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Developing and Defining a Legal Health Record Policy

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....

HIM Spin on the Revenue Cycle

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....

Are Ethics Guiding Your Workplace?

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....

Using CPT Modifier -25 for Professional Billing

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....

Release of Information: the Basics

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....

Preventing Risk in Long-term Care: Lessons Learned

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....

Health Record Banking: an Emerging PHR Model

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....

Reaffirming Your HIPAA Compliance Efforts

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....

Privacy and Security: Are Two Hats Better Than One?

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....

The Pros and Cons of Getting ‘App-y’

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....

New Focus on Process and Measure: Raising Data Quality with a Standard Coding Workflow and Benchmarks

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....

New Changes De-Spookify Modifier -59

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....

Can You Manage Managed Care?

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....

Getting the Next Generation to Work for You

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....

Standards for Safety, Security, and Interoperability of Medical Devices in an Integrated Health Information Environment

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....

Reporting Social Determinants of Health

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....

Making a Proactive Transition to APCs

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....

1999 CPT Revisions

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....

Coding Preventive Care Services

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....

New Blueprint for HIM Education

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....

Choosing Modalities for Carotid Stenosis

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....

Tackling the Modern Privacy Challenge

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.

Keeping Our Eye on the Revenue Cycle Ball

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....

Opportunity Behind the Headlines

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’....

Inside Look: Navigating Change with Courage

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....

Taking the Next Step Toward the Future

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....

Status Check on CDI Transformation

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....

Taking Action for Health Information

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....

Understanding Different Healthcare Legal Documents

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....

Will the Real John Smith Please Stand Up?

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....

Using Clinical Photos in EHRs

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....

Deleting Errors in the EHR

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....

ARRA FAQs

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....

Informatics Harnesses Healthcare’s Wild, Rich Data

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....

Using CDI to Meet Federal Quality Measures

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....

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