: Journal of AHIMA

Publication Date: March 2002

Many in the healthcare industry are facing the difficulty of incorporating HIPAA into their organizations. As a newly appointed privacy officer for a healthcare clearinghouse, I, too, was presented with the challenge of assimilating HIPAA into our organization.

Always Ask Questions<....

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....

Author: Bhuttar, Vijaya Kumar

Source: Journal of AHIMA

Publication Date: June 2011

Payers that are not ready to migrate from legacy systems are looking at tactical solutions for making their existing systems ICD-10 compliant in the near term. Most solutions involve a crosswalk between old and new code sets, created from four basic options.

For a long time, le....

Author: Biedermann, Sue E.; Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: November 2004

HIM professionals are naturals for careers in research. Here’s how data management, analysis, and reporting skills can help make the transition.
HIM professionals know research is critical to the advancement and delivery of healthcare. Research is “a way to create knowledge.....

Author: Biedermann, Sue E.; Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: May 2003

How can you share your expertise? Consider a career in education, where plenty of opportunities await you—and the profession needs you.
Educators play a critical role in the viability of the HIM profession. But will there be enough of them to sustain the profession in the future? If....

Author: Biedermann, Sue E.; Fenton, Susan H.

Source: Journal of AHIMA

Publication Date: August 2012

The journey of a thousand miles begins with a single step.
-Proverb

With the current whirlwind of changes taking place in HIM, along with the increasing volume of evolving roles and functions that are becoming a part of the HIM domain due to the enhanced use of data, HIM o....

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: October 2012

New, deleted, and revised ICD-9-CM codes are included every year in the Centers for Medicare and Medicaid Services’ (CMS) annual update to the Inpatient Prospective Payment System (IPPS). But only one new ICD-9-CM code, effective October 1, 2012, has been added to the code set due to the ongo....

Author: Bielby, Judy A

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

Publication Date: October 2014

A poorly managed coding process can thwart the effective use of coded diagnosis and procedure data. Take for example Hospital A, a fictitious hospital that does not effectively manage their coding processes. At this hospital, the coding professionals are concerned primarily with the impact....

Author: Bielby, Judy A

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2011

ICD-10-CM codes provide greater detail than ICD-9-CM codes for reporting neoplasms. In many instances, ICD-10-CM neoplasm codes can provide information on whether a neoplasm occurred in a right-sided or left-sided body part. ICD-10-CM also provides codes for reporting neoplasm sites with great....

Author: Bielby, Judy A

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

Publication Date: May 2016

In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States wo....

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: September 2019

Author: Bielby, Judy A

Source: Journal of AHIMA

Publication Date: July 2013

The demand for trustworthy data has never been more apparent than it is today, and the coding process plays a critical role in meeting the need for complete, accurate, and reliable healthcare data. Accurate and compliant coding of ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II de....

Author: Bielby, Judy A; Comfort, Angie; Reed, Andretta; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2014

Organizations were well on their way to an October 1, 2014 implementation of ICD-10-CM/PCS when Congress passed H.R. 4302, the Protecting Access to Medicare Act of 2014. This bill contained a section stating that the Department of Health and Human Services (HHS) could not adopt the new code set....

Author: Bielby, Judy A; Williams, Margaret

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: August 2010

This practice brief has been retired. It is made available for historical purposes only.

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: April 2009

Several well-publicized medical record breaches in California, including the unauthorized access of the governor’s wife’s record, led to sweeping changes in the oversight, reporting, and enforcement of penalties for privacy breaches in the state. Two new laws signed by Governor Sch....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: September 2007

After decentralizing traditional HIM functions, one hospital is reuniting them piece by piece. Centralized data reporting is in the works.



Rady Children’s Hospital San Diego has come full circle with respect to centralization of HIM functions. In the 198....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: January 2015

As I enter my 35th year as an AHIMA leader, educator, practitioner, and volunteer, I am excited to celebrate AHIMA’s 86 years of accomplishments and to have a role in paving the way for a bright future for HIM professionals everywhere.


I look forward to the months ahead, b....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: February 2003

Does your organization have a policy in place for protecting patient health information (PHI) over the phone?


This article will discuss how a workgroup at Children’s Hospital and Health Center (CHHC) in San Diego, CA, implemented a policy to protect verbal PHI and how your....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: February 2015

New technology, an evolving regulatory environment, financial pressures, and consolidation in the marketplace have all emerged as factors that are shaping the health information management (HIM) career path. Now is the time to examine the maturity state of the electronic health record (EH....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: September 2015

Putting the consumer in the driver’s seat represents a paradigm shift for health information management (HIM) professionals in many ways. Traditional release of information functions grow increasingly outdated in the face of work to remove barriers between consumers and their health infor....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: October 2015

Data are the lifeblood of our healthcare ecosystem, with the potential of enabling organizations to improve care, manage chronically ill patients, lower costs, achieve compliance, support research, increase patient safety, and meet operational and strategic initiatives. Although health inf....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: April 2015

From the year 2009 through 2014, nearly 42 million people had their protected health information (PHI) compromised, according to data from the Department of Health and Human Services’ Office for Civil Rights (OCR). Each passing year brings into sharper focus the challenges associated with....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: August 2015

Not a day goes by for HIM and healthcare industry leaders without challenges that result from a lack of trust in the data and information we encounter in our work—or in caring for our loved ones. Years ago, when I was working as the director of quality and resource management at a well kn....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: July 2015

The health information management (HIM) profession reached a new milestone in 2014 with over 79 percent of clinical documentation improvement (CDI) programs now led by HIM professionals.


The 2014 AHIMA Workforce Survey revealed strong similarities between the priorities of....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: May 2015

WHEN I DECIDED to pursue my graduate education in health information management (HIM) and informatics seven years ago, adoption rates for advanced electronic health record (EHR) systems were evolving, data was siloed, and interoperability was far from reality. Organizations were up to the....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: June 2015

Chills run up and down my spine as I write this article, knowing how hard we have worked as a profession, association, and industry to get to this red letter date for ICD-10-CM/PCS.


Just before I wrote this column, I was on the edge of my seat along with the rest of indust....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: November 2015

As we wind down the year, I can rest assured that our members have successfully arisen to the occasion of the new challenges that confront us, from ICD-10-CM/PCS to conquering data quality challenges with sound information governance (IG) practices.


One of the many highlig....

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: March 2015

Despite the fact that "strides have been made in the sharing of information across technology systems and information platforms," according to Karen DeSalvo, MD, MPH, MSc, national coordinator for health IT, I believe that our work has only just begun when it comes to developing a seamles....

Author: Birnbaum, Cassi L; Hall, Terri; Sweet, Helayne; Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: March 2009

For the last five years the Certification Commission for Healthcare Information Technology (CCHIT) has been working to promote the adoption of health IT by certifying electronic health record (EHR) products against common, baseline criteria.

The private, nonprofit certification body....

Author: Bisbee, Walter L.; Lillback, Debra Harris

Source: Journal of AHIMA

Publication Date: June 1998

Good documentation is a cornerstone of data quality. But how can an organization ensure that all disciplines will take responsibility for the comprehensiveness and accuracy of their documentation? The authors describe the steps one facility took to implement a process of record....

Author: Blackford, Gwendolyn; Whitehouse, Rosanne

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

Publication Date: October 2007

Obtaining codeable clinical documentation at the point of care in a large teaching facility can be challenging. However, the HIM department at the University of Michigan Health System (UMHS) in Ann Arbor, MI, took on the task, implementing a clinical documentation improvement program (CDI....

Author: Black, Michelle A

Source: Journal of AHIMA

Publication Date: June 2015

If you don't use it, you lose it. This is true for much of what we learn in life, and it’s particularly true when it comes to ICD-10-CM/PCS. Although most organizations initiated ICD-10 coder training in 2013, many decided to cease training and dual coding practice after the second ICD-10....

Author: Blair, Barclay T

Source: Journal of AHIMA - website

Publication Date: October 2014

Having an effective information governance (IG) program is critical in the healthcare industry. Not only does the regulatory environment and sensitivity of the information involved pose unique challenges, the information’s importance to the health and lives of patients makes handling....

Author: Blair, Barclay T

Source: Journal of AHIMA

Publication Date: June 2018

By Barclay T. Blair


On May 25, 2018, the European Union’s (EU’s) General Data Protection Regulation1 (GDPR)—hailed as “the most important data privacy regulation in 20 years”—took effect.2 Most people who are familiar with the....

Author: Blair, Barclay T

Source: Journal of AHIMA

Publication Date: May 2018

By Barclay T. Blair


The Information Governance Initiative’s (IGI) annual report sheds light on the current state of information governance in organizations large and small, around the world, and throughout all industries—including healthc....

Author: Blair, Barclay T; Snyder, Ann

Source: Journal of AHIMA

Publication Date: February 2016

Though the discipline of information governance (IG) is relatively young, research from the Information Governance Initiative (IGI) shows that organizations today are spending real money on IG and taking on a variety of IG projects. Simply put, IG work is getting done.


But ho....

Author: Blevins, Alicia; Davis, Nancy; Hjort, Beth M.; Lemery, Chrisann; Mangin, Wendy L; Mikels, Debra A; Nicholas, Cindy

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: August 2006

This practice brief has been retired. It is made available for historical purposes only.

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2008

The long-anticipated update to the Home Health Prospective Payment System (PPS), released in the August 29, 2007, Federal Register, goes into effect January 1, 2008. The final rule encompasses a wide range of changes for home health agencies.
An Overview of the Final Rule
....

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2004

Home care coding has always been a challenge given the fact that codes are assigned upon admission or on the “front end” of care provision. The luxury of having a complete medical record filled with physician documentation to support diagnoses (e.g., in acute-care facilities) is a....

Author: Blevins, Ida K.

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

Publication Date: October 2006

Home health agencies are required to use the ICD-9-CM Official Guidelines for Coding and Reporting for Medicare Outcome and Assessment Information Set (OASIS) reporting for MO230 (principal/primary listed diagnosis) and MO240a–MO240f (secondary/additional diagnoses). The stipulation too....

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2009

Sweeping PPS changes for home health went into effect January 2008, making much of the prior coding guidance issued by the Centers for Medicare and Medicaid Services (CMS) incompatible with changes in the revised data collection set. Home health coding professionals anxiously awaited further i....

Author: Blobel, Bernd; Pharow, Peter

Source: Journal of AHIMA

Publication Date: February 2005

Smart cards help keep consumers and their health data in the same place. In Germany, a national project enters the test phase.
It’s a major challenge getting patients and their data in the same room. As consumers increasingly receive their care from a variety of providers, their hea....

Author: Bloomrosen, Meryl

Source: Journal of AHIMA

Publication Date: October 2005

Health IT has been a hot topic in the two years since AHIMA published "A Vision of the e-HIM Future." Members of the original task force take a look back.
This fall marks the second anniversary of the AHIMA report "A Vision of the e-HIM Future." The report, published in September 2003,....

Author: Bloomrosen, Meryl; Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: April 2006

Rapidly advancing data exchange initiatives have left a trail of acronyms in their wake. Is a SNO a RHIO, and where did LHIIs go?



As thinking on the nature of regional and nationwide data exchange evolves, terms devised from necessity have been left behind just as....

Author: Blumenthal, Jane E

Source: Journal of AHIMA

Publication Date: March 1998

Kathleen H. Stanfield, RRA, was so nervous when she first took on her current job as health information systems coordinator at the Austin Diagnostic Medical Center (ADMC) in Texas that she felt physically ill. "It was like closing my eyes and jumping into a fire," she says of....

Author: Blumenthal, Jane E

Source: Journal of AHIMA

Publication Date: January 1999

A recent survey questioned healthcare executives to determine the current standing of healthcare compliance officers in today's healthcare industry. Survey results showed that compliance is a top priority among all facets of the healthcare industry, as shown by the 86 percent o....

Author: Blumenthal, Jane E

Source: Journal of AHIMA

Publication Date: January 1998

I am the proverbial optimist—if you think that way, everything will come true,” says Ruthann Russo, JD, ART, about her successful Bethlehem, PA-based health information management consulting firm, Cabot Marsh Corporation.

And you wouldn’t expect to hear anythi....

Author: Blumenthal, Jane E

Source: Journal of AHIMA

Publication Date: October 1998

Though issues about establishing an inter-departmental computer-based patient record (CPR) between the Department of Defense and Department of Veterans Affairs (VA) have been on the table for a long time, real action toward a CPR began in November 1997, according to Colonel Lynn....