Author: Kudla, Karen M.; Rallins, Marjorie C.

Source: Journal of AHIMA

Publication Date: May 1998

SNOMED is a detailed and specific coded vocabulary of names and descriptions used in healthcare -- explicitly designed for use in the computerized patient record. Here's an overview of this system and a look at its next generation.
Methods to collect data about human morbidity and morta....

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....

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....

Author: Krautwald, Peter

Source: Journal of AHIMA

Publication Date: October 2001

Voice recognition, electronic signature, combined system interfaces-the future is now in many HIM departments. In this article, the author focuses on the use of advanced report processing technologies in HIM departments and how they are changing the way we work.
Technology and....

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....

Author: Kraft, Kristine N; William, Fiala C

Source: Journal of AHIMA

Publication Date: April 2019

By William C. Fiala, MA, CCS-P, CPC, RMA, and Kristine N. Kraft, DC, RMA


Complication coding is “considered to be one of the more challenging aspects of coding,” as an article in ICD10monitor once put it.1 The reporting of complication codes brings with it certain risks to pr....

Author: Kowalski, Christine

Source: Journal of AHIMA

Publication Date: May 2015

Just as the world is held together and shaped by a delicate and intricate global ecosystem, the US healthcare system’s community of connected components, surviving and thriving when working together toward common goals, represents its own sort of ecosystem. As healthcare moves toward an i....

Author: Koval, Dianne

Source: Journal of AHIMA

Publication Date: March 2005

By distributing costs and benefits among providers and payers, a regional physician association is creating a data exchange network with an ambitious goal: interoperable EHR systems in every physician’s office.
Mark Foster, MD, of Hudson Valley Primary Care in Wappingers Falls, NY,....

Author: Koval, Dianne

Source: Journal of AHIMA

Publication Date: March 2007

A pioneering data exchange network shares lessons from its practice management software implementations-a first step in bringing physician offices online.
Mark Foster, MD, waits for his Hudson Valley Primary Care staff to locate the medical record of his next patient. The Wa....

Author: Kostick, Karen M.; Sanvik, Gina

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

Publication Date: June 2015

All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.

ICD-10-PCS Scope of Work


On October 1, 2015, hospital inpatient pr....

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....

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....

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....

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....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2012

At the request of the American Academy of Pediatrics, the FY 2012 ICD-9-CM code update expanded subcategory 041.4, Escherichia coli, to create unique codes for Shiga toxin-producing Escherichia coli (STEC). This article describes STEC and its clinical features and summarizes the new STEC ICD-9....

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....

Author: Kostick, Karen M.

Source: Journal of AHIMA

Publication Date: September 2017

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic neurobehavioral disorder and often associated with serious areas of impairment and comorbidities over a life span. Physician practice coding professionals are at the forefront to ensure quality ICD-10-CM coded data across a life....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2011

The ICD-10-CM external causes of morbidity tabular list includes significant enhancements to the ICD-9-CM supplementary classification of external causes of injury and poisonings (E800–E999). The ICD-10-CM list features category restructuring, reorganization, and major code expansion.

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2004

V codes, described in the ICD-9-CM chapter “Supplementary Classification of Factors Influencing Health Status and Contact with Health Services,” are often misunderstood in reporting healthcare services. These codes are designed for occasions when circumstances other than a disease....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2011

Editor's note: This column supercedes the February 2004 article "From V Codes to Z Codes: Transitioning to ICD-10."

V codes, described in the ICD-9-CM chapter "Supplementary Classification of Factors Influencing Health Status and Contact with Health Services," are designed for occasi....

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....

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....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2012

The use of many distinct standardized clinical vocabulary terminologies and classifications is integral to the development of a nationwide health IT infrastructure that allows for electronic use and exchange of health information. SNOMED CT is one of the key clinical terminologies designated f....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2002

Since 1997, AHIMA has offered a Certified Coding Specialist--Physician-based credential (CCS-P) for HIM professionals who are employed in the physician setting. In recent interviews, an office manager, coding manager, coding coordinator, and two physician-based consultants shared their coding....

Author: Kostick, Karen M.

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2010

WHEN CODING Questions arise, coding professionals should evaluate all possible resources, including querying physicians, networking with other coding professionals, and seeking official coding advice. These techniques help ensure consistent healthcare diagnostic and procedure coding.

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....

Author: Kostick, Karen M.

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

Publication Date: May 2016

On October 1, 2015, the ICD-10-CM coding classification was implemented in the United States. This article provides a coding update on how to report injuries resulting from terrorism, which is now classifiable under ICD-10-CM. In the US, ICD-10 (mortality coding) and ICD-10-CM (morbidity c....

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....

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: September 2004

Your healthcare facility is digitally capturing information at a staggering pace. But if a subpoena showed up tomorrow, could you produce the information you need?
While mounds of analog paper and film continue to overwhelm most healthcare organization record and film libraries, the fac....

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: March 2000

Because the World Wide Web has become a popular place for healthcare users to browse and search for information, it offers healthcare providers, payers, and patients access to the widest range of healthcare information as well as the ability to disseminate information. As a result, the healthc....

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....

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: March 2010

Most HIM departments have yet to master the management of patient health information exchanged across healthcare organizations. Typically the well-established processes and standards for managing internally generated information do not address health information that is generated outside the o....

Author: Koering, Susan M.

Source: Journal of AHIMA

Publication Date: March 2008

In the last 20 years, the role of the cancer registrar has evolved dramatically. The need for trained and qualified cancer registrars will only grow as the oncology healthcare industry increasingly calls for quality data. This article defines how cancer registrars can affect quality healthcare....

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'....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: June 2003

Summertime, and the living is easy...” At this time of year, we remember the promise held by the summers of our childhood. There were so many wonderful possibilities—bike riding, trips to the beach, summer camp, family vacations, long evenings to play outdoors—and so much time b....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: June 2009

The American Recovery and Reinvestment Act requires adoption of measures for the “meaningful use” of health IT in order to unlock billions of dollars in incentives. After years of growing support for health IT adoption that improves healthcare, this is the time to get specific abou....

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,....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 2006

The most perplexing issues facing health information exchange (HIE) include patient identification, provider authentication, consent and other privacy issues, financial sustainability, and meaningful consumer engagement.


Intense work on these issues is under way. A new confid....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2007

We all believe that healthcare can be more effective when people are armed with trusted information about their needs and best options. This premise is driving the urgent push for personal health records (PHRs) and quality and cost transparency.

Information Views and....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: January 2007

An improved healthcare system depends not only on wiring it up but also ensuring that data are usable for evidence-based clinical practice, to empower consumers, and to improve the health of the population. Progress is being made on data transmission standards; however, similar progress is need....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2010

On one of the first days of my tenure on staff at AHIMA, I read the earliest association journals, then the Journal of the Association of Record Librarians of North America. These pre-1930 publications discussed practice issues in maintaining accurate and complete clinical documentation and us....

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....

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.

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....

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....

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....

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....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 1999

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....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: May 2005

AHIMA’s work force research found that HIM professionals hold 200 different job titles in 40 types of organizations, from hospitals to veterinary clinics. Just 20 years ago, most worked in acute care hospitals. Today that number is just over 50 percent.

For decades we differen....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: May 2009

The passage of the American Recovery and Reinvestment Act means that American taxpayers are now directly funding the adoption of electronic health records and the investment in health information exchange. Yes, you and I are writing the checks that defray some of the cost of this important tra....

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. <....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2009

The way we manage health information continues to evolve. For many who work in hospitals, the medical record is now some combination of digital data, imaged documents, and residual paper. Most provider organizations are somewhere along this transition continuum from paper to fully digital.

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.
<....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: January 2005

The question is often asked whether HIM will be able to make the transition from paper to electronic records. My answer is an unequivocal “yes, we already are.”

In the story “Bridge Builders: HIM Professionals Blend Core Skills and New Opportunities to Meet the Fut....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 2008

Healthcare is entering a new era of records management, one that will be digital, enterprise-wide, and dynamic. However, many healthcare organizations describe their current state as hybrid, meaning a combination of paper and electronic.

While a convenient way to depict the often mes....

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....

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....