Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2005

Last issue’s article presented some ways that DRG criteria redefine well-established clinical entities such as respiratory failure and sepsis. This article will discuss two other incompatibilities between DRG criteria and clinical practice: the clinical distinctions required by the DRG s....

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2005

A major frustration among coding professionals, particularly in the inpatient setting, is the difficulty in translating physician documentation into diagnostic related group (DRG) data. Some hospitals have attempted to improve their coding effectiveness by establishing time-consuming physician....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: October 2004

The 2004 Phoenix Health System/HIMSS HIPAA compliance survey indicates that providers find audit controls the most difficult of the HIPAA security standards to implement.
While it is recognized that every organization must conduct a risk analysis to determine the systems or activities th....

Author: Hill, Emily

Source: Journal of AHIMA

Publication Date: January 2000

From physician assistants to nurse practitioners, the number of healthcare professionals offering patient care services has increased dramatically in recent years. With this increase comes a challenge to coders—accurately reporting the services provided by these prof....

Author: Abraham, Prinny

Source: Journal of AHIMA

Publication Date: May 2001

The implementation of the Home Health Prospective Payment System (PPS) on October 1, 2001, has presented some unique compliance risks for HIM and billing managers. This article will briefly describe some of the compliance-related issues on the OIG's agenda that are of interest to HIM....

Author: Reich, Kimberly A. Baldwin-Stried

Source: Journal of AHIMA

Publication Date: May 2012

Paper-based and electronic record keeping systems each record valuable information about a patient's medical care. Electronic systems, however, capture something more-they record information about the record itself.

This "information about the information," called metadata, has caug....

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: October 2005

It’s an amazing challenge,” Suzanne Columbus admits. By 2008 the senior EHR implementation advisor must help at least 500 physician practices adopt health IT.

Columbus works at IPRO, New York State’s quality improvement organization (QIO). That puts her in the middl....

Author: Deming, Sally; Dooling, Julie A; Kadlec, Lesley; Kirby, Annessa; Munns, Megan

Source: Journal of AHIMA

Publication Date: April 2016

The 2015 Supreme Court decision requiring states to license a marriage between two people of the same sex and to recognize same sex marriage across state lines has widespread implications for health records management.1


This article will describe these implications and issu....

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2012

Patient-Centric Stage 2 Meaningful Use Measures Considered Treatment for Ailing US Health System



The US healthcare system is ill. Higher costs, sicker patients, and struggling providers are the symptoms of the disease that has sent industry stakeholders scrambling t....

Author: Rihanek, Theresa

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

Publication Date: June 2014

Traumatic brain injury (TBI) has received considerable attention by the media recently, especially bringing attention to the prevalence of TBI in sports-related activities. According to the Centers for Disease Control and Prevention (CDC), “A TBI is a bump, blow or jolt to the head o....

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: June 2015

Niall Brennan, director of the Office of Enterprise Data and Analytics and the first chief data officer at the Centers for Medicare and Medicaid Services (CMS), recognizes the pivotal role that data and information should play in transforming healthcare.


Before Brennan took....

Author: Foley, Margaret M.; Hall, Candace; Perron, Kathryn; D'Andrea, Rachael

Source: Journal of AHIMA

Publication Date: February 2007

Clinical mapping is essential because healthcare has no single medical terminology, making it difficult to understand and translate meanings across the different terminologies developed for different uses. Mapping allows the capture of data in the electronic health record (EHR) with the t....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: June 2003

There were no big surprises in the final security rule. As promised, it has been reconciled with the privacy rule and most redundancies were removed. The security rule addresses only electronic protected health information (ePHI), though we must not forget the privacy rule’s “mini-se....

Author: Giannangelo, Kathy

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

Publication Date: June 2007

Every profession has its own body of knowledge. This specialized knowledge leads the profession to create a language of its own, also.

The HIM profession has a distinct language and body of knowledge. Through them HIM professionals deliver a unique service to the healthcare industry.....

Author: Helbig, Susan

Source: Journal of AHIMA

Publication Date: April 2003

Life in today’s healthcare organizations is challenging for everyone involved—patients, providers, third-party payers, vendors, and HIM professionals. As HIM professionals, we are constantly in a state of transition in some area of our practice, which can be both challenging and rewa....

Author: Person, Carol; Terlep, Minnette

Source: Journal of AHIMA

Publication Date: July 2013

Facing a diminished role, transcriptionists at Sanford Health worked with the organization to move into open, and in-demand, coding roles



The need for transcription was diminishing at Sanford Health, and transcriptionists needed to make a choice-transition into another....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 10, 2015

With just four months until the big implementation day, you are probably feeling one of two things… Relief that it’s finally here and you can begin putting into practice everything you’ve learned over the past 5-6 years of preparation, or panic because you still have much more to do to pre....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2012

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: AHIMA ICD-10-CM/PCS Academic Transition Workgroup

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2009

The content in this practice brief has been retired. It is made available for historical purposes only. More recent information is available here.

Author: Houser, Shannon H.; Meadows, Jean M

Source: Journal of AHIMA

Publication Date: February 2017

There are a number of recent factors driving changes to how healthcare quality is being measured. First, there’s the rapid adoption of healthcare information technology (HIT) due to the Centers for Medicare and Medicaid Services (CMS) “meaningful use” Electronic Health Re....

Author: Smith, Gail I.; Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010

The coding world is not immune to technology advancements. Computer-assisted coding (CAC) technology is changing how the coding process is accomplished across all healthcare settings. CAC technology continues to integrate into a coding professional's daily life. This article focuses on the too....

Author: Dooling, Julie A; Houser, Shannon H.; Mikaelian, Raymound; Smith, Clarice Pittillo

Source: Journal of AHIMA

Publication Date: October 2016

Are you a data-driven individual? Is your health information management (HIM) department focused on becoming data-driven or informatics-oriented?


Today’s data analytics and informatics-oriented organizations are the centerpiece of operations and strategic visioning&mda....

Author: AHIMA e-HIM Work Group on the Transition to ICD-10-CM/PCS

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2009

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

Author: Wiedemann, Lou Ann; Dooling, Julie A

Source: Journal of AHIMA

Publication Date: March 2013

The Nationwide Health Information Network (NwHIN) was originally defined as a “set of standards, services, and policies” by the Office of the National Coordinator for Health IT (ONC) in 2007. Further changes were established in February 2009 as a part of the Health Information....

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 13, 2014

ICD-9-CM includes a supplemental section, E codes, to describe the external causes of injuries and poisonings. These codes are secondary codes for use in any health care setting, which are used to provide data for injury research and evaluation of injury prevention strategies. E codes....