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Establishing a CDI Program: How One Organization Leveraged Nursing and Coding Skills to Improve Clinical Data

Author: Lopez, Barbara A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010


Establishing a clinical documentation improvement (CDI) program is an organization-wide, transformational process that affects a hospital’s culture, reaching across all disciplines and touching every colleague and the way they perform their jobs. Many factors can lead healthcare organizations....

Ten Steps to Selecting a Document Imaging Vendor

Author: Lofton, Sandra

Source: Journal of AHIMA

Publication Date: September 2000


On the road toward an electronic medical record, many organizations will need to evaluate and select document imaging systems. Because of the time and expense involved in these types of implementations, it is critical that the vendor selected be the right one for the organization. The process....

ICD-10-CM Coding Guidance for Long-Term Care Facilities

Author: Liebner, Carole S; Lowery, Amanda L; Maccariella-Hafey, Patricia C; Usher, Joan L; Ward, Maria; Young, Carol

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2015


Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident's clinical conditions.


ICD-10-CM facilitates the collection and....

Demystifying Nonphysician Practitioner Billing

Author: Lich, Denisha

Source: Journal of AHIMA

Publication Date: February 2000


To address today's financial challenges, healthcare facilities are increasing their use of nonphysician practitioners, such as nurse practitioners, clinical nurse specialists, and physician assistants, to provide patient care. As a result, providers need to pay close attention to the employmen....

Where to Begin with Cyber Defense

Author: Lewis, Sharon; McDonald, Kevin B

Source: Journal of AHIMA

Publication Date: April 2015



As data is made more readily available through a growing number of public and private channels, understanding the risks is critical. Patients expect organizations to take the steps required to protect their sensitive and personal information as it is being produced, processed, shared, and....

RAC Primer for LTC Facilities

Author: Leonard, Mary Ann

Source: Journal of AHIMA

Publication Date: January 2010



Last year the Centers for Medicare and Medicaid Services (CMS) began rolling out the Recovery Audit Contractor (RAC) program to all 50 states and all providers, including long-term care facilities. HIM professionals working in LTC facilities need to understand the basics of the program in....

Another Career Avenue for HIM: Coding Compliance

Author: Lemire, Diane

Source: Journal of AHIMA

Publication Date: June 2001




If you're armed with a background in coding and management, a position in coding compliance may be an exciting next step in your HIM career. When I applied for coding compliance manager positions, many positions had been open for a year because facilities could not find individuals w....

House of Delegates Helping Govern HIM Profession

Author: Lemery, Chrisann

Source: Journal of AHIMA

Publication Date: February 2017



The AHIMA House of Delegates (House) is tasked with governing the health information management (HIM) profession as identified in the AHIMA bylaws. The delegates are 231 members from the 52 component state associations (CSAs) and the AHIMA Board of Directors. With the focus having been on....

House of Delegates 2016 to 2017 Year in Review

Author: Lemery, Chrisann

Source: Journal of AHIMA

Publication Date: October 2017



The 2016-2017 YEAR has been busy and engaging for the members of the House of Delegates (House) as we build on the present and prepare for the future, working to guide the health information management (HIM) profession through its work in the healthcare industry.


The House....

Coding Respiratory Failure

Author: Leisch, Monica RHIA, CDIP, CCS

Source: Journal of AHIMA

Publication Date: June 2019


By Monica Leisch, RHIA, CDIP, CCS


Consider the following scenario: a patient is admitted through the emergency department (ED) with acute shortness of breath. The ED notes and history and physical document acute respiratory failure. Blood gases show an oxygen level of 75, pCO2 lev....

Teach Your Attorney Healthcare Contracting

Author: Le, Huan N.

Source: Journal of AHIMA

Publication Date: February 2003


Medicare regulations, HIPAA compliance, and the threat of litigation have made it impossible to draft a one-page healthcare contract. Standard language alone now extends to up to four pages. It’s a good idea to hire an attorney for contract negotiations and drafting, but even then, you mi....

Is Your NPP Your Best Defense?

Author: Lee, Michael R.

Source: Journal of AHIMA

Publication Date: April 2003


In the event of a privacy-related legal challenge, the content of your organization’s notice of privacy practices (NPP) will be a focal point for both plaintiff and defense arguments with respect to the protected health information (PHI) disclosure activities of your organization. Is your....

Research Lessons: Designing a Study for a Clinical Setting

Author: Lee, Frances Wickham; Wager, Karen A.; White, Andrea Weatherby; Ward, David M

Source: AHIMA Foundation | Journal of AHIMA

Publication Date: April 2004


Conducting a study in a clinical setting is a study in itself. Here, researchers share four important lessons learned.
When research moves from the laboratory to the field, it faces unique challenges. A research team that included the authors discovered the challenges of a busy clinic fi....

Bringing Physician Practices into the HIM Fold: Guidance on Making a Smooth Transition and Ensuring the MD/Hospital/HIM Relationship Remains Mutually Beneficial

Author: Lee, Christine

Source: Journal of AHIMA

Publication Date: April 2016



According to the American Medical Association (AMA), physician practices continued a slow but steady transition toward hospital ownership in 2015. In their July 2015 study, the AMA reported a decrease in physician-owned practices alongside a continual increase in physicians working direct....

Softer Skills Key to Leadership Position

Author: LeBlanc, Madonna M.

Source: Journal of AHIMA

Publication Date: June 2003


You landed the job. Your first day is a week away and you’ve left yourself enough time to recharge your batteries before jumping into a new adventure. To best position yourself for success as a new manager, think back to the human resources and personnel management courses you’ve tak....

DRG Changes for FY 2006

Author: Leary, Renee; D'Amato, Cheryl

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2005


The final Medicare DRG changes for fiscal year (FY) 2006, which were published in the August 12, 2005, Federal Register, include 16 new DRGs, the deletion of 10 existing DRGs, and numerous changes to DRG assignments of current diagnosis and procedure codes. These DRG changes, along with other....

10 HIPAA tips for the physician office

Author: Lazarus, Steven S.

Source: Journal of AHIMA

Publication Date: February 2001




The Health Insurance Portability and Accountability Act (HIPAA) and its accompanying regulations present opportunities and concerns for physician practices. Many of the HIPAA requirements and issues are the same for physician practices as they are hospitals and other providers. Howe....

Bringing Patients and Their Information Together

Author: Lane, Pamela

Source: Journal of AHIMA

Publication Date: October 2017



In July, AHIMA unveiled the first-of-its kind Patient Request for Health Information Model Form, which you can find online. Developed by two AHIMA practice councils, the form is designed to be a plain-language document that explains to consumers their right to access health information fro....

Embarking on the Road of New Beginnings

Author: Lane, Pamela

Source: Journal of AHIMA

Publication Date: January 2018

By Pamela Lane, MS, RHIA, interim chief executive officer

January is the month of new beginnings. It’s a great time to make lists, clean out cabinets, and take stock of what’s ahead of us. Sometimes the road ahead is clear… other times, we need to make educated guesses ab....

Change, Challenge, and Opportunity

Author: Lane, Pamela

Source: Journal of AHIMA

Publication Date: September 2017



Although change can be difficult, it always comes with opportunity. As members of the ever-evolving HIM community, we are uniquely prepared to meet the challenges that come with change as we continue to move toward reaching our profession’s strategic goals.


As interim....

Communities of Practice: Harnessing the Power of Knowledge

Author: Lane, Laura

Source: Journal of AHIMA

Publication Date: June 2002


AHIMA's Communities of Practice was designed with members's needs in mind: up-to-date industry news, links to helpful resources, and, most importantly, solutions and ideas from peers. Already, the CoP is an indispensable tool. Read how AHIMA members are making it work for them.
Imagine a....

Distance Learning: Getting Closer all the Time

Author: Lane, Laura

Source: Journal of AHIMA

Publication Date: June 2001




In recent years, distance learning has become an increasingly viable option, and HIM students have benefitted. How does this new way of learning work, and is it working for students? Some instructors and students tell their success stories.
Five years ago, the concept of dista....

Legacy of the ‘First Lady of HIM’ Lives on through Grace Award: AHIMA Founder Grace Whiting Myers’s Work Set Stage for Award Winners to Thrive in HIM

Author: Land, Daniel

Source: Journal of AHIMA

Publication Date: October 2017



The transient nature of memory is greatly influenced by the passage of time, and successive generations often possess only a vague knowledge of what came before them. Thus is the case of Grace Whiting Myers. Many health information management (HIM) professionals today know little about the....

HIM’s Vital Role in Healthcare Ratings

Author: Land, Daniel

Source: Journal of AHIMA

Publication Date: October 2018






By Daniel Land, RHIA, CCS


Coded data has a long and influential life span, and its importance goes beyond that of just today’s revenue cycle. It is important for health information management (HIM) professionals to understand the micro and macro purposes of cod....

Heart of the Matter: ICD-10-PCS Cardiac Coding

Author: Land, Daniel

Source: Journal of AHIMA

Publication Date: January 2017



A robust knowledge of anatomy and cardiac surgery techniques, a comprehensive understanding of coding guidelines, and an eye for precision are key components of correct ICD-10-PCS cardiac coding.


This article will review ICD-10-PCS Official Guidelines for Coding and Reportin....

Making the Clerical Transition to e-HIM

Author: Lambton, Karanne

Source: Journal of AHIMA

Publication Date: May 2005


As we move forward with the developing electronic health record (EHR), the emphasis on changing work processes, increasing productivity, and eliminating many paper-driven tasks may leave clerical staff fearful of an uncertain future. Helping clerical staff understand how their current skills a....

EHRs in the Cloud: Contract Protection for a Rainy Day

Author: Lamar, Marilyn

Source: Journal of AHIMA

Publication Date: July 2011


Cloud computing has been suggested as a cost-effective way to use electronic health records (EHRs), particularly for small providers that may not have an IT staff. Cloud-based EHRs store patient health records and the EHR software on computers operated by the EHR vendor.

The healthc....

Making the Call for Patient Experience: Using Health IT to Address Gaps in Patient Data-Sharing, Communication, and Interoperability

Author: Labow, Kim

Source: Journal of AHIMA

Publication Date: August 2016



Interoperability and integration within the health IT landscape remain high priorities for providers, patients, and technology firms. Interoperability in health IT holds the promise of more satisfied patients, providers, and health information management (HIM) professionals. But approachi....

Performance Improvement for Documentation

Author: Labak, Carol

Source: Journal of AHIMA

Publication Date: October 1998


We've all seen it before: that look of bewilderment on a physician's face when a discussion about documentation arises. While this is not the first incidence of this discussion between the physician and the health information manager, neither is it the first time the HIM professional ....

Coding Dementia

Author: Laakso, Roz

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2004


Dementia is defined as “a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living.”1 Alzheimer’s disease is an age-related, irreversible brain disorder that occurs gradually and results in me....

Preparing for ICD-10-CM in Physician Practices

Author: Kuehn, Lynn

Source: Journal of AHIMA

Publication Date: August 2009




What will change under ICD-10-CM, and what must be done to prepare? This is the year for physician practices to get their ducks in a row: become informed, assess their IT and training needs, and make a plan that leads to the October 1, 2013, deadline.



On September....

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