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Hybrid Records in a Hospice Setting

Author: Barbera, Linda

Source: Journal of AHIMA

Publication Date: May 2006


The hospice setting is no stranger to the challenges of transitioning from paper to electronic documentation. Ensuring that hybrid medical records provide complete and accurate documentation is a significant issue, particularly for reimbursement processes. In order for the documentation to prov....

ICD-10-CM/PCS Project Management Resources

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2009


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



Transitioning to ICD-10-CM/PCS will be a major undertaking for healthcare organizations. Below are ICD-10-CM/PCS project management resources and templates that organizations can use to h....

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....

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....

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....

Identity Proofing: Just a Fancy Name for Verification?

Author: Herrin, Barry S.

Source: Journal of AHIMA

Publication Date: May 2007


Among the issues being brought to the fore in the movement to electronic health records (EHRs) is identity proofing. However, this is the same issue healthcare providers have faced for as long as patients have been contacting providers in ways other than face-to-face communications. This artic....

IHC Eyes E-health Code of Ethics

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: June 2000


The privacy of personal information on the Internet is a hot topic nationwide. Is an e-health code of ethics in order? AHIMA and several other organizations are offering guidance this spring to the industry's first attempt at one.

Together with the American Medical Informa....

Imaging System Propels HIM Department to EHR

Author: Bechert, Londa

Source: Journal of AHIMA

Publication Date: September 2002


St. Vincent Hospital and Health Services in Indianapolis, IN, is a member of the Ascension Health network, a nationwide Catholic health ministry. The HIM department has centralized responsibility for the main campus (650 beds) in Indianapolis, the St. Vincent Carmel Hospital (65 beds), and mul....

Implementing a Document Imaging System

Author: Myjer, D'Arcy; Madamba, Roderick

Source: Journal of AHIMA

Publication Date: October 2002


The benefits of a document imaging system are myriad once it's installed—it's the implementation that you need to prepare for. In this article, get a bird's eye view of one facility's implementation and the many lessons learned along the way.

Healthcare has been inching toward....

Implementing the Enterprise Master Patient Index

Author: Adragna, Lisa

Source: Journal of AHIMA

Publication Date: October 1998


In implementing a cross-facility initiative, the importance of planning and understanding the implications for all facilities can't be overlooked. Here's how one integrated delivery network navigated the challenges of implementing a cross-facility enterprise master patient inde....

Implementing the Wireless Computerized Patient Record

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: July 1997


The ability to provide timely, relevant, and accurate in-formation to the healthcare decision maker at the point of care is a critical success factor for any provider. For enterprises that operate in extremely competitive healthcare markets, the ability to meet this challenge could mean the d....

Improving Coding and Documentation Quality Through Real-Time Collaboration: Nurses and Coding Professionals Team Up to Tackle Documentation Issues

Author: Horn, Kelli; Younger, Adrienne; Snow, Trevor

Source: Journal of AHIMA

Publication Date: August 2016



While working through the recent implementation of ICD-10, leaders at Ardent Health Services began to focus on the re-bill process and what it would look like in the months following use of the new code set. Re-billing means submitting a corrected bill to the payer after it has been rejec....

Improving the Collection of Race, Ethnicity, and Language Data to Reduce Healthcare Disparities: A Case Study from an Academic Medical Center

Author: Lee, Wei-Chen; Veeranki, Sreenivas P; Serag, Hani; Eschbach, Karl; Smith, Kenneth D

Source: Perspectives in Health Information Management

Publication Date: October 2016


Abstract


Well-designed electronic health records (EHRs) must integrate a variety of accurate information to support efforts to improve quality of care, particularly equity-in-care initiatives. This case study provides insight into the challenges those initiatives may face in colle....

Information Asset Inventory for Information Governance - Retired

Author: Downing, Kathy; Fahy, Kristi; Foster, MeShawn; Hermann, Michelle; Meehan, Ann M.; Washington, Lydia; Woebkenberg, Jami

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2017


When an organization begins to implement an enterprise information governance (IG) program, one of the major initial tasks is to understand the scope and types of information in its possession. An inventory of an organization’s information is necessary in order to facilitate decision maki....

Information Security—An Overview (2014 update)

Author: Miaoulis, William M

Source: AHIMA practice brief

Publication Date: January 2014

This practice brief provides an overview of information security, including some of the background and basic concepts involved in securing the privacy of health information. Included are key roles and responsibilities as well as a list of specific policies and procedures that should be considered when developing an organizational security program. References, a checklist, and assistance in developing policies and procedure are also provided to assist readers in the actual development of a security program.

Integrating Research Data Capture into the Electronic Health Record Workflow: Real-World Experience to Advance Innovation

Author: Laird-Maddox, Marsha; Mitchell, Susan B; Hoffman, Mark

Source: Perspectives in Health Information Management

Publication Date: October 2014


Abstract


As the adoption of electronic health records (EHRs) increases, more opportunities are available for leveraging the system and the data to facilitate research. Historically, for patients enrolled in clinical research trials or studies, data have been documented in the medi....

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