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Key Points of the UB-04 (2010 update)

Author: AHIMA Clinical Terminology and Classification Practice Council; Garrett, Gail S.; Jorwic, Therese M; Novak, Natalie; Ruhnau-Gee, Becky; Safian, Shelly C; Zeisset, Ann M.

Source: AHIMA practice brief

Publication Date: April 2010


Editor’s note: This update replaces the October 2006 practice brief “Key Points of the UB-04.”

In 2005 the National Uniform Billing Committee (NUBC) approved the Uniform Bill (UB-04) paper claim and data set as the replacement to the UB-92 paper form.1 Currently, all paper claims must....

Using Medical Scribes in a Physician Practice

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2012


With the push to develop and deploy electronic health records (EHRs) and the need for more detailed documentation, there is a growing concern in the medical community regarding the time expended to capture information-electronic or otherwise. The time providers spend during a patient visit capt....

Retention and Destruction of Health Information

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013


Editor's note: This update supersedes the August 2011 practice brief "Retention and Destruction of Health Information."



Health information management professionals traditionally have performed retention and destruction functions using all media, including paper, images, optic....

Meaningful Use Vocabulary Toolkit

Author: AHIMA

Source: AHIMA toolkit

Publication Date: April 02, 2013

This toolkit provides guidance to health information management (HIM) professionals and the industry on vocabularies as defined by ARRA’s meaningful use criteria. It includes a table of standard vocabularies required for Meaningful Use, a case study that shares lessons learned from Stage 1, and sample job descriptions to address the need for mapping professionals in the workplace.

Role-based Model for ICD-10 Implementation: Long Term Care

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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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,....

Performing a Breach Risk Assessment - Retired

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2013


On August 24, 2009, the US Department of Health and Human Services (HHS) published 45 CFR Parts 160 and 164 Breach Notification for Unsecured Protected Health Information; Interim Final Rule to implement the breach notification provisions of the Health Information Technology for Economic and Cl....

Ethical Standards for Clinical Documentation Improvement (CDI) Professionals (2016)

Author: AHIMA

Source: AHIMA

Publication Date: June 2016

The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity. They are relevant to all clinical documentation improvement professionals and to those who manage the clinical documentation improvement (CDI) function, regardless of the healthcare setting in which they work.

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