Author: Vlahos, Nikos F.; Zeisset, Ann M.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2003

Coding professionals routinely code abdominal or pelvic adhesions. Recent advances in treatment and a newly approved ICD-9-CM procedure code, however, bring the topic to the forefront. Is your knowledge current?

This article will explain what pelvic adhesions are, the surgical techn....

Author: Viola, Allison F.; Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2010

CMS will pay meaningful use bonuses through three programs: Medicare Fee for Service (FFS), Medicare Advantage (MA), and Medicaid programs.
FFS Payments to Providers

For eligible professionals (EPs), understanding the payment system is especially important, because they must ch....

Author: Viola, Allison F.; Mookencherry, Shefali

Source: Journal of AHIMA

Publication Date: February 2012

The healthcare industry will find out soon if ONC intends to include metadata requirements in stage 2 of the meaningful use program. Many feel it is too soon. But given metadata's potential to support health information exchange, the expanded and standardized use of metadata tagging....

Author: Viola, Allison F.; Kallem, Crystal; Bronnert, June

Source: Journal of AHIMA

Publication Date: April 2009

A voluntary quality improvement program just under way will assist organizations in better understanding the underlying causes associated with adverse events.




Publication of the Institute of Medicine’s report To Err Is Human in 2000 placed substant....

Author: Viola, Allison F.; Kallem, Crystal

Source: Journal of AHIMA

Publication Date: April 2011

With the federal government ramping up efforts to further tie healthcare reimbursement to quality of care through initiatives like value-based purchasing and accountable care organizations, quality measurement organizations are gaining more national prominence.

Many different organi....

Author: Viola, Allison F.; Halamka, John; Torkzadeh, Rita MS; Moscovitch, Ben MA; Rising, Josh MD; Asnaani, Jitin MBA; De Mooy, Michelle MA; Ferguson, Jamie BS; Gingrich, Mark MS; Grannis, Shaun MD; Heflin, Eric BS; Hohwald, Andrew MBA; Miri, Aaron MBA; Rudin, Robert S PhD; Schulten, Catherine BS; Worzala, Chantal PhD

Source: Journal of AHIMA

Publication Date: July 2018

By Rita Torkzadeh, MS; Ben Moscovitch, MA; Josh Rising, MD; Jitin Asnaani, MBA; Michelle De Mooy, MA; Jamie Ferguson, BS; Mark Gingrich, MS; Shaun Grannis, MD; Eric Heflin, BS; Andrew Hohwald, MBA; Aaron Miri, MBA; Robert S. Rudin, PhD; Catherin....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: January 2010

This month the Journal introduces a new column on practical applications and emerging issues related to data standards.



The need for standards has never been more pervasive as the healthcare industry moves toward increased health IT adoption.


Provisio....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: October 2019

Pushing Paper Aside as eCR Changes HIM’s Quality Practices


By Allison Viola, MBA, RHIA


Public health agencies across the country continue to face new challenges, from surveilling chronic and infectious diseases such as Ebola and Zika, to managing the anticipated &ld....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: October 2018

By Allison Viola, MBA, RHIA


When innovative technologies make a splash on the international stage, healthcare professionals wonder how these technologies can translate or be scaled for the healthcare industry. Health information management (HIM) profession....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: December 2017

By Allison Viola, MBA, RHIA

Since congress passed an omnibus appropriations act for fiscal year (FY) 1999, Public Law 105-277, the Department of Health and Human Services (HHS) has been prohibited from spending funds to promulgate or adopt any final standard providing for the assignment of....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: June 2012

As outlined within the HITECH Act of 2009, in order for providers to become meaningful users of electronic health records (EHRs), their use must, "in accordance with law and standards applicable to the exchange of information… improve the quality of health care, such as promoting care coordina....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: November 2012

The summer of 2012 ended with a bang when the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) issued final regulations outlining requirements for the stage 2 “meaningful use” EHR Incentive Program. The stage 2 final regulation did....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: May 2011

The Centers for Medicare and Medicaid Services' meaningful use program includes a set of requirements for the exchange of clinical information. The Office of the National Coordinator for Health IT outlined the EHR standards and certification requirements necessary to enable clinical informatio....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: June 2012

The release of STAGE 2 of the meaningful use program introduced adjustments that increased the challenges providers must overcome to meet the program requirements laid out by the Centers for Medicare and Medicaid Services (CMS). Stage 2 maintains the same core-menu structure and slightly incre....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: October 2011

As the meaningful use program marches forward, the Office of the National Coordinator for Health IT (ONC) continues to sharpen its focus on health information exchange (HIE). One of the main components in the HITECH Act mandated "the use of certified EHR technology for electronic exchange of h....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: February 2011

In March 2010 President Obama signed into law the Patient Protection and Affordable Care Act (ACA), which includes many provisions calling for the implementation of quality measurement programs. One program that must be established by January 2012 is the Medicaid Quality Measurement Program, w....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: September 2008

As adoption and implementation of electronic health records (EHRs) and personal health records (PHRs) continues to grow, so does the need for a skilled work force to facilitate the transition, implementation, and management of these health information systems. There has never been a more criti....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: April 2009

The first several months of 2009 brought sweeping changes, some surprises, and a renewed support for healthcare reform. This article provides an overview of the latest HIM developments in Washington.



Jumpstarting Health IT Implementation




Just wee....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: April 2012

From diagnoses coding, software development and deployment, and payment change the transition to ICD-10-CM/PCS will revolutionize healthcare and health information. Each sector within the industry is coming to understand the scale of the change, but many have yet to fully understand and appre....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: October 2012

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have certainly put a new spin to the old saying “things happen in threes.” During late August, CMS issued the final rule for the stage 2 “meaningful use” Elec....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: February 2012

In February 2011 the federal government launched health.data.gov, a Web site that allows healthcare professionals and the public to access healthcare data collected by the federal government through its multiple quality reporting programs and initiatives. The site is a community within the dat....

Author: Viola, Allison F.

Source: Journal of AHIMA

Publication Date: November 2007

As the pace for pay-for-performance initiatives has increased, so too has the number of organizations that are joining the already burgeoning quality initiatives.

Many public and private organizations develop, endorse, and implement performance measures. Navigating the maze of organ....

Author: Vincze, L. Stephan

Source: Journal of AHIMA

Publication Date: January 1998

The possibility of an investigation related to fraud and abuse is the last thing most people want to think about, but it's important to be prepared, just in case. The author gives some advice on how to react if your facility is the target of an investigation and points out some imp....

Author: Vigoda, Michael M.

Source: Journal of AHIMA

Publication Date: October 2008

Physicians face unique medico-legal implications when using EHRs. Careful planning and practice help minimize risk.

While payers, patient safety groups, the federal government, and healthcare systems advocate widespread deployment of electronic health records (EHRs), physicians....

Author: Viangteeravat, Teeradache; Rao Nagisetty, Naga Satya V

Source: Journal of AHIMA

Publication Date: May 2014

Editor’s note: This article is an excerpt from a manuscript published in the Winter 2014 issue of AHIMA’s quarterly scholarly research journal, Perspectives in Health Information Management, “Giving Raw Data a Chance to Talk: A Demonstration of Exploratory Visual Analytics with a Pe....

Author: VanOver, Jennifer; Lusk, Katherine

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 16, 2016

When health information management involved keeping paper records in file rooms, a rule of thumb was that after two years with infrequent activity, medical records were often moved to off-site storage. This reduced the cost of maintaining medical records onsite long term. The records often....

Author: Van Doornik, William

Source: Journal of AHIMA

Publication Date: October 2013

There is growing interest within the healthcare payer community to promote patient engagement through various means, including the integration of patient-generated data into clinical care documentation and quality measures. This is evident in the suggestions for stage 3 "meaningful use" EH....

Author: Valyi, Catherine; Gann, Robin; Liquori, Carol; Marshall, Pamella

Source: Journal of AHIMA

Publication Date: February 2016

Today’s healthcare systems have become a hotbed of activity ripe with new trends, opportunities, and roles for HIM professionals. Centralization of HIM services is one of these megatrends that places the profession at the heart of unparalleled change. Driven by value-based payment mo....

Author: Valo, Carolyn R.; Rulon, Vera; Schuller, Matthew D.

Source: Journal of AHIMA

Publication Date: June 2001

Managed care offers many career opportunities to HIM professionals. If you’re interested in making a transition to this area, the first step is understanding the ways HIM adds value to managed care processes. This article kicks off the first in a series on HIM opportunities in manage....

Author: Valdez, Margarita

Source: Journal of AHIMA - website

Publication Date: June 29, 2012

On June 28 the Supreme Court of the United States upheld certain provisions of the Patient Protection and Affordable Care Act (ACA), the healthcare reform legislation passed in 2010.


Several pieces of ACA relate to HIM professionals’ work and faciliti....

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2001

Is the Web a part of your work day? Make sure it is. From purchasing products to distance learning to online coding, coding professionals can find all kinds of resources online to meet their needs.

A Look at the Future

In a recent survey, health system CEOs were ask....

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2000

As coding professionals move into management, other HIM-related professions, or retire, coding supervisors are left with staffing shortages that impede productivity. Record numbers of experienced coding professionals are and will be needed, and recruitment efforts to find this new staf....

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2001

The 2002 diagnosis related group (DRG) updates went into effect October 1, 2001. With the implementation of these changes to the hospital inpatient DRGs portion of the prospective payment system (PPS), there will be 499 DRGs in 25 Major Diagnostic Categories (MDCs).


Changes t....

Author: Uppena, Mary

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2001

Change has been a constant factor in coding and reimbursement with the intensified focus on billing, compliance, and cost control. Out of necessity, coding professionals in physician settings have learned to be organized, adaptable, and armed with the latest information. The mandates....

Author: Ulmer, Stephen E.; Fuller, Jan C.

Source: Journal of AHIMA

Publication Date: November 2010

The vocabulary standards adopted in the meaningful use final rule provide the language to capture primary health data required for the meaningful use objectives. It is through these standards that health information will be captured and transmitted. Knowing the vocabulary standards and underst....

Author: Twiggs, Mariela; Goldstein, Sara

Source: Journal of AHIMA

Publication Date: October 2016

Healthcare provider organizations rely on a variety of entities to help them carry out healthcare activities and functions. If these entities create, maintain, or transmit protected health information (PHI) on behalf of a provider organization, they are considered a business associate (BA....

Author: Tully, Melinda; Perez, Mario A. III

Source: Journal of AHIMA

Publication Date: September 2009

HIM professionals understand how critical final coding accuracy is for acute care billing and reporting—they live and breathe it every day. Yet, over the past several years the importance of coded data has extended beyond acute care.

Coding now has an impact on everything from....

Author: Tully, Melinda

Source: Journal of AHIMA - website

Publication Date: May 31, 2016

Before many health information management (HIM) professionals feel fully confident that they have the new ICD-10 codes under control, they should know that there are more on the way. More than 5,500 new procedure and diagnosis codes will go into effect beginning in October 2016, follo....

Author: Tully, Lorraine

Source: Journal of AHIMA

Publication Date: November 2001

HealthMarket, Inc., is a Norwalk, CT-based company offering “self-directed health plans” to employers and insurers as a new choice in health benefits. Founded in 1999, the company aims to shift healthcare decision making from insurance intermediaries to physicians and patients. As part of its....

Author: Trivedi, Amber

Source: Journal of AHIMA

Publication Date: June 2006

The call for legislation prohibiting genetic discrimination is growing, and for HIM professionals this requires the complicated task of securing genetic information. While the industry has extensive experience keeping medical records confidential, the difficulty of defining genetic information....

Author: Trites, Patricia

Source: Journal of AHIMA

Publication Date: July 2008

Metadata are not inherently good or bad, they just are. Metadata have been defined as “data about data.”1 They can be further described as the “who, what, where, and when” of electronic documents.2 Their importance depends on who is viewing the information—promine....

Author: Tripathi, Micky

Source: Journal of AHIMA

Publication Date: October 2012

Electronic health records (EHRs), like all computerized technologies, have undergone rapid transformation over the past 50 years. The pace of change has greatly accelerated since the January 2009 passage of the Health Information Technology for Economic and Clinical Health Act (HITECH)-a $30....

Author: Tremlett, Janie

Source: Journal of AHIMA - website

Publication Date: September 2015

The conversation in healthcare is shifting from “patient engagement” to “consumerism.” This changing lingo indicates a new mental model—a new approach to thinking about patients as consumers and to delivering a healthcare experience as consumer-centric, just like many other industries. Dra....

Author: Tremlett, Janie

Source: Journal of AHIMA - website

Publication Date: March 2016

Payment models in healthcare are transforming—which should be no surprise to health information management (HIM) professionals. What may come as a surprise though is how quickly these models are transforming.


Healthcare is rapidly moving to incorporate measures of value....

Author: Treloar, R. William

Source: Journal of AHIMA

Publication Date: October 2003

Not only has my role in HIM changed dramatically in the last several years, my title has too: from director of case mix management to director of clinical resource management. And in my department, our role has moved from educating clinicians and staff about Medicare and DRGs to the facilitati....

Author: Trela, Patricia

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

Publication Date: May 2007

Inpatient rehabilitation facility (IRF) coding can be a challenge due to the Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS), which was implemented in 2002 to cover patients paid under Medicare Part A. IRF PPS requires completion of the IRF-Patient Assessment In....

Author: Trela, Patricia

Source: Journal of AHIMA

Publication Date: January 2002

As of January 1, 2002, inpatient rehabilitation facilities will implement the Medicare Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS). What is covered under this system, what data collection tool is used, and why are many facilities enthusiastic about the new system?....

Author: Traverse, Cheryl

Source: Journal of AHIMA

Publication Date: May 2008

Testing and monitoring access policy controls are critical best practices for all healthcare organizations. By testing and monitoring IT resources, perimeter security systems, and technical user activities, organizations can ensure service delivery, the protection of the resources that deliver....

Author: Tracy, Wayne R.; Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: September 2002

NCVHS' endorsement of HL7 as the standard for electronic exchange of patient medical record information promises to simplify the transmission of such information between healthcare organizations. However, this endorsement also empowers HL7 to serve as the architect of the electronic health rec....

Author: Townsend, Hilary

Source: Journal of AHIMA

Publication Date: March 2013

The emergence of electronic health records (EHRs) has necessitated the use of innovative technologies to facilitate the transition from paper-based records for healthcare providers. Natural language processing (NLP) is one technology providers are turning to for improving clinical outcomes....

Author: Towers, Adele L

Source: Journal of AHIMA

Publication Date: July 2013

The following is likely not a surprise to those clinical documentation improvement specialists (CDS) working day in and day out improving physician documentation. But for the record-clinical documentation improvement (CDI) is not taught in medical school. The truth is that most physicians....

Author: Torrance, Kelly

Source: Journal of AHIMA

Publication Date: February 2010

The HIM department can sometimes feel like the invisible department, because often no one acknowledges it until there is a problem. HIM professionals often bemoan the fact that they are not included in key organizational decisions like IT implementations that impact their departments. There ar....

Author: Toporoff, Steven

Source: Journal of AHIMA - website

Publication Date: April 17, 2009

Millions of Americans each year fall victim to identity theft.  When identity theft involves healthcare, the consequences can be severe. It can result in losses to the healthcare provider from unpaid bills, the exhaustion of the victim’s benefits, or even potentially life-threate....

Author: Tomes, Jonathan P.

Source: Journal of AHIMA - website

Publication Date: January 2014

This is the third installment in a three-part article series on avoiding liability for breaches by business associates. This article will discuss adjustments needed in the business associate relationship, as well as ongoing strategies for adapting to the recent changes.
....

Author: Tomes, Jonathan P.

Source: Journal of AHIMA - website

Publication Date: January 2014

HIM professionals and privacy and security officers are likely already familiar with their facility’s business associates. But with the recent dramatic changes to the business associate relationship in the HITECH Act and the Omnibus Final Rule, there is plenty of new ground....

Author: Tomes, Jonathan P.

Source: Journal of AHIMA - website

Publication Date: January 2014

This is the second installment in a three-part article series on avoiding liability for breaches by business associates. This article will provide guidance on how to avoid liability for breaches by business associates.


For background on the changes to the busin....

Author: Tomes, Jonathan P.

Source: Journal of AHIMA

Publication Date: October 2005

To avoid the improper destruction or alteration of records, HIM departments must follow a retention schedule, train personnel, and ensure that corrections leave original entries intact.
Although the legal concept known as spoliation of evidence has been a part of the American legal syste....

Author: Tomes, Jonathan P.

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2002

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

Author: Tomes, Jonathan P.

Source: Journal of AHIMA

Publication Date: March 2012

HHS's renewed interest in auditing for compliance is a good reminder to covered entities to ensure their privacy and security programs are up to date.

The Department of Health and Human Services' (HHS) announcement of a new program to audit compliance with the HIPAA priva....

Author: Thorp, Jeremy

Source: Journal of AHIMA

Publication Date: September 2010

The European Union (EU) provides a common framework for policies and services across its 27 member states. There are common policies in many areas, but healthcare remains a national prerogative.

While there are substantial variations between the United States and European national h....

Author: Thompson, Nell S.; Koch, Doreen

Source: Journal of AHIMA

Publication Date: January 1999

As compliance becomes an increasingly hot topic, how can a facility ensure its coding quality? Here are some ways that HIM departments can improve the quality of coding on a daily basis.



Coding practices are continually evolving, and this evolution has brough....

Author: Thompson, Nancy A.

Source: Journal of AHIMA

Publication Date: July 2000

If you feel like you've ever reinvented the wheel when changing or improving processes, the Department of Veterans Affairs may have the answer. Read on to learn more about the Virtual Learning Center, an online knowledge base of healthcare solutions.



We all have....

Author: Thomas, Shirlyn; Tyson, Carla

Source: Journal of AHIMA

Publication Date: July 1998

It is obvious that the HIM field will be affected by the implementation of the computerized patient record, but what can HIM professionals do to prepare? To effectively impact healthcare delivery of the near future, HIM practitioners must be computer literate and feel at ease with co....

Author: Thomason, Mary

Source: Journal of AHIMA

Publication Date: April 2004

Yesterday’s privacy compliance preparations can contribute to meeting tomorrow’s security mandates. One organization is tackling risk analysis with both matrix and memories.
The 2003 HIPAA privacy rule implementation is still fresh in many minds throughout healthcare organiza....

Author: Thomas, Liisa; Udofia, Idara

Source: Journal of AHIMA

Publication Date: February 2015

The Food and Drug Administration (FDA) has joined other regulators in sounding a call for data protection and security in our rapidly digitizing world.


Studies reveal that many health providers’ devices or systems have been breached without their knowledge of such breach o....

Author: Thomas, John R

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2009

Each year healthcare adds programs, initiatives, and regulations to improve transparency and create efficiency. Unfortunately, many, if not all, add further complication, leading to higher CPT rejects. To effectively control the increasing time pressure of identifying, measuring, and repai....

Author: Thomas, Jeane

Source: Journal of AHIMA

Publication Date: April 2015

Imagine your organization is involved in a lawsuit or government investigation and needs to access documents or information located outside the United States. If you think you can just demand that they be sent to the US because they are relevant or maybe even necessary for the legal matte....

Author: Thomas, Felicia A; Harding, Wahiyda A

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

Publication Date: October 2018

By Felicia A. Thomas, RHIT, CCS, CPC, CIC, CPC-I, CCDS, and Wahiyda Harding, MSA, RHIA, CCS


To understand the power of coded data, let’s first take a look at its definition. Data analytics is the science of examining raw data with the purpose of drawing conclus....

Author: Thoman, Deborah J.

Source: Journal of AHIMA

Publication Date: May 2001

Are HIM professionals ready to make the most of APCs? This article suggests some strategies to improve the way we work with APCs, focus on complete and accurate coding, and improve our expertise.
Are HIM professionals ready for the next step in APCs? Are we ready to use APC data....

Author: Thierry Sheridan, Patty; Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: February 2016

Information governance (IG) captures the soul of health information management (HIM), yet many HIM professionals may not engage in IG due to a lack of knowledge, inexperience, or a misunderstanding of all that IG entails. Because of this, experts in IG leadership took part in a focus group....

Author: Thierry Sheridan, Patty

Source: Journal of AHIMA

Publication Date: February 2012

Digitized information has had a profound effect on the current generation of children. You just have to spend a few minutes with an eight-year-old to see how technology literate this generation has already become. Imagine how different their lives will be from the current workforce because the....

Author: Thieleman, William; Postal, Susan

Source: Journal of AHIMA

Publication Date: March 2000

The uses of the Internet are well known, but companywide intranets are popular as well. In this article, two HIM professionals share how their organizations are putting the power of intranets to work for training, communicating, and more. An Intranet in the Healthcare Environm....

Author: Thieleman, William

Source: Journal of AHIMA

Publication Date: May 2002

HIPAA promises patients the right to access and amend their medical records, but HIM departments are responsible for making it happen. How will your facility provide this service for patients? The author offers ideas from experts on designing an access and amendment process.
Among the ch....

Author: Tessier, Claudia

Source: Journal of AHIMA

Publication Date: April 2010

Mobile devices are moving into healthcare with rapid speed, becoming a common health tool for both clinicians and consumers. Provider organizations face a challenge in realizing the opportunities, managing the information, and mitigating the risks.

Just a few short years ago, CIOs we....

Author: Teslow, Mary; Mueller, Irene L.E.; Schmidt, Krista

Source: Journal of AHIMA

Publication Date: May 2005

A structured interview process adapted from the library profession offers HIM professionals a model well suited to their emerging roles as data brokers.
For more than 75 years HIM professionals have been charged with the role of record custodian, retrieving health records for a wide vari....