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EHRs as the Business and Legal Records of Healthcare Organizations. Appendix A: Issues in Electronic Health Record Management (2010 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


Electronic health record management (EHRM) is the process by which electronic (e.g., digital) health records are created or received and preserved for legal or business purposes. EHRM requires decision making throughout the EHR’s life cycle-through the processing, distribution, maintenanc....

EHRs as the Business and Legal Records of Healthcare Organizations. Appendix B: Checklist for Transition to the EHR (2010 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


Editor's note: This checklist combines and updates the October 2004 practice brief appendix "The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the EHR" and the June 2005 practice brief "A Checklist for Assessing HIM Department Readiness and Planning f....

Migrating from Paper to EHRs in Physician Practices. Appendix A: Historical Medical Record/Chart Abstraction Checklist—Primary Care

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


This checklist can help physician practices migrate all the appropriate data from an individual patient paper record into the EHR. Each record or data element should be expanded upon with descriptions based on the practice’s definitions, the location of the information in the paper chart,....

Migrating from Paper to EHRs in Physician Practices - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2010


A successful transition from paper-based charts to electronic health records (EHRs) in the physician practice or clinic requires careful coordination of many moving parts. A myriad of challenging and complex decisions must be made, ranging from selection and implementation to training and maint....

ICD-9-CM Coding Guidance for LTC Facilities. Appendix B: Reporting and Sequencing Diagnoses on the Health Record and UB-04 Claim Form

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010


The "ICD-9-CM Official Guidelines for Coding and Reporting" is updated annually, thought it may be changed more frequently. Coders should be familiar with the guidelines and use the most current version.

The guidelines provide the following guidance for principal/first-listed and con....

Strategies for Remote Coding Success: Remote Coding Program Helps Norman Regional Retain Quality Coders

Author: Miller, Amy; Ridpath, Debra

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2010


Remote coding is helping organizations attract and retain experienced coding professionals at a time when highly skilled coding professionals are in short supply. Successfully implementing a remote coding program requires that facilities have their entire clinical documentation online and qual....

ICD-9-CM Coding Guidance for LTC Facilities - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2010


Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. LTC facilities assign ICD-9-CM codes to capture a resident's clinical conditions.


ICD-9-CM facilitates the collection and organization of healthcare stat....

ICD-9-CM Coding Guidance for LTC Facilities. Appendix C: Regulatory Guidance for Reporting Diagnoses Related to Reimbursement

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010


In August 2000, the HIPAA Transaction and Code Sets required the use of the ICD-9-CM code set. Subpart J, section §162.1002 Medical data code sets, states the adoption of the following code sets as standard medical data code sets:
ICD-9-CM, volumes 1 and 2 (including the "ICD-9-CM Official....

Success with Speech Recognition

Author: Clawson, Cathy

Source: AHIMA Convention

Publication Date: September 28, 2010


Introduction: Since Mountain States Health Alliance implemented the Dolbey Speech Recognition platform in October 2007; gains in productivity, decrease in outsourcing, and financial savings have confirmed the successful implementation of this technology.
Background/History: Mountain Sta....

Role of Data Analysis in Revenue Cycle Improvement

Author: White, Susan E

Source: AHIMA Convention

Publication Date: September 27, 2010

Introduction

Data analysis techniques are becoming increasingly important for HIM professionals. The application of relatively simple and straightforward data analytics can identify significant opportunities for improvement in the revenue cycle. Traditional chart audits can be enhanced b....

Understanding the HIE Landscape

Author: AHIMA

Source: AHIMA practice brief

Publication Date: September 2010


The health information exchange (HIE) landscape has changed dramatically over the past five years. More HIEs are available to organizations and providers than ever before. Industry initiatives leveraging technological advances and the call for all Americans to have an electronic health record b....

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