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Guidelines for Achieving a Compliant Query Practice FAQs

Author: AHIMA

Source: AHIMA

Publication Date: October 2019


This FAQ document was created by the authors of the AHIMA Practice Brief “Guidelines for Achieving a Compliant Query Practice (2019 Update)” to provide additional clarity to the subject matter covered in the original Brief.

Prior Encounters


Question: Is there....

Three Ways Analytics Optimizes Health Outcomes

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019


By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


Over the summer I was fortunate to participate in several conferences. I was both honored to be involved and enthralled at the expertise of all of the individuals who participated and presented.


Data is powerful. Data litera....

A Time to Be Bold

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019


By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


HIM professionals are well aware of the work involved in matching patients to their unique records. Mismatched records can cost us time, lead to frustration, and cause headaches and dissatisfaction for patients and provide....

Appendix D: Qualitative Productivity Tool Example

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019


Productivity expectations can be both qualitative and quantitative. Qualitative productivity is measuring the quality of the work being performed. This is typically measured by performing audits of the CDI professional’s work and then assigning a numeric value so it can be measured (see e....

Appendix C: Ongoing Education Plan

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019


An annual plan for ongoing education can be developed and started at the beginning of each calendar or fiscal year, or with the annual employee evaluation. The manager of the CDI team or designee can be required to ensure each education topic is offered to the employee during the year. It is im....

Appendix A: Key Points in Developing a CDI Program

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019

Recruitment Best Practices


Create a culture where great employees want to work

Consider the candidate’s cultural compatibility, leadership skills, communication skills, and intellectual ability

Consider all candidate streams when recruiting both internally an....

Appendix B: Orientation for New CDI Professionals

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2019


Orientation for new clinical documentation professionals should include the nuances involved in diagnosis, procedure, inpatient prospective payment systems (IPPS), and outpatient prospective payment systems (OPPS) capture. Some of these topics include concepts such as major diagnostic categorie....

Collaboration is Key to Leading Through Transformation

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019


By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


I am so inspired by our leaders all across the country. At last year’s CSA Leadership Symposium it was agreed that AHIMA was in a state of decline and that change was needed. It was an amazing moment—one I will never forget an....

New Starts and Transformation Wins

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019


By Wylecia Wiggs Harris, PhD, CAE, chief executive officer


September is a time of new starts. At AHIMA, it’s our busiest time of year as we prepare for our annual conference and a host of other fall and winter activities. It’s also a time to look back on the year: two-....

PHI Hide and Seek: Hidden PHI Carries High Financial Risk

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019


By Ken Reiher, MBA









Ken Reiher, MBA




New App Gives Patients a Chance to ‘Share This Appointment’ With Caregivers.

Author: AHIMA

Source: AHIMA

Publication Date: August 2019


When families unite to coordinate care for a sick loved one, getting everyone on the same page can feel like playing a high-stakes game of Telephone.


Even when the logistics of getting the patient to their tests, procedures, or hospital discharge planning sessions at the right tim....

The Danger of Being Connected

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2019


By Ty Greenhalgh, HCISPP


In 2014, the American Recovery and Reinvestment Act required and incented hospitals to demonstrate “meaningful use” of an electronic health record (EHR). Hospitals, desiring to maintain existing Medicaid and Medicare reimbursement levels and av....

Comcast Eyes Home Health Monitoring

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2019


A couple years ago, Saturday Night Live spoofed how senior citizens use automated home assistant products such as Amazon’s Echo by imagining a fictional product called Amazon Echo Silver—a device designed to help forgetful, hard of hearing seniors manage activities like turning up the thermosta....

Definition, History, and Use of the Problem List

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2019


The problem list was first defined and created by Lawrence Weed in the 1960s at a time when care continuity was its primary purpose. Problem lists have become more widely used as a basis for problem-oriented charting, a methodology for clinical documentation embraced by many in the medical esta....

Guidelines for Achieving a Compliant ICD-10-PCS Query (2019 Update)

Author: AHIMA

Source: AHIMA

Publication Date: June 2019


Editor’s Note: This Practice Brief supersedes the June 2016 Practice Brief titled “Guidelines for Achieving a Compliant ICD-10-PCS Query.”


The integrity of the documentation within the health record is vital as it reflects the care, treatment, and services delive....

Paper Workaround Defeats EHRs’ Purpose

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2019


In research findings that should surprise very few health information management (HIM) professionals, attending physicians and the colleagues they conduct morning rounds with think electronic health records (EHRs) aren’t well suited for rounding in patient rooms. Their disdain for this now perv....

Using CC/MCC Capture Rates as a Key Performance Indicator

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2019


The goal of this Practice Brief is to provide an explanation of the complication/comorbid condition and major complication/comorbid condition (CC/MCC) capture rate, review the calculation, and introduce the uses of this key performance indicator (KPI) by different functions of the mid-revenue c....

When Bedside Manner is Conveyed Through a Screen

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2019


If medicine is also an art and not just a science—as physicians who argue that each patient requires a different approach assert—then it’s hard to understand the rationale that led a California hospital to deliver end-of-life treatment plans via telemedicine “robots.”1


As several....

Health Information Management and Litigation: How the Two Meet

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2019


Editor’s Note: This Practice Brief supersedes the November-December 2013 “E-Discovery Litigation and Regulatory Investigation Response Planning: Crucial Components of Your Organization’s Information and Data Governance Processes” and October 2005 “Legal Process and Electronic Health Record....

IFHIMA Prepares for 19th Congress as Health Information Goes Global and Digital

Author: Fernandes, Lorraine M.; Butler-Henderson, Kerryn CHIA, FAHIMA; MacDonald, Marci; Skurka, Margaret A.; Lewis, Carol; AlBishi, Hussein; Axford, Kylie

Source: Journal of AHIMA

Publication Date: March 2019


By Lorraine Fernandes, RHIA; Kerryn Butler Henderson, PhD; Carol Lewis, MPH, RHIA; Marci MacDonald, CHIM; Margaret Skurka, MS, RHIA, CCS, FAHIMA; Hussein AlBishi; and Kylie Axford


Healthcare, like manY other segments of society and the economy, has become truly global.

<....

Digital Assistants Record First Privacy Breaches

Author: AHIMA

Source: Journal of AHIMA

Publication Date: March 2019

Incidents Create Questions About the Emerging Tech’s Use in Healthcare


Unquestionably, artificial intelligence (AI) is destined to revolutionize healthcare. It’s also highly likely that in the near future, lawmakers in the United States will pursue legislation to strengthen privacy law....

Best Practices for Denials Prevention and Management

Author: AHIMA

Source: AHIMA practice brief

Publication Date: March 2019


The direct fiscal impact of ever-increasing claim denials spans the healthcare continuum, including large health systems, independent hospitals, physician group practices, solo providers, and post-acute care facilities. A 2017 analysis of 850 hospitals’ payment transactions revealed that initia....

HIM Can Play a Role in Price Transparency

Author: AHIMA

Source: Journal of AHIMA

Publication Date: February 2019


While a lot has been done to fight some of the biggest inequities in healthcare—such as higher premiums or insurance denials for pre-existing conditions—some mysteries of the system remain impenetrable for consumers. Chief among those is price transparency and the quagmire that must be navigate....

IPPS Final Rule Changes for Fiscal Year 2019

Author: AHIMA

Source: Journal of AHIMA

Publication Date: January 2019




By Moira Hunger, RHIT


Though hard to believe, a new fiscal year (FY) is already well underway. The Centers for Medicare and Medicaid Services (CMS) released the final rule for the Hospital Inpatient Prospective Payment System (IPPS) on August 17, 2018. All changes were e....

Practice Brief: Ensuring the Integrity of the EHR

Author: AHIMA

Source: AHIMA practice brief

Publication Date: January 2019


Editor’s Note: This Practice Brief supersedes the August 2013 “Integrity of the Healthcare Record: Best Practices for EHR Documentation” and the May 2015 “Assessing and Improving EHR Data Quality” Practice Briefs.





Nearly 20 years have....

Future Forward

Author: Smith, Diann H. MS, RHIA, CHP, FAHIMA

Source: Journal of AHIMA

Publication Date: November 2018










By Diann H. Smith, MS, RHIA, CHP, FAHIMA


It is hard to believe this is my last Journal of AHIMA column as AHIMA’s President/Chair of the Board of Directors. I am genuinely grateful to have joined you in bringing to life the theme for AHIMA’s....

What’s in a Name?

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2018







It’s not at all uncommon for organizations to change their names several times before landing on one that captures their presence in the past, the present, and the future—especially if they are technology-focused. Take NCR Corp., which today sells every....

“Alexa, Let’s Schedule Some HIPAA Training”

Author: AHIMA

Source: Journal of AHIMA

Publication Date: October 2018








When a new technology emerges, there’s always a split between the early adopters and their more cautious counterparts. So when it comes to using a digital voice assistant like Amazon’s Echo, Google Home, or Apple’s Siri in a hospital’s intensive care unit (ICU), do....

Using Population Health, Inclusive HIM Practices to Better Treat LGBTQ Patients

Author: Dooling, Julie A; Kadlec, Lesley; Pruente, Megan; Ward, Maria; Woebkenberg, Jami; Butler-Henderson, Kerryn CHIA, FAHIMA; Ginn, Dustin MA, MHA, RHIA; Retallack, Donna RHIT; Young III, John RHIA, CHPS, CPHIMS, HCISPP

Source: Journal of AHIMA

Publication Date: September 2018









By Kerryn Butler-Henderson, CHIA, FAHIMA; Julie Dooling, MSHI, RHIA, CHDA, FAHIMA; Dustin Ginn, MA, MHA, RHIA; Lesley Kadlec, MA, RHIA, CHDA; Megan Pruente, RHIA; Donna Retallack, RHIT; Maria Ward, MEd, RHIA, CCS, CCS-P; Jami Woebkenberg, MHIM, RHIA, CPHI; and....

Celebrating 90 Years of AHIMA Conventions

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2018






From its founding era to present day, AHIMA’s signature event has been its annual convention and exhibit. The event has consistently drawn the most talented health information management (HIM) professionals for educational sessions and keynote speakers, sporting ba....

Appendix B: Query Escalation and Retention

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2018












Whatever the size and structure of the practice, and regardless of who is responsible for the query, general practices for escalation and retention should apply.

Timeframes


A pre-visit review of documentation may be usefu....

Appendix C: Query Examples

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2018











Example #1: Diagnosis is documented but is not clinically validated




Dear Doctor,


COPD exacerbation is documented within the clinic note dated 3/5/xx.


There is no documentation in the current h....

Appendix A: Query Monitoring/Auditing

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2018












Physician practices vary greatly in terms of number of physicians, size of staff, type of setting, management structure, and even whether they have CDI and/or credentialed coding professionals. As the healthcare industry moves toward population....

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