Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: September 1999

Internet and intranet technology is beginning to alter the development of electronic medical records. How do these systems work, and how have they affected the way HIM professionals work? Here's a look at some successful examples of the use of this technology.
Technology is driving infor....

Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: July 1998

What is personal effectiveness, and how can qualities of leadership be developed? Six AHIMA members (Leslie Fox, Barbara Fuller, Maida Herbst, Sandra Nunn, Brenda Olson, and Gerri Smothers) were asked to comment. Here's advice from the experts on how to perform effectively.
What Makes an....

Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: February 1999

Throughout the healthcare industry, the computer-based patient record (CPR) is in various stages of development. This article assesses the progress long term care facilities are making in moving toward the CPR. The article also suggests some ways HIM professionals can devel....

Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: September 1998

Are smart cards a viable solution for storing patient information? What about companies that store and provide emergency medical information? The author examines the possibilities these services offer.





These days, wallets are bulging with a proli....

Author: Schnitzer, Gregory L.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2001

Nearly two years ago, the AHIMA Coding Futures Task Force predicted that coders would eventually need to go beyond assignment of diagnostic and procedural codes.1 The task force was right-and that future is now for coders in certain specialties. Natural language processing (NLP), in which comp....

Author: Schnitzer, Gregory L.

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2000

Despite understandable skepticism from the medical community, natural language processing (NLP) is slowly emerging as a viable rival to human coding professionals’ speed and accuracy. NLP autocoding software teaches computers to "understand" English well enough to "read" p....

Author: Sawatsky, Elaine; Warner, Diana

Source: Journal of AHIMA

Publication Date: April 2016

Interoperability standards and their continuing adoption by e-health programs expand the capacity of information systems to capture, use, and exchange clinical data. For exchange to occur, the majority of data processing decisions need to take place both computationally and automatically.....

Author: Savage, Lucia

Source: Journal of AHIMA

Publication Date: November 2017

One hallmark of my work as chief privacy officer at the Office of the National Coordinator for Health IT (ONC) was reminding everyone about the individual’s right to get a copy of their own protected health information (PHI) and, since 2009, to download or transmit it directly f....

Author: Sartori, Natalie

Source: Journal of AHIMA

Publication Date: January 2018

By Natalie Sartori, MEd, RHIA

In addition to thousands of new codes, the October 2016 ICD-10-CM update included a new general rule in Section I of the 2017 ICD-10-CM Official Guidelines for Coding and Reporting. The convention I.A.19 specifically states:



“The assign....

Author: Sardinas, Joseph L. Jr.; Muldoon, Jeannine D.

Source: Journal of AHIMA

Publication Date: November 2001

You might think computer hackers’ activities are restricted to viruses and hoaxes. Unfortunately, their repertoire is far larger, which puts your facility’s computer system-and patient privacy-at risk. This article provides a look at how hackers work and the best ways to protect your systems.....

Author: Sarabu, Naveen

Source: Journal of AHIMA

Publication Date: February 2014

As the healthcare industry business model shifts from a volume-based to a value-based model, accountable care organizations (ACOs) are a critical piece of healthcare’s new structure. The number of ACOs has almost tripled since 2011—increasing from 146 to 488 in two years.1 Financial and p....

Author: Saponaro, Charlie

Source: Journal of AHIMA

Publication Date: January 2016

Often viewed as the backbone of a facility’s revenue cycle, health information management (HIM) outsource vendors have seen an explosion in demand as the healthcare industry has transitioned to ICD-10-CM/PCS. Many HIM service companies have seen an increase in volume and client reque....

Author: Sanvik, Gina

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 10, 2016

How to code viral sepsis has been a topic of discussion on AHIMA’s Engage Coding, Classification and Reimbursement community, and has be the subject of several inquiries to AHIMA’s Code-CheckTM coding question service.


The viral sepsis coding confusion may com....

Author: Sanvik, Gina

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 14, 2016

With the release of the FY 2017 updates to the ICD-10-CM Official Coding Guidelines, there’s a lot for coding professionals to review. This post will take a closer look at one of the updates in Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A). The guideline for “P....

Author: Sanvik, Gina

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 13, 2016

Although many HIM professionals and coding professionals were just starting to get comfortable with ICD-10-CM/PCS, it is time to prepare for the thousands of new ICD-10 changes coming soon.


The upcoming ICD-10 updates for the Fiscal Year (FY) 2017 will also represe....

Author: Sanvik, Gina

Source: Journal of AHIMA - website

Publication Date: June 08, 2016

While working on the team for AHIMA’s Code-CheckTM Coding Question Service, I’ve noticed several questions related to providing clarification in ICD-10-CM for a fracture in a patient with known osteoporosis.


ICD-10-CM expands the code selection to more than 150 pa....

Author: Sanvik, Gina

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2018

Untitled Document



CY 2018 OPPS Update


By Gina Sanvik, MS, RHIA


Facilities had the ominous task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule at the beginning of the year to ensure their chargemaste....

Author: Sanvik, Gina

Source: Journal of AHIMA

Publication Date: April 2018

Untitled Document




Many ICD-10-CM codes were added throughout code category L97, Non-pressure chronic ulcer of the lower limb, not elsewhere classified, and subcategory L98.4, Non-pressure chronic ulcer of the skin, not elsewhere classified, to provide....

Author: Sanvik, Gina

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 11, 2016

There has been some confusion among coding professionals regarding interpretation of the coding guideline of “with.”  An area that contains many instances of using this guideline in ICD-10-CM is coding Diabetes Mellitus with associated conditions. There are 53 instances of....

Author: Sandefer, Ryan; Marc, David; Mancilla, Desla; Hamada, Debra

Source: Journal of AHIMA

Publication Date: July 2015

The American Health Information Management Association (AHIMA) conducted a study to assess the future needs of the health information workforce. The study was intended to define the current reality of HIM within the healthcare industry, how the market is shifting to meet future needs, and....

Author: Sandefer, Ryan; Karl, Ellen Shakespeare

Source: Journal of AHIMA

Publication Date: March 2015

In January 2014, the AHIMA Council for Excellence in Education (CEE) released updated curricular competencies for all accredited academic programs, including those at the associate, baccalaureate, and graduate levels. The curricular competencies were intended to better align education with....

Author: Sandefer, Ryan; DeAlmeida, Dilhari R; Dougherty, Michelle; Mancilla, Desla; Marc, David

Source: Journal of AHIMA

Publication Date: November 2014

Ponder this for a moment. From the beginning of recorded history to 2003, five exabytes (five billion gigabytes) of information was created by humans, according to recent IBM calculations. The rate at which that level of information is being created is increasing exponentially. In 2012, fi....

Author: Sandefer, Ryan

Source: Journal of AHIMA

Publication Date: August 2019

By Ryan Sandefer, PhD, and David Marc, PhD, CHDA


Skills in data analytics are critical to the future of health information management (HIM), yet there has been considerable confusion regarding how to articulate what data analytics means for the profession. In a survey of more than....

Author: Sandefer, Ryan

Source: Journal of AHIMA

Publication Date: April 2018

The health information management (HIM) profession is nothing if not resilient. With every change in the process of health data collection, maintenance, and use, HIM professionals have adapted to industry transitions to ensure health information quality....

Author: Sandefer, Ryan

Source: Journal of AHIMA

Publication Date: January 2019

By Ryan Sandefer, PhD, and Amy Watters, EdD, RHIA, FAHIMA


The May 2014 cover of Journal of AHIMA featured an image of a chameleon and the words “Adapt or Disappear.” This hyperbolic warning for health information management (HIM) professionals was delivered in the context of the r....

Author: Sandefer, Ryan

Source: Journal of AHIMA

Publication Date: February 2019

By Ryan Sandefer, PhD, and Amy Watters, EdD, RHIA, FAHIMA


In the January issue of Journal of AHIMA, health information professionals were asked to take action by highlighting their work and the value of the health information management (HIM) profession through publishing. Yes, t....

Author: Saharia, Devendra

Source: Journal of AHIMA

Publication Date: July 2016

Think back to the last time you went out for dinner and had a dreadful experience. Did you rush home and write a negative online review of the restaurant? If so, you’re not alone. More and more, restaurant patrons, home improvement customers and, yes, even patients are taking to the Inter....

Author: Saharia, Devendra

Source: Journal of AHIMA

Publication Date: April 2016

Disruptive technology can turn any industry on its head—virtually overnight. Just five years ago, summoning a taxi was an inefficient, time-consuming effort that often involved dialing up a dispatcher, who contacted a driver, who would then make their way to your location, perhaps in an h....

Author: Sager, Michael; Mangin, Wendy L; Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2006

What led you to become a privacy officer for your facility?


Sager: I work in the compliance office at my facility, and when the privacy rule was first published in all of its draft forms, I took a special interest and was assigned to organize an implementation committee. As I bec....

Author: Safian, Shelly C

Source: Journal of AHIMA

Publication Date: August 2009

The national rollout of the Recovery Audit Contractor (RAC) program this year will require much of healthcare entities. In order to prepare for the program, entities should designate one person as the main point of contact for all RAC activity. The RAC coordinator helps ensure compliance with....

Author: Ryznar, Barbara

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: October 12, 2016

Understanding the cost of prescription drugs can be challenging. The recently introduced Centers for Medicare and Medicaid Services (CMS) Medicare Spending Dashboard, an example of the principle of collecting healthcare data once and reusing it to serve the needs of multiple stakehold....

Author: Rynberg, Sally J.

Source: Journal of AHIMA

Publication Date: March 2009

An efficient revenue cycle is critical to ensuring timely and appropriate reimbursement for patient services. That efficiency requires that multiple systems, departments, and processes work together to smooth workflow, promote consistency, and reduce rework.

Most hospitals employ e-H....

Author: Ryan, Betty; Poole-Rice, Katherine; Asbury, Teri

Source: Journal of AHIMA

Publication Date: February 2001

Improved relations between physicians and HIM professionals, a shorter and faster chart completion process, and decreased chart deficiencies are just a few of the benefits Zale Lipshy University Hospital has enjoyed by implementing an electronic signature system. A partner of the U....

Author: Russo, Ruthann; Russo, Joseph J.

Source: Journal of AHIMA

Publication Date: January 1998

Recent developments indicate that government scrutiny of healthcare providers will continue well into the next century. This article sheds light on the Federal False Claims Act and its recent interpretation by the Department of Health and Human Services' Office of the Inspector General and th....

Author: Russo, Ruthann

Source: Journal of AHIMA

Publication Date: May 2012

As integrated medicine becomes more common, HIM professionals have a unique opportunity to improve its documentation.

With integrative medicine (IM) services now offered by 80 percent of hospitals and healthcare systems, it's safe to say that integrative medicine is no longer a nic....

Author: Russo, Ruthann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2001

Although coding professionals are not ultimately responsible for ensuring appropriate release of patient-protected information, it is important that they understand that coded data is not only one of the most desired pieces of information in the patient’s record, it is also the....

Author: Russo, Ruthann

Source: Journal of AHIMA

Publication Date: July 2003

Tired of haranguing physicians about the importance of clinical documentation? Our expert’s strategies will improve documentation and make physicians happy, too.

Clinical documentation is the foundation for the codes that serve as links between patient care and payment, individu....

Author: Russell, Matthew

Source: Journal of AHIMA

Publication Date: September 2011

When a tornado struck St. John's Regional Medical Center in May 2011, its patient records were stored in a newly launched electronic health record system, helping prevent a bad situation from being worse.

In the days following the tornado that decimated Joplin, MO, strikin....

Author: Russell, Lynda A.; Patena, Karen

Source: Journal of AHIMA

Publication Date: June 2004

Dramatic change in HIM demands new thinking about how we educate tomorrow’s professionals. Redefining roles, competencies, and educational progression is the first stage in AHIMA’s new framework for HIM education.
When tomorrow’s graduates enter the HIM workplace, will....

Author: Russell, Lynda A.

Source: Journal of AHIMA

Publication Date: April 2001

When was the last time you talked about using an "icebox," a "horseless carriage," or a "ditto machine"? Just as time and innovation have changed our ideas about familiar objects, they have also changed the definition of our profession. HIM professionals have come a long way since the organiza....

Author: Russell, Lynda A.

Source: AHIMA book excerpt | Journal of AHIMA

Publication Date: April 2003

This excerpt from AHIMA’s textbook, Health Information Management: Concepts, Principles, and Practice, offers a basic look at the legal actions most commonly affecting the healthcare industry.
To understand the role of the HIM professional in protecting confidential health informatio....

Author: Ruppersburg, Patricia L.

Source: Journal of AHIMA

Publication Date: April 1999

Compliance is an issue that has earned much respect from healthcare professionals. It has become imperative to all HIM professionals to focus on providing the best possible solution for compliance. The ultimate goal: to create a scenario in which compliance supports the existing heal....

Author: Rupp, Cheryl

Source: Journal of AHIMA

Publication Date: November 1999

In any situation, there is a positive side and a negative side. At any moment, I decide.
—author unknown        


Compliance has become the trendy buzzword in almost every industry these days, but perhaps nowhere is it quite as prevalent as....

Author: Rulon, Vera; Tully, Lorraine

Source: Journal of AHIMA

Publication Date: February 2000

Here's how HIM professionals came to the fore at Oxford Health Plans as a new clinical audit process became a way to address claims submission isssues and save money. (FORE Best Practice, AHIMA Foundation)

Author: Rulon, Vera; Sica, JoAnn

Source: Journal of AHIMA

Publication Date: June 1997

History of HEDIS
Employer Issues Leading to HEDIS
The Health Plan Employer Data and Information Set (HEDIS) is a set of standard performance measures designed to provide purchasers and consumers with the information they need to compare the performance of managed healthcare plans.....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: January 2009

We have begun an important year. New leadership in the federal government signals major changes ahead, and healthcare reform could be the forefront of that change. HIM is looking forward to an exciting, challenging year.

I thank all of you for the awesome opportunity to serve as your....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: October 2005

HIM cannot claim an exclusive domain any more. No longer a “back end” function, HIM is part of a larger continuum. Author Daniele Bolelli writes: “The age of specialization is over. Mixing together aspects of life that have apparently little to do with each other will be the....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: September 2015

Walk into any midsize medical practice and you’ll see firsthand that technology is reshaping healthcare. The move to electronic health records has gone beyond the tipping point, while mobile technologies are revolutionizing information sharing. Yet despite the array of technology at....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: May 2009

These are turbulent times, and healthcare is feeling the effects of many external forces. A PricewaterhouseCoopers’ report recently outlined nine issues that will disrupt the industry this year. While not every issue is relevant to the HIM profession, several will have a major impact.

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: June 2009

Many factors contribute to medical errors. Ensuring patient safety entails tying together pieces of information so that patients get the right care at the right time in the right way. While this may sound simple, it requires input and efficiency at every level of care.
A Patient’s....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: January 2015

At AHIMA’s National Convention Angela Kennedy, EdD, MBA, RHIA, shared a story about her adopted daughter’s diagnosis of cystic fibrosis, and the difficulty Kennedy faced in getting her daughter’s medical history. Kennedy’s story made it clear: Without this essential....

Author: Rulon, Vera

Source: Journal of AHIMA - website

Publication Date: April 2009

The Journal of AHIMA kicks off our Health Information Privacy and Security Week series with a post from AHIMA president Vera Rulon, MS, RHIT, CCS, FAHIMA. Rulon is director of strategy and communications in the chief medical office of Pfizer, Inc.

So I get this communication that my c....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: February 2009

In the past several years medical information has made the news, though not in the way HIM professionals would like. Consider the following headlines:
“Data Breach Hits Close to Home” from the February 22, 2007, Washington Post
“Staff Suspended for Leaking George C....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: November 2009

What an overwhelming year it has been.

Not only have I learned a lot, I have also had the privilege of getting to know many of AHIMA’s members. I am in awe of our association and how we have responded to the many challenges our healthcare system is facing and will continue to f....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: August 2009

Physician practices face many challenges, especially in the areas of HIM. In particular, they have key concerns in successfully implementing electronic health records. These issues include empowering patients, gathering information that supports sound clinical decision making, navigating reimb....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: September 2009

Data integrity is paramount to successfully implementing electronic health records. It is also the foundation of HIM practice.

In order to improve documentation and ensure data integrity, HIM professionals must partner with other healthcare professionals. This can be done in several....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: April 2009

Health disparities are a major concern in the healthcare industry. Many studies related to health disparities cite the need for accurate and accessible data to identify where the differences in health exist.

“The National Healthcare Disparities Report” from the Agency for....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: July 2009

The influx of information technology in the healthcare industry has led many to wonder what the future holds for coding and what coders must do to remain vibrant and knowledgeable.

Back in 2000, the coding futures task force asked the same questions. In the Journal article “A C....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: October 2009

The American Recovery and Reinvestment Act notes the need for trained professionals across the healthcare continuum who are savvy with technology. Health IT is playing and will continue to play a prominent role in healthcare’s evolution—and for good reason.


In ord....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: March 2009

Social media has boomed with the advent of online networking sites such as Facebook, MySpace, and LinkedIn. Now healthcare is getting involved, too.

One can only imagine the impact the new ways of patient-doctor, consumer-consumer, and doctor-doctor communications will have on health....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: January 2000

What will facilitate medical product regulation and related electronic data interchange worldwide? For some regulatory authorities, the answer is the Medical Dictionary for Drug Regulatory Affairs—also known as MedDRA.

MedDRA (the name is a trademark of the International Federat....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: April 1998

Increasing expenditures in Medicare have caused the Health Care Financing Administration (HCFA) to rethink its approach to reimbursing—and caring for—beneficiaries. Since managed care emerged as the acceptable alternative to help keep costs under control, the number of Medic....

Author: Ruhl, Jennifer L; Zumar, Wendy

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2013

When ICD-10-CM is officially implemented, its code set will not only be used for primary care purposes but also as an invaluable secondary data source used by many types of healthcare registries in the US. A registry can be defined as “an organized system that uses observational stud....

Author: Rugg, Donna

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

Publication Date: November 2016

The ICD-10 Coordination and Maintenance Committee’s code freeze, first implemented after the October 1, 2011 annual update, has finally thawed. For fiscal year (FY) 2017 the ICD-10-CM classification is back on track with annual code and guideline updates. Due to the thousands of new/....

Author: Rugg, Donna

Source: Journal of AHIMA

Publication Date: February 2018

By Donna Rugg, RHIT, CDIP, CCS

The fiscal year (FY) 2018 Hospital Inpatient Prospective Payment System (IPPS) final rule was released August 3, 2017 and impacted discharges beginning October 1, 2017. This is version 35 of the MS-DRG grouper. The Centers for Medicare and Medicaid Services (C....

Author: Rudman, William J.; Hewitt, Calvin R.

Source: Journal of AHIMA

Publication Date: June 1999

You've heard a lot about ORYX. But have you considered these questions?


How many HIM professionals feel comfortable with or understand the meaning and application of statistical equations? Probably not many of us.


How many may feel intimidated, fru....

Author: Rudman, William J.; Hart-Hester, Susan; Jones, Warren A.; Caputo, Nadine; Madison, Mary

Source: Journal of AHIMA

Publication Date: October 2010

Integrating records of systemic and oral health would improve patient care. It would also open up a new frontier in health information management.

A fully integrated patient record and care model for both systemic health (medical) and oral health (dental) is needed for health informa....

Author: Rubin, Joshua C; Friedman, Charles P

Source: Journal of AHIMA

Publication Date: May 2014

As the “Vision” section of AHIMA’s website states, AHIMA aims to “lead the advancement and ethical use of quality health information to promote health and wellness worldwide.” In many ways, the Learning Health System’s (LHS) overarching vision represents....

Author: Ruano, Michael

Source: Journal of AHIMA

Publication Date: January 2003

Is your organization up to the challenge of creating a unified information security program?


A unified information security program has been all but mandated for healthcare organizations by the federal government. HIPAA requires that electronic, paper, and oral patient identif....

Author: Roth, Julie A.

Source: Journal of AHIMA

Publication Date: September 2004

When the HIPAA privacy rule went into effect, HIM professionals began juggling HIPAA standards along with all the other federal and state laws impacting health information privacy. While this juggling act is always difficult, the mix of HIPAA and the Family Educational Rights and Privacy Act....

Author: Roth, Julie A.

Source: Journal of AHIMA

Publication Date: February 2004

Although HIPAA currently enjoys the privacy spotlight, it is only one of several federal laws aimed at privacy protection. We have federal protections for everything from our medical and financial information to what videos we rent. When you add the various state privacy laws and accrediting....

Author: Roth, Julie A.

Source: Journal of AHIMA

Publication Date: March 2004

The HIPAA privacy rule is just one of several federal laws that protect the privacy of non-public information. But privacy is not a new concept in healthcare. Healthcare workers have long protected medical information under a varety of state and federal laws, accreditation standards, and rules....

Author: Roth, Julie A.

Source: Journal of AHIMA

Publication Date: February 2019

By Julie Roth, JD, MHSA, RHIA


Imagine the following scenario. Jane has served as the HIPAA security officer for a 200-bed community hospital for five years. Fortunately, the hospital’s governing board understands the importance of HIPAA compliance and provides the health informati....

Author: Rose, Eric

Source: Journal of AHIMA

Publication Date: July 2009

America’s physician practices are facing the biggest change in healthcare coding in decades: the replacement of ICD-9-CM by ICD-10-CM. This article discusses ICD-10-CM from a clinical perspective and reviews how electronic health record (EHR) systems will need to adapt to the transition.....

Author: Rose, Angela Dinh; Greene, Adam H

Source: Journal of AHIMA

Publication Date: February 2014

The final HITECH-HIPAA Omnibus Rule was released in January 2013 and expanded some of HIPAA’s original requirements involving its privacy, security, and enforcement components. The Omnibus also finalized the Breach Interim Final Rule as well as the Genetic Information Nondiscrimination Act (GINA).

The following are some commonly asked questions about the HITECH Omnibus Rule implementation and compliance requirements, specifically regarding the rule’s areas addressing business associates, breaches, and GINA.