Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2002

The AHIMA Policy and Government Relations (P&GR) staff in Washington receives a number of questions concerning how a particular proposed law, legislation, or possible regulation will affect the management of an HIM department, coding section, or other functions that are typically performed by....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2005

In January we discussed how AHIMA members can get involved in local health information and advocacy projects. In February we examined 2004 federal legislative activities. This month we will review AHIMA’s federal agenda for 2005.
The Ball Is Rolling on NHIN

In November the....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: September 2003

Through your ingenuity and your innovation, the people in this room can transform healthcare in America.” With these words, Department of Health and Human Services (HHS) Secretary Tommy Thompson opened the first conference on a national health information infrastructure (NHII) in late Jun....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2011

In early December the President's Council of Advisors on Science and Technology (PCAST) released "Report to the President Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward." The council's path represents some significant departu....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: February 2010

Several 2009 federal regulations describe new requirements and compliance deadlines for this year, including breach notification reporting and testing 5010 transaction standards. HIM professionals should be aware of these due dates to ensure their organizations’ compliance.
Breach Notifi....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: November 2012

The Centers for Medicare and Medicaid Services (CMS), along with the Office of the National Coordinator for Health IT (ONC), formally released three final rules around the the time of the Labor Day holiday. Appropriately enough, the arrival of these final rules spells out much work ahead for t....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2004

In November 2003 the National Committee on Vital and Health Statistics (NCVHS) agreed to recommend that the secretary of Health and Human Services (HHS) adopt the ICD-10-CM and the ICD-10-PCS classification standards as replacement for the ICD-9-CM classification currently used in the US.

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: April 2012

There has been a great deal of activity in the last few months on ICD-10-CM/PCS and other HIM issues. Here is a review of the latest news and events related to ICD-10, as well as updates on AHIMA's other advocacy issues.
ICD-10's Status

The road to ICD-10 has been long and windi....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: September 2004

Without introduction, Department of Health and Human Services Secretary Tommy Thompson brought the room to a hush, announcing that the healthcare industry had reached its “tipping point” and now was the time to begin the industry’s movement into the decade of electronic heal....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2000

The availability of patient health data continues to be a hotly debated topic on Capital Hill. Noting that the "lack of complete and comprehensive PMRI (patient medical record information) is a major constraint on the ability of our healthcare delivery system to enhance quality, i....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: April 2011

Data stewardship is a hot topic. As this issue went to press, the Department of Health and Human Services was expected to publish a notice of proposed rulemaking on accounting of disclosures, an expansion of the HIPAA requirements mandated by the HITECH Act.

Rulemaking was also expe....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: July 2010

As this issue goes to press, healthcare remains unsettled, waiting on the publication of key rules related to ARRA and the HITECH Act.

Until these rules appear, providers cannot assess with any certainty their willingness and ability to apply for the meaningful use incentive program....

Author: Rockendorf, Betty

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 09, 2017

Regarded as a landmark bill, the 21st Century Cures Act was passed into law in December of 2016. It’s aims are lofty and it covers a lot of ground, including transparency, breaking down silos in healthcare, interoperability, and an electronic health record (EHR) reporting program, as....

Author: Rockendorf, Betty

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 10, 2016

Ministry Door County Medical Center (MDCMC) is a 25-bed critical access hospital in Sturgeon Bay, WI that offers many services, from inpatient and outpatient care to rehabilitation services, emergency department and urgent care, six clinics, and a skilled nursing facility. So, how doe....

Author: Robinson, Steven

Source: Journal of AHIMA - website

Publication Date: December 29, 2016

Clinical documentation programs’ success is a result of the healthcare team keeping a constant vigil on communication while operationalizing outcomes and instilling provider support. Patient care is largely dependent on accurate communication among the healthcare provider team. In a....

Author: Roberts, Rosemary; Innes, Kerry; Walker, Sue; Scott, Peter

Source: Journal of AHIMA

Publication Date: October 2004

With major changes under way worldwide, the evolving roles and relationships of classifications and terminologies are uncertain. But the future lies in collaboration, not competition.
Classifications and clinical terminologies have coexisted for decades. Both use clinical language, but t....

Author: Robertson, April D.

Source: Journal of AHIMA - website

Publication Date: May 25, 2010

ARRA's modifications of HIPAA have shaken up many areas of HIM practice, including off-site records storage, where facilities often have indexed their inventory no further than by box.


Today’s HIM departments face a montage of mediums: electronic health records, paper health....

Author: Robb, Deborah; Owens, Lori

Source: Journal of AHIMA

Publication Date: March 2013

According to the Centers for Medicare and Medicaid Services, evaluation and management (E/M) services accounted for $28 billion in Medicare Part B payments during a one-year period.1 And of these, 8.4 percent were billed at the wrong level-either too high or too low. Chasing these potentia....

Author: Robb, Deborah

Source: Journal of AHIMA

Publication Date: January 2009

Medical practices are facing changes in information management and technology. HIM professionals can help manage today’s needs and tomorrow’s transition to electronic systems.

The coming years do not bode well for the status quo at medical practices. In late 2008 the Medi....

Author: Roat, Lisa

Source: Journal of AHIMA

Publication Date: January 2014

Healthcare data is being touted as a means to improve population health management. It is also feeding public competitive market reporting for providers and facilities. The integrity of the clinical data being reported is essential to supporting and improving the quality of care to patien....

Author: Roadman, Charles H. II

Source: Journal of AHIMA

Publication Date: May 2000

As we prepare to address the challenges and opportunities ahead, providing compassionate, quality care to residents in long term care settings must remain our top priority. The 21st century is an opportunity for the long term care community to work on behalf of elderly and disabled cit....

Author: Roach, Michael C.

Source: Journal of AHIMA

Publication Date: February 2001

If your organization is covered by HIPAA, do you know what’s expected of you-and of your vendors-with regard to privacy of health information? To make sure your organization is in compliance, contracts with business partners will need careful review. The author offers an overview of....

Author: Roach, Daniel R.

Source: Journal of AHIMA

Publication Date: May 2001

In the 1970s, the defense budget consumed the largest share of the federal budget. Concerns about both the size and efficiency of the defense bureaucracy triggered a massive crackdown on federal contractors who had either intentionally or inadvertently failed to follow the Department....

Author: Ritter, Jennifer

Source: Journal of AHIMA - website

Publication Date: May 01, 2016

An often discussed theme in the health information management (HIM) profession as well as the 2015 AHIMA Convention is the ability for facilities to grow their own coding professionals. As coding resources continue to be scarce, having an in-house coding training program on any scale is a....

Author: Rippen, Helga E.; Yasnoff, William A.

Source: Journal of AHIMA

Publication Date: May 2004

Linking community-based health information sources into a national network would improve care and save money. A collection of public andprivate organizations have begun sketching the plans.
Some of the most serious challenges facing healthcare today—medical errors, inconsistent qu....

Author: Rinehart-Thompson, Laurie A.

Source: Journal of AHIMA

Publication Date: July 2009

HIM professionals are familiar with the HIPAA privacy rule, the federal law that serves to safeguard protected health information. However, they may be less familiar with the Family Educational Rights and Privacy Act (FERPA, 20 USC 1232g; CFR Part 99), which is also relevant to managing the pr....

Author: Rinehart-Thompson, Laurie A.

Source: Journal of AHIMA

Publication Date: October 2008

Financial identity theft has become ubiquitous in our global society. Its consequences are familiar, and fear of its repercussions has created a widespread reliance on credit bureaus for protection. According to the Federal Trade Commission, 8.3 million Americans were reportedly affected by fi....

Author: Rihanek, Theresa; DeVault, Kathryn

Source: Journal of AHIMA

Publication Date: May 2012

Many healthcare organizations use historical coded data in governance and planning activities, contracting, quality improvement, research, and trending. The upcoming implementation of ICD-10-CM/PCS will require organizations to identify the types of coded data that will require conversion in o....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2014

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


In this article, the Journal of AHIMA continues the 10-part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This article will describe three....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2013

Updates have been released for the 2013 ICD-10-CM code set, approved by the ICD-9-CM Coordination and Maintenance Committee, as well as the 2013 ICD-10-CM/PCS updates maintained by the Centers for Medicare and Medicaid Services (CMS). There were minimal changes to the draft code sets in li....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2014

With this article the Journal of AHIMA concludes its 10-part Coding Notes series focusing on the 31 root operations of ICD-10-PCS. This installment focuses on three root operations in the Medical and Surgical Section that define other objectives:

• Fusion
• Alteration
• Creation

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2012

The final rule for calendar year 2012 Hospital Outpatient Prospective Payment System (OPPS) was released on November 30, 2011. The rule went into effect for outpatient hospital-based services January 1, 2012.

This article outlines the updates in the final rule.
Financial Impact....

Author: Rihanek, Theresa

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

Publication Date: June 2014

Traumatic brain injury (TBI) has received considerable attention by the media recently, especially bringing attention to the prevalence of TBI in sports-related activities. According to the Centers for Disease Control and Prevention (CDC), “A TBI is a bump, blow or jolt to the head o....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012

Limited updates were made to ICD-10-PCS for fiscal year 2012 as set forth under the partial code freeze established by the ICD-9-CM Coordination and Maintenance Committee.1 The freeze is intended to aid the transition to the new code set by limiting updates for 2012 and 2013 to essential chan....

Author: Rihanek, Theresa

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2013

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


In the Journal of AHIMA's continuing Coding Notes series focusing on the 31 root operations of ICD-10-PCS, this article will focus on the definitions of four root ope....

Author: Richter, Lori L

Source: Journal of AHIMA

Publication Date: October 2017

Regulatory developments in the healthcare industry, including the Health Information Technology for Economic and Clinical Health (HITECH) Act, accountable care organization provisions, and the “meaningful use” Electronic Health Record (EHR) Incentive Program, have contributed t....

Author: Richmond, Rosalind; Chapman, Claudia; Cook, Jane; Levy, Brian

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2005

The health information technology (HIT) field can provide HIM professionals with many career opportunities at software and content companies. HIT roles require highly developed content analysis skills, including abstracting, coding, documentation compliance, and utilization review. The availab....

Author: Richey, John

Source: Journal of AHIMA

Publication Date: January 2001

After examining their CDM management processes, HIM professionals, along with clinical and support departments, redesigned and automated several practice aspects with successful results. (FORE Best Practice, AHIMA Foundation)

Author: Richey, John

Source: Journal of AHIMA

Publication Date: July 2011

Periodic audits of the charge description master are a key piece of an organization's compliance program. But they can do more than verify compliance-they can help improve the business.

The Centers for Medicare and Medicaid Services requires that all healthcare entities develop and i....

Author: Rhodes, Harry B.; Scichilone, Rita A

Source: Journal of AHIMA

Publication Date: May 2009

Current health information exchange (HIE) initiatives continue to develop data exchange models and adopt standards required to support them. Their progress is complicated by the independent nature of the initiatives and a lack of common agreement for data content.

Metadata registries....

Author: Rhodes, Harry B.; Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2010

This month the Journal introduces a new “Working Smart” column titled “ARRA on the Job,” offering HIM professionals practical guidance on interpreting, planning for, and implementing provisions of the American Recovery and Reinvestment Act.



....

Author: Rhodes, Harry B.; Mon, Donald T.; Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: January 2004

2003 was a busy year for the electronic health record. And if the federal government and the HIM industry have their way, 2004 will only get busier.
In 2003 a number of electronic health record (EHR) issues active in the previous decade all intersected at the same time. Behind the synchro....

Author: Rhodes, Harry B.; Hughes, Gwen

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2003

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Rhodes, Harry B.; Hughes, Gwen

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2003

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

Author: Rhodes, Harry B.; Dougherty, Michelle

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2003

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

Author: Rhodes, Harry B.; Dennis, Jill Callahan; Roach, Michael C.

Source: Journal of AHIMA

Publication Date: April 2004

In today’s complex transcription environment, outsourcing is a standard business practice that requires managing some privacy risk.
Contract medical transcription has increased dramatically in recent years, and the issues surrounding it are becoming more complex, but the industry it....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: November 1998

Recently, I had the opportunity to visit with two longtime AHIMA members: Earline H. Earhart, RRA, a member since 1937, and Mildred P. St. Leger, RRA, who joined in 1953.

Earhart became a member under the organization's original name—the Association of Record Libraria....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: January 2016

All of the current excitement about the potential of mobile technologies and patient engagement opportunities comes at a time when many providers are frustrated about their electronic health record (EHR) systems. Struggling against poor EHR system usability, a lack of interoperability, and....

Author: Rhodes, Harry B.

Source: Journal of AHIMA - website

Publication Date: August 2013

A recent federal study of the potential unintended consequences of electronic health information exchange revealed several characteristics that, if not addressed soon, could lead to data and privacy issues.


The construct that health IT undertakings can hav....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: January 2017

Research dating back to the 1970s has verified the dominant influence of social, economic, and environmental determinates in the maintenance of health and well-being. Working from a set of values that focus on overall health, quality of life, and well-being, population health management en....

Author: Rhodes, Harry B.

Source: Journal of AHIMA - website

Publication Date: July 19, 2011

Low-level technology risks continue to be the leading cause of reportable data breaches, according to a review of the Office for Civil Rights’ security breach statistics for breaches affecting more than 500 patients.


An analysis of OCR breach statisti....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: February 2013

Health information technology systems have supported the administrative functions of healthcare for more than a decade. Historically, these healthcare administrative systems primarily focused on performing fiscal transactions or supporting key ancillary departments. Widespread use of elect....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: September 2014

A rapidly aging global population in many industrialized countries accompanied by an increase in chronic diseases and the high cost of managing such diseases has led many to turn to a technological solution to ease the burden on healthcare professionals and provide useful tools to the elde....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: April 2007

Despite the proliferation of personal health record (PHR) technologies and services, only a small portion of the population uses them.1 Indeed, some observers have expressed concern that PHRs will never catch on with the general public.2 Yet when surveyed, consumers remain enthused about....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: February 1998

Q: I have been asked to head up a committee assigned the task of selecting the hardware and software applications that are to become the platform for our organization's computerized medical record (CPR). Our committee is composed of representatives of all the "end users" of the CPR. The vastne....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: February 2006

Although we’ve made progress in advancing the EHR initiative, we continue to struggle with data content management. The data content management crisis is not unique to healthcare, according to Ruth Stanat, global business consultant. All businesses—not just healthcare—are &l....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: June 1998

Edward I. Koch, former mayor of New York City, is known for asking, "How am I doing?" Koch, of course, was speaking of the positive progress of his administration. But he could have just as easily been talking about the state of performance measurement in healthcare today. Even though quality....

Author: Rhodes, Harry B.

Source: AHIMA Q and A | Journal of AHIMA

Publication Date: July 1998

Q: My facility recently purchased a new computerized patient record application. I am concerned about the system's established protocol for making corrections and/or addenda to entries in the computerized patient record. The way the application is currently written, the original entry can be d....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: July 2006

On a recent trip out of town, I had a very enlightening conversation with a cab driver on the way to the airport. Even though it was early in the morning, the driver was extremely talkative and initiated a conversation about what I did for a living. This immediately led to direct questions rega....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: April 1996

Shortly after I accepted my first position as director of medical records, I began to develop time management skills and created a "to do" list. One item on my list that got very little attention was my department's disaster plan. Working in a 55-bed hospital in a peaceful eastern Texas commu....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: July 1997

The ability to provide timely, relevant, and accurate in-formation to the healthcare decision maker at the point of care is a critical success factor for any provider. For enterprises that operate in extremely competitive healthcare markets, the ability to meet this challenge could mean the d....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: September 1998

Q: My facility will begin imaging its paper medical records as part of the migration toward a computerized patient record. I am a member of the planning committee that is responsible for preparing the RFP and seeking out possible vendors. I have heard of optical imaging but have never had the....

Author: Rhodes, Harry B.

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2001

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

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: June 2001

The medical transcription industry is a $10.6 billion market nationally, according to a recent study of trends and measures. And, like other sectors of the healthcare industry, transcription continues to evolve along with available technologies.

These and other facts make u....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: January 2001

We live in the so-called Information Age, but we should actually refer to it as the Data Age. As a nation, we are data rich and information poor.

The dilemma of holding large amounts of valuable data but little useful information is not unique to healthcare. The inability....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: November 2007

As noted in the article “Confusion Continues over HIPAA Minimum Necessary Standards,” (J AHIMA, Nov-Dec 2007) the state-level research under the HISPC project identified a number of privacy and security barriers to health information exchange (HIE). Several reports came from this p....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: July 2005

Establishing private-sector certification of health IT products is one of the key actions outlined by the Office of the National Coordinator for Health Information Technology in the report “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Heal....

Author: Retterer, John; Casto, Brian

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2004

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Reno, Danielle; Kersten, Sandra K.

Source: Journal of AHIMA

Publication Date: May 2013

Information governance is becoming a priority for healthcare organizations. Today's healthcare organizations invest in information technology at unprecedented rates, and IT generates more data than ever before. Stakeholders expect healthcare organizations to use health IT to bring improvem....

Author: Reiter, Autumn BSN, RN, CCDS, CDIP, CCS; Dixon, Lori A. MSN, RN-BC, CDIP

Source: Journal of AHIMA

Publication Date: July 2018

A Case Study in CDI Expansion at an 11-Hospital Health System


By Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, and Lori A. Dixon, MSN, RN-BC, CDIP


Clinical documentation improvement (CDI) programs have proven they are worth t....

Author: Reich, Kimberly A. Baldwin-Stried

Source: Journal of AHIMA

Publication Date: May 2012

Paper-based and electronic record keeping systems each record valuable information about a patient's medical care. Electronic systems, however, capture something more-they record information about the record itself.

This "information about the information," called metadata, has caug....

Author: Reich, Kimberly A. Baldwin-Stried

Source: Journal of AHIMA

Publication Date: October 2007

The e-discovery amendments to the Federal Rules of Civil Procedure (FRCP) and the Uniform Rules Relating to the Discovery of Electronically Stored Information (approved in August 2007 at the National Conference of Commissioners on Uniform State Laws) are creating new roles and responsibil....

Author: Reich, Kimberly A. Baldwin-Stried

Source: Journal of AHIMA

Publication Date: October 2010

While healthcare facilities are familiar with the process of discovery-often in the form of subpoenas-many are just seeing their first e-discovery requests. Do e-discovery requests differ from subpoenas, and do they require different responses?

The answer is not a simple yes or no. I....

Author: Regard, Dan; Hedges, Ron

Source: Journal of AHIMA

Publication Date: May 2015

As the healthcare industry moves into an electronic health record (EHR)-only environment, practitioners increasingly have to “search” electronically stored information (ESI). They may need to do this to find, for example, the date on which a patient was given a specific drug and the dosag....

Author: Reeves, Mary G; Bowen, Rita K.

Source: Journal of AHIMA

Publication Date: October 2012

Many individuals have a high degree of confidence in the validity and integrity of data if it comes from a computer. When they encounter data in this form, the assumption is the data has been vetted, scrubbed, and signed off by a reliable source. In truth, however, this is rarely the case.