Author: Zangl-Milbrand, Evelyn

Source: Journal of AHIMA

Publication Date: April 2001

When I was hired as the assistant director of the HIM section with the Department of Veterans Affairs, Greater Los Angeles Healthcare System (GLAHS), I faced a major challenge. Congress had recently required the Department of Veteran Affairs (VA) to submit claims to third-party payer....

Author: Zakoworotny, Cindy; Rutz, Cheryl; Zwingman-Bagley, Cheryl

Source: Journal of AHIMA

Publication Date: May 1997

In 1994, Hartford Hospital began to prepare for a 1995 survey by the Joint Commission on Accreditation of Healthcare Organizations. In reviewing the hospital's policies, it was clear that they addressed the assignment of user IDs and passwords for a mainframe environment rather than a network....

Author: Zak, Cindy

Source: Journal of AHIMA

Publication Date: August 2019

By Cindy Zak, MS, RHIA, PMP, FAHIMA


Yale New Haven Health (YNHH) began implementing the electronic health record (EHR) across four delivery networks in 2012. As the system moved to the electronic world, it became evident that YNHH needed to address the issue of defining the organi....

Author: Zach, Henry

Source: Journal of AHIMA

Publication Date: June 2004

Sharing data electronically rather than verbally or on paper benefits healthcare by reducing medical errors, improving the quality of routine and emergency care, and lowering administrative costs. Capturing and transmitting information digitally also ensures patients and providers are able to....

Author: Younkin, Jim

Source: Journal of AHIMA

Publication Date: September 2010

A study authored by the Center for Information Technology Leadership found a completely interoperable healthcare system (that is, each organization could share every piece of its healthcare information with another organization as discrete and normalized data) could yield annual savings of $77....

Author: Youmans, Karen; Scichilone, Rita A; Dougherty, Michelle

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2001

In the October 2000 Journal of AHIMA, we outlined the new home health care prospective payment system (PPS).1 Coding professionals working with home health providers have learned new terms and additional guidelines for reporting. However, confusion remains concerning code assignments, because s....

Author: Youmans, Karen

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2001

FRGs, RIC, CMGs, FIM, MDS-PAC, IRF, RPPS, UDSMR...What do these letters mean? They are all part of the inpatient rehabilitation prospective payment system (RPPS). This article will explain the history and key pieces of this system.

A Brief History of PPS

As we know,....

Author: Youmans, Karen

Source: Journal of AHIMA

Publication Date: March 2004

HIM plays an integral role in an organization’s revenue cycle. That means health information managers have a role to play in revenue cycle management.
Is the following scenario familiar? The CEO is complaining about accounts receivable (AR) climbing to $10 million. The coders a....

Author: Youmans, Karen

Source: Journal of AHIMA

Publication Date: September 2019

By Karen Youmans, MPA, RHIA, CCS, and Vanessa Youmans, MA, RHIA, CCS, CPC


As healthcare organizations strive for continuous efficiency and sustainability, mergers and acquisitions (M&A)among diverse medical facilities provides organizations new opportunities to reduce costs an....

Author: Yokubaitis, Pamela R.

Source: Journal of AHIMA

Publication Date: September 2003

Sanctions under the HIPAA regulations mean serious financial consequences for healthcare professionals who release protected health information to others without following proper disclosure protocols. But HIM professionals should not be motivated by fear of financial consequences alone. Ou....

Author: Yoder, Lois M.

Source: Journal of AHIMA

Publication Date: June 1999

Good documentation is a must in all settings—but long term care faces some special problems. Improving a long term care documentation program takes education, awareness, vigilance, and attention to detail. Here are some strategies.
It's a fact—when patient loads are hig....

Author: Yoder, Lois M.

Source: Journal of AHIMA

Publication Date: January 2000

You may want to consider a focused review of how your practice assigns CPT modifier -25, "a significant, separately identifiable Evaluation & Management (E&M) service by the same physician on the same day of the procedure or other service."1 The Health Care Financing Admini....

Author: Yaniszewski, Linda

Source: Journal of AHIMA

Publication Date: January 2011

We all know the state of the economy. Cutting costs has been a mantra in healthcare for years, but recent pressures have been more demanding than ever.

In HIM, the downward pressures in cost conflict with the upward forces in workload. Additional tasks related to recovery audits, IC....

Author: Yaggie, Elaine

Source: Journal of AHIMA

Publication Date: May 2001

Whether you're new to the HIM profession or a long-time expert, release of information presents perennial challenges-especially in light of HIPAA. This article brings you the basics and the latest updates.
Release of health information has been a hot topic for years. Today, more....

Author: Wright, Amy

Source: Journal of AHIMA

Publication Date: January 2003

“If you or a loved one has been the victim of nursing home abuse, please call for a free consultation.” This refrain is familiar to Floridians and is quickly moving to other states where laws allow large punitive or damage awards for malpractice lawsuits.


Long-term c....

Author: Wood, Jane

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 09, 2017

Every fall, coding professionals anxiously await the list of new and revised ICD-10 diagnostic and procedural codes. They read articles and listen to webinars that describe the changes and are eager to prepare themselves for compliant, accurate use of the updated code set on October 1. But....

Author: Wolter, Julie; Friedman, Beth

Source: Journal of AHIMA

Publication Date: November 2005

Consumers who maintain personal records of their health history help bring comprehensive information to the point of care. And they have the potential to be more actively involved in their health.
Consider the following scenario. A patient is visiting a cardiologist for the first time.....

Author: Wolter, Julie; Dolan, Marsha; Dooling, Julie A

Source: Journal of AHIMA

Publication Date: September 2012

PHRs and patient portals can provide much needed links to health information in times of catastrophe

When a disaster hits, the impact is vast and devastating for victims and their loved ones. This point was driven home in 2011, when the Federal Emergency Management Agency (FEMA) repo....

Author: Wolter, Julie

Source: Journal of AHIMA

Publication Date: October 2007

Many patients have their personal health information scattered across various practitioners and settings. Personal health records (PHRs) can help patients keep track of all their medical information. There are many different PHR products and models available today.


Cu....

Author: Woloszyn, William

Source: Journal of AHIMA

Publication Date: April 2005

Two years after the HIPAA privacy compliance date, is it time for your organization to reassess your efforts and recommit to enforcing HIPAA?
Revisiting HIPAA’s Roots

The HIPAA privacy regulation was created in response to public healthcare concerns about the privacy of pa....

Author: Woloszyn, William

Source: Journal of AHIMA

Publication Date: June 2002

Who, me? Work as both a privacy officer and a security officer? It may seem impossible, but it can be done. While the roles of privacy officer and security officer are often presented as two distinct jobs in relation to HIPAA, if a lack of resources or personnel demand it, a daring HIM pro....

Author: Woebkenberg, Jami; Hernandez, Sandra MSMIS, RHIA, CPHI, CCS, CHC; Dean, A. Andrews

Source: Journal of AHIMA

Publication Date: May 2019

By Jami Woebkenberg, MHIM, RHIA, CPHI, FAHIMA; Sandra Hernandez, MSMIS, RHIA, CPHI, CCS, CHC; and A. Andrews Dean, CPHIMS, CHDA, CPHI, CPPM, CPC


Technology is a major part of our lives and healthcare is certainly not exempt from its influence. Under the 2009 HITECH Act, eligible....

Author: Witmer, Marna

Source: Journal of AHIMA

Publication Date: September 2017

Quality coding has always been a goal for health information management (HIM) departments. Traditionally, HIM focused on coding for acute care services while physician practice coding was accomplished by physician office staff—typically using super-bills with CPT lists and generic IC....

Author: Wise, Lee A; Miller, Nicole; Warner, Diana

Source: Journal of AHIMA

Publication Date: April 2018

Untitled Document


The Role of CDI in Semantic Interoperability


By Lee Wise, MS, RHIA, CHCO; Nicole Miller, MS, RHIA; and Diana Warner, MS, RHIA, CHPS, CPHI, FAHIMA


Improving documentation quality has been the passion of many health inf....

Author: Wise, Lee A; Miller, Nicole

Source: Journal of AHIMA

Publication Date: February 2019

By Nicole Miller, MS, RHIA, and Lee Wise, MS, RHIA, CHCO


We live in an era where we can order groceries online and have them delivered right to our kitchen. We are able to do nearly all banking online, making it possible to never set foot in a brick-and-mortar bank branch. It can....

Author: Winter, Kitt; Hastings, Bob

Source: Journal of AHIMA

Publication Date: May 2011

The Social Security Administration has plenty of reasons to streamline its records request process-more than 15 million reasons each year, in fact. That's why it has been pioneering information exchange projects with the private sector, including use of the Nationwide Health Informa....

Author: Wing, Paul; Salsberg, Edward S.

Source: Journal of AHIMA

Publication Date: April 2002

What forces are propelling the healthcare industry’s prolonged period of change? How are these forces shaping the future of HIM? In this article, investigators from the Center for Health Workforce Studies examine the roots of the work force shortage and reveal trends that will continue to....

Author: Wing, Paul; Langelier, Margie; Continelli, Tracey; Armstrong, David

Source: Journal of AHIMA

Publication Date: May 2003

What does AHIMA's membership look like as a whole--and how will it look in the future? Early findings from the Association's work force study paint a diverse and dynamic picture?
Health information management is a fascinating set of professional disciplines, roles, and functions that rev....

Author: Wing, Paul; Langelier, Margaret H.

Source: Journal of AHIMA

Publication Date: June 2004

Profound change is coming to HIM. Leading organizations say HIM professionals must be willing to rethink their traditional jobs and acquire new skills in order to meet challenges and claim new roles.
HIM has been in transition for more than three decades, but the healthcare system is now....

Author: Wilson, Valerie; Hammer, Juanita; Washburn, Daniel

Source: Journal of AHIMA

Publication Date: February 1999

St. Mary's Mercy Hospital is a 277-bed acute care facility in northwestern Oklahoma. Serving as a regional referral center, the facility provides acute medical and surgical services, critical care, neurosurgical services, inpatient rehabilitation, a skilled nursing unit, ambulatory sur....

Author: Wilson, Valerie

Source: Journal of AHIMA

Publication Date: March 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


The process for preparing to run a marathon is similar to that of building strategy. Both begin with asking a seemingly simple question: “Why?”


We may decide to run a marathon for personal achievement, to support charity, o....

Author: Wilson, Patricia S; Scichilone, Rita A

Source: Journal of AHIMA

Publication Date: July 2011

There is a growing need for document standardization in health information systems to facilitate efficiency and ensure interoperability. Terminologies enable collection of data that can be reused without recoding or data entry duplication.

The Logical Observation Identifiers Names a....

Author: Wilson, Donna D; Hampton-Bagshaw, Kim; Jorwic, Therese M; Bishop, Jean; Giustina, Elizabeth

Source: Journal of AHIMA

Publication Date: March 2008

Establishing a standard coding workflow that incorporates continuous improvement and creating performance benchmarks is key to improving the quality of coded data.



HIM professionals who assign codes or manage coded data take responsibility for translating clinical....

Author: Wilson, Donna D

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2012

The Recovery Audit Contractor (RAC) demonstration program found that "most of the overpayment amounts collected by the RACs (about 85 percent) were from inpatient hospital providers," and "almost half of the improper payments were the result of incorrect coding."1 Things have changed with....

Author: Wilson, Donna D

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2009

The Centers for Medicare and Medicaid Services (CMS) expects to have four Recovery Audit Contractors (RACs) operating by 2010. Each RAC will be responsible for identifying overpayments and underpayments in a region of the country. Based on the results of the demonstration program, the permanen....

Author: Wilson, Donna D

Source: Journal of AHIMA - website

Publication Date: October 30, 2014

The proper application of modifier -59 (Distinct Procedural Service) has mystified many a coder. The Centers for Medicare and Medicaid Services (CMS) has recently indicated that modifier -59 is the most commonly used and abused of all the modifiers—mainly due to the fact that it is used to....

Author: Willner, Sue

Source: Journal of AHIMA

Publication Date: July 2001

HIM professionals’ data management skills make them a hot property in many settings, but none more so than managed care. In this second installment of the Journal of AHIMA’s special series on managed care, the author describes the ways managed care organizations use data and how HIM....

Author: Willner, Jordana

Source: Journal of AHIMA

Publication Date: March 1999

Your entry-level job applicants resemble the teenyboppers on MTV. Your youngest employees look like your children. The media's hype about an apathetic, short-attention-spanned new generation causes you to doubt the abilities of your "twenty-something" workers.

We....

Author: Williams, Patricia A.H

Source: Journal of AHIMA

Publication Date: April 2017

Information sharing between healthcare organizations increasingly includes the use of electronic health records (EHRs) as well as data from medical devices that have been integrated into existing networks. When exchanging such data, providers should be mindful not only of the interoperabil....

Author: Williams, Adrian

Source: Journal of AHIMA

Publication Date: February 2006

Well-designed software screens are more than just user-friendly. They encourage accurate, consistent data capture. An example from coding shows how.
Computer technology is supposed to make our lives easier, especially at work. Sometimes, however, it’s easy to question if this is t....

Author: William, Fiala C

Source: Journal of AHIMA

Publication Date: August 2019

By William C. Fiala, BS, MA, CCS-P, CPC, RMA


Capturing socioeconomic data, also referred to as social determinants of health (SDOH), is rapidly becoming a necessary element of documentation. SDOH “are among the most influential factors that determine health outcomes of indiv....

Author: Willett, Lyn

Source: Journal of AHIMA

Publication Date: July 2000

There's no doubt APCs are going to change the way your facility operates, but do you know how? By taking a look at your existing systems, you'll get a better idea of how to prepare for changes. This article spotlights specific functions to consider and optimize for the new outpatient prospect....

Author: Willard, Dianne; Worthington, Debbie; Ashley, Patti

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2004

ICD-9-CM coding and DRG changes for fiscal year 2005 include 150 new diagnosis codes, 21 new V codes, 54 new procedure codes, 25 invalid diagnosis codes, and 3 new DRGs. The changes were released in the August 11 Federal Register and went into effect October 1, 2004, for discharges occurring o....

Author: Willard, Dianne

Source: Journal of AHIMA

Publication Date: June 1998

On January 7, 1998, the Health Care Financing Administration (HCFA) released the final instructions on hospital outpatient modifiers from Medicare Hospital Manual transmittal number 726 dated January 1998. These instructions were electronically released to the Medicare fiscal intermediaries,....

Author: Willard, Dianne

Source: Journal of AHIMA

Publication Date: January 1999

This article will summarize some of the major additions and revisions in the 1999 Current Procedural Terminology (CPT). A complete review of all the code and guideline changes -- including the rationale for these changes -- can be found in the November 1998 issue of the CPT Assistant newslette....

Author: Willard, Dianne

Source: Journal of AHIMA

Publication Date: October 2002

This is Part 2 of a two-part article on laboratory services regulations. Part 1, which appeared in the September Journal of AHIMA, dealt with the administrative policies contained in these regulations. Part 2 addresses the specific national coverage decisions that were developed as part of thi....

Author: Wilkinson, Dianne

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2008

According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....

Author: Wilhelm, Carol Ann; Dixon-Lee, Claire

Source: Journal of AHIMA

Publication Date: September 2007

The shift to electronic practice has enlivened the profession and opened doors to new work settings. There remains a critical need for HIM professionals to guide and manage EHR implementations in acute care settings, but the marketplace for HIM graduates is expanding to additional markets such....

Author: Wiley, Sean

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2003

One of the leading causes of stroke and transient ischemic attack (TIA) is carotid artery disease (CAD). With technology changing at such a rapid rate, it is difficult for physicians to decide on the gold standard of care when it comes to visualizing carotid stenosis. This article will explain....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: April 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


We’re seeing a powerful case for the profession to keep privacy and security high on its priority list as we drive forward to a more modernized HIM practice. It’s an area that continues to evolve and challenge us.

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: March 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


How would you spend $262 billion? It’s an eye-popping number, but according to a 2017 report by Change Healthcare, that’s how much in claims are initially denied every year due to insufficient clinical documentation. The r....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: February 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


Recently, the Network for Excellence in Health Innovation (NEHI) released a report on “Health Care Without Walls.” The authors describe “Health Care Without Walls” as “a system that came to people, meeting them where they....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: April 2018

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


Writing my first column in the Journal of AHIMA, I feel like I’m on solid ground. That’s because the topic for this issue, privacy and security, is a universal concern. It’....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: June 2018

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


We don’t often see HIM in the headlines, due to the “behind the scenes” nature of the profession. But we may be seeing that change as patients and patient advocates ma....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: November 2018

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


In late 2017, a Vox.com article titled “The fax of life: Why American medicine still runs on fax machines” had people talking. It described the endurance of fax machines and their us....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: January 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


Navigating change can be exciting—or it can be scary. It can be especially hard to cope when you feel like you’re right in the middle of change and you don’t know how everything’s going to turn out.


In his se....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: September 2018

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


You can tell a lot about an industry by reading its news headlines. Some recent examples illustrate how health information and patient data are becoming part of the transformation of the....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: October 2018

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


This summer, the healthcare industry was reminded of the value of data with an announcement regarding the rules of ICD-10-CM. Coding Clinic published guidance reaffirming that providers can as....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: May 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


In a recent article in the New Yorker, historian Jill Lepore puts predictions about the future of work—and how it may be changed by automation and artificial intelligence—into perspective. While stoking these fears can con....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: July 2019

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


The Journal’s clinical documentation improvement (CDI) issue gives me an opportunity to provide an update on some of the important work AHIMA has been doing in 2019.


As you know, we’ve been undertaking what w....

Author: Wiggs Harris, Wylecia

Source: Journal of AHIMA

Publication Date: October 2019

Taking Action for Health Information

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


Throughout the year we’ve been talking about AHIMA’s transformation. Our aim with this project has been to keep AHIMA relevant in light of today’s trends and to be....

Author: Wieland, LaVonne R.

Source: Journal of AHIMA

Publication Date: October 2000

Having served on a corporate compliance committee, I know HIM professionals can bring a lot to the table. If we are not already acting as the chief compliance officer, as committee members we can assist in identifying compliance issues and more importantly, assist in solving problems of nonco....

Author: Wieland, LaVonne R.

Source: Journal of AHIMA

Publication Date: October 2009

Although many have focused on its health IT provisions, the American Recovery and Reinvestment Act (ARRA) also includes significant privacy provisions. HIM professionals should read through the various provisions and outline how each is going to affect their organization and what they need....

Author: Wiedemann, Lou Ann; Zeisset, Ann M.

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

Publication Date: February 2007

A number of changes to the current CPT codes took effect on January 1, 2007. These changes affect categories I, II, and III codes, with a total of 258 additions, 308 deletions, and 79 revisions. A summary of all additions, deletions, and revisions can be found in appendix B of the 2007 C....

Author: Wiedemann, Lou Ann; Dooling, Julie A

Source: Journal of AHIMA

Publication Date: March 2013

The Nationwide Health Information Network (NwHIN) was originally defined as a “set of standards, services, and policies” by the Office of the National Coordinator for Health IT (ONC) in 2007. Further changes were established in February 2009 as a part of the Health Information....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2007

PEPPER data help facilities compare their Medicare payments with state and national averages. Here’s how to read yours.
Hospitals can take advantage of a report that helps them compare their Medicare reimbursement to state and national averages. What they learn can help them....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2012

Managing healthcare issues today places many HIM professionals in the role of consumer educator. This is especially true when consumers are coping with end-of-life issues. Legal documents are imperative for determining a patient's treatment care wishes, managing requests for information, and f....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2014

Patient matching and identity management has been a critical component of health information management (HIM) since the beginning of the profession, when master patient indices (MPI) were kept on 3x5 inch index cards. HIM professionals don’t have to be told about the challenges with dupli....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2013

Clinical documentation requirements are expected to increase as healthcare systems are challenged with complex new audits, ever-changing compliance rules, and a transition to ICD-10-CM/PCS. All of these initiatives will specifically challenge clinical documentation improvement (CDI) profes....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: April 2010

For most organizations, patient-identifiable source data include data from interpretations, summaries, or notes. These data are usually maintained within the originating department, separate from the HIM department and the health record, and sometimes in a different database. Examples incl....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: June 2014

There is a growing hunger in healthcare today for attaining meaningful data. It is no longer an option to sift through large amounts of data stored in a variety of systems, spending valuable man hours to produce information that can be utilized to make good business decisions. Allowing fo....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: September 2010

Many types of documentation errors can occur in electronic health records (EHRs), such as incorrectly recording the sex of a patient, documenting in the wrong patient record, and incorrectly identifying the ordering physician on a laboratory report.


It is important to addres....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: September 2009

On February 17, 2009, President Barack Obama implemented sweeping healthcare legislation when he signed the American Recovery and Reinvestment Act of 2009 into law. ARRA includes many privacy, security, work force, and health IT provisions that will have a major impact on the healthcare in....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2014

Healthcare has become a data-rich field, and any data rich environment requires the ability to analyze large, complex data sets. The field of informatics provides tools to integrate data, information, knowledge, and wisdom when processing data. Good informatics includes many functions, and....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2013

Clinical documentation is the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has been an ongoing challenge to health informati....