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SNOMED Takes the Next Step

Author: Kudla, Karen M.; Blakemore, Margo

Source: Journal of AHIMA

Publication Date: July 2001


Healthcare terminologies SNOMED and the Read Codes have been around for a long time. Now, a new terminology combining the two promises to take the industry one step closer to realizing the vision of an electronic patient record. Here’s a sneak peek at SNOMED® CT.
As technology e....

Cost of Converting Small Physician Practices to ICD-10 Much Lower than Reported

Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.

Source: Journal of AHIMA - website

Publication Date: November 2014




The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....

Off-Site Coding Success Story

Author: Kramer, Lynette; Meeks, Richard

Source: Journal of AHIMA

Publication Date: January 2000


If you asked HIM professionals about key success factors that substantially impact timely and accurate coding, three of the most common answers might be:
availability of the record immediately after the patient visit
availability of the complete record....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: September 2014



Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: July 2014



Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....

Internal Radiation Brings Hope to Prostate Cancer Patients: With Brachytherapy Treatment Come New HCPCS Codes

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003


In 2003, the American Cancer Society estimates that 220, 900 men will be diagnosed with prostate cancer in the US, making it the second leading cause of cancer deaths in men.1 Today in the US, patients with prostate cancer have access to less invasive surgical cancer treatment plans. This arti....

ICD-10-CM Update 2012

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2012


This article highlights the 2012 ICD-10-CM update as approved by the ICD-9-CM Coordination and Maintenance Committee. The 2012 ICD-10-CM update includes the addition of new codes that already exist in ICD-9-CM, implemented in the FY 2012 ICD-9-CM update or recently incorporated into ICD-10 th....

Coding Diabetes Mellitus in ICD-10-CM

Author: Kostick, Karen M.

Source: Journal of AHIMA - website

Publication Date: May 16, 2012



ICD-10-CM diabetes codes complement present medical science—separate type 1 and type 2 diabetes category codes and body system combination codes represent a major improvement over ICD-9-CM.  Diabetes mellitus codes are no longer classified as controlled or uncontrolled. Instead ICD-10....

Staying Alert on Sleep Medicine Coding

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2011


The field of sleep medicine is rapidly expanding, and its coding and reimbursement are attracting more attention from federal and state governments, public health organizations, scientists, payers, auditors, the transportation industry, and healthcare consumers. Emerging topics in the area of....

Coding in Critical Access Hospitals

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2009


National health policy has been increasingly responsive to the healthcare needs of rural residents and providers. Rural America has a large percentage of the nation’s Medicare population, and this percentage continues to grow as residents born in the Baby Boomer generation begin to retir....

Coding Diabetes Mellitus in ICD-10-CM: Improved Coding for Diabetes Mellitus Complements Present Medical Science

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2012


Results of a recent coding and clinical documentation pilot study indicate that the ICD-10-CM coding classification changes made for diabetes mellitus have significantly improved coding for this disease. The results of the study noted that although a few ICD-10-CM "unspecified" diabetes codes....

Patient’s Role in Ensuring Legal EHR Data Integrity

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2011


For nearly 40 years I have served as an HIM and health IT professional, but for my entire life I have been a healthcare patient. My understanding of the processes that create medical records has helped me identify system and human mistakes in my own records. Consequently, I know well that the....

Too Many Coding Systems, Too Much to Do: Different Clinical Classification and Clinical Terminology Systems Uniquely Impact IT, Quality Management

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2014



The notion of managing and being accountable for the health status of defined populations requires much more sophisticated clinical data collection methods and skills than most healthcare organizations have today. Numerous “coding systems” have been used for decades to successf....

Four Critical Steps to Choosing an Auditor

Author: Knutson, Julie

Source: Journal of AHIMA

Publication Date: June 2000


In this compliance-driven age, many organizations are seeking the services of outside firms or "auditors" to conduct record reviews. But the proper selection process is often short-circuited by time considerations. Given the cost of audits, however, even if you'....

Skilled Knowledge Workers in Short Supply

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2008


This is a demanding time for coders. MS-DRGs and present on admission requirements would have been challenging on their own; however, both came at virtually the same time, straining coders already stretched to meet their job requirements.

Recruitment and retention of coding staff is....

Benchmarking For a Burst of Creative Thinking

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: May 1999


It is precisely when an old paradigm crumbles and the new one is not yet in place that we get great bursts of creative thinking."1 I'm convinced that this is such a moment for HIM.

The old paradigm of a static, facility-bound record is, unfortunately, still the norm,....

HIM Enters an Era of “Powerful Possibilities”

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2009


Discussing his enthusiasm for the HIM field, he said, “I am fortunate to be coming into the field at this time... I missed all the boring stuff and am getting in it when things are really happening.” I laughed and assured him that those of us who have been around for a while have n....

Transforming Healthcare: the Time for Change is Now

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2005


In recent remarks to Connecting for Health’s steering group, David Brailer, MD, PhD, the national health information technology coordinator, noted that if this is the decade of health IT adoption, 2005 could well turn out to be the year of “maximum flexion.” Brailer urged the....

Re-examining HIPAA Six Years Later

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2008


It was six years ago this month that the HIPAA privacy rule went into effect. For many in healthcare, compliance has become a routine part of doing business. But for too many, the current regulations remain poorly understood and poorly implemented. All the while, the environment has been chang....

HIM Leadership Challenge...for the Next 80 Years!

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2008


As AHIMA celebrates its 80th anniversary this month, we focus on the significant challenges that lay ahead. Though most emphasis today is on acquiring and implementing health IT, this will give way to an emphasis on managing and creating value from an organization’s information assets.

Data Content Standards: the Nexus of HIM Practice

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2006


One of AHIMA’s key goals for 2006 is to promote quality and safety through standards for data content and documentation. Quality and safety require that the right information is available at the right time to support patient care and health system management decisions. Gaining consensus....

Coding at a Crossroads

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2005


It has been nearly 25 years since ICD-9-CM codes became the basis for hospital inpatient payment. Over the years, code-based payment has extended to virtually all healthcare services, and CPT and HCPCS code sets have been added to the mix. We now use software tools to facilitate coding and hav....

New Ways to Work

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2007



The demand for competent HIM professionals is at an all-time high. That’s true for traditional employers as well as for organizations that didn’t even employ HIM professionals 20 or even 10 years ago. Remember, about 50 percent of HIM professionals now work for hospitals, down....

Accuracy Imperative: New Stakes for Coded Data

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2007


The requirements for coding accuracy have always been high, even before coding became the basis for reimbursement. HIM professionals have championed improvements to medical record documentation and classification systems essential to accurate coding, and the profession has also led the wa....

PHRs—The Hook to Engage and Inform Consumers?

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: June 2008


The Internet, cell phones, and other technologies have forever changed how we communicate and gain access to information. We manage and track our finances and medical and other benefits online. Some are even fortunate enough to be able to communicate with their physicians through secure e-mail....

Patients' Perspective: a Growing Information Gap

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: September 2003


For a moment, forget that you are a health information manager. Instead, think of yourself as a person seeking healthcare. Are you frustrated when you have to repeat medical history information when you visit a specialist in your clinic? Do you search for lab results jotted on the back of an e....

Standardized Data: the Difference for EHR Solutions

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2005


This month, Dallas will be the center of the health IT world as HIMSS hosts its 2005 trade show, of which AHIMA again will be a sponsor. We look forward to learning how electronic health record (EHR) solutions are maturing and how provider organizations are succeeding in improving patient care....

New Expedition Begins: Privacy Under HIPAA

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2001




While all regulations under the Health Insurance Portability and Accountability Act (HIPAA) directly affect how we manage health information, the privacy regulations are central for HIM professionals. It has always been our privilege to serve as patient advocates for information priv....

Managing the Unintended Consequences of EHRs

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: August 2009


Broadly deployed health information and communication technology is crucial to every aspect of healthcare reform. Financial assistance through ARRA should speed EHR adoption via financial incentives and other forms of support. This, in turn, will cause unintended and unforeseen consequences. <....

Building an EHR Learning Community

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 2009


It is fitting that the theme for the last issue of 2009 is electronic health records (EHRs). Nearly 20 years have passed since AHIMA provided financial support for the publication of the Institute of Medicine’s Computer-Based Patient Record: An Essential Technology for Healthcare.
<....

E-HIM: Our Commitment to Lead

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2005



For the past two years, AHIMA’s report “Vision of the e-HIM® Future” has served as a touchstone in our rapidly adapting field. When published in 2003, the report painted a picture of evolving HIM roles and practice in a healthcare industry moving from paper to an elec....

AHIMA Welcomes the HIM World Community

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2004

We’re thrilled to host the 14th Congress of the International Federation of Health Records Organizations (IFHRO), the long-awaited gathering of HIM professionals from 30 countries, in Washington, DC. IFHRO was established in 1968 to advance professional practice, assist developing countries t....

New Languages of Medicine: Inform and Influence Now

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2004


Many healthcare decision makers do not understand the many ways coded data are used throughout healthcare and the urgency of moving forward with ICD-10. They also are unable to visualize how reference terminologies such as SNOMED CT are used in electronic health record systems and how these te....

EHR and Interoperability: Reaching the Tipping Point

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: September 2004


The drive to create an interoperable health information system accelerated during the summer. Four major initiatives came together in the summer heat, and our nation is poised to move from talk to action about health information infrastructure. We have reached the tipping point.
Nationa....

States—Laboratories for E-Health

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: May 2008


States are often described as “laboratories of democracy.” Today they are also serving as laboratories for e-health. Virtually every US state is pursuing IT initiatives to improve the safety, quality, and affordability of healthcare. Leadership is coming from governors’ offic....

Recipe for Information-based Healthcare

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2006


Creating an information-based health system is like following a recipe. First, include essential ingredients, such as accurate and complete clinical documentation organized in architectures that enable access and interoperability. Then add protocols, terminologies, and classification systems to....

EHR Progress: Reaching the Tipping Point?

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: June 2007


There are many forecasts about how long it will take for EHRs to be the norm across healthcare. There is talk of a tipping point where penetration and momentum are great enough to move the rest of the industry. But just when will EHRs truly be mainstream technologies, and what are the stages f....

RHIOs at a Crossroads

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2007


Regional health information organizations (RHIOs) represent what is best about public service organizations in our country. They are voluntary organizations formed by people who want to improve the safety and quality of healthcare by making reliable information available where it is neede....

Connecting Interoperability to HIM

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: January 2006


This year the vision of connected health information will come into sharper focus. Federally funded initiatives for sharing health information are taking place in a dozen communities across the country. Four consortiums are under contract with the Department of Health and Human Services to de....

Driving Change through Rapid Demonstrations

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2003


The American healthcare system is in crisis and consumers are taking notice. Insurance costs are rising at double-digit rates and employers are passing along more of the cost to employees, leading to a recent nationwide strike at GE earlier this year. One in seven Americans is uninsured and fe....

Legal EHR—Friend, Not Foe

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2008


AHIMA has been working hard to advance the industry’s understanding of the legal electronic health record and to develop practical advice for ensuring that EHRs protect patients and providers at each stage of development. While descriptive, the phrase legal EHR seems to strike fear in some who....

Standards: Solutions or Culprits?

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2000


No other country on earth has as regulated a healthcare system as the US, and no country on earth comes close to our level of health spending. According to one estimate, Medicare regulations span more pages than the notorious Internal Revenue Code.1

Are all these standards....

NHIN Comes into Focus

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2005


The Office of the National Coordinator for Health Information Technology issued a request for information (RFI) to gather broad input about how the US national health information network (NHIN) should be designed. In just six short weeks, hundreds of organizations and thousands of stakeholders....

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