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Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities

Author: Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M.

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2017


In order to effectively discuss clinical documentation improvement (CDI) opportunities in physician practices, it is important to first understand the drivers and goals of a physician practice CDI program. Historically, diagnosis codes have had little impact in regard to physician practice paym....

How Small Organizations Handle HIPAA Compliance

Author: Primeau, Debra

Source: Journal of AHIMA

Publication Date: April 2017



Smaller healthcare facilities typically lack the resources and expertise to address the constant flow of competing priorities, forcing leadership to wear many hats in a fragmented environment. Few have a designated privacy, security, or compliance officer, let alone the corporate support s....

Nothing Lasts Forever: How Physicians Can Prepare for the End of the One-Year Amnesty from Post Payment Reviews Due to Unspecified Codes

Author: Lee, Christine

Source: ICD-TEN Top Emerging News | AHIMA newsletter article

Publication Date: May 2016




Just as ocean tides shift with the earth's gravitational pull, physician practice administrators align staff and focus resources to address their organizations' most pressing concerns. This year, the tsunami grabbing administrators' attention is the conclusion of a one-year grace peri....

Bringing Physician Practices into the HIM Fold: Guidance on Making a Smooth Transition and Ensuring the MD/Hospital/HIM Relationship Remains Mutually Beneficial

Author: Lee, Christine

Source: Journal of AHIMA

Publication Date: April 2016



According to the American Medical Association (AMA), physician practices continued a slow but steady transition toward hospital ownership in 2015. In their July 2015 study, the AMA reported a decrease in physician-owned practices alongside a continual increase in physicians working direct....

Enhancing Practice Efficiency and Patient Care by Sharing Electronic Health Records

Author: Keller, Megan E; Kelling, Sarah E; Cornelius, Douglas C; Oni, Hafusat A; Bright, David R

Source: Perspectives in Health Information Management

Publication Date: 2015


Abstract


One primary function of community pharmacies is to dispense medications to patients. In doing so, pharmacists frequently communicate with physicians’ offices to clarify prescription orders and obtain additional information to ensure the safe and accurate dispensing of med....

Physician Coding Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: September 2015

This provider practice coding toolkit provides multiple tools and resources to help providers successfully navigate through the many changes in today’s healthcare environment.

Clinical Documentation Improvement in the Outpatient Setting

Author: Arrowood, Danita; Johnson, Laurie M.; Wieczorek, Michelle M.

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

Publication Date: July 2015



Clinical documentation improvement (CDI) programs have proven their worth with over a decade of success and continued role expansion in the inpatient setting. As the healthcare industry prepares for new initiatives such as value-based purchasing, electronic health records (EHRs), and ICD-1....

Implementing EHRs: An Exploratory Study to Examine Current Practices in Migrating Physician Practice

Author: Dolezel, Diane; Moczygemba, Jackie

Source: Perspectives in Health Information Management

Publication Date: January 2015


Abstract


Implementation of electronic health record (EHR) systems in physician practices is challenging and complex. In the past, physicians had little incentive to move from paper-based records. With the passage of the Health Information Technology for Economic and Clinical Healt....

Cost of Converting Small Physician Practices to ICD-10 Much Lower than Reported

Author: Kravis, Thomas C; Belley, Susan; Smith, Donna; Averill, Richard F.

Source: Journal of AHIMA - website

Publication Date: November 2014




The controversial delay of ICD-10 implementation was based in part on the perceived time, cost and lost productivity for physician offices to perform the necessary assessment, training, software conversions, testing and “super bill” updates.1 Current evidence suggests that....

Setting the Facts Straight About ICD-10: What Physicians Need to Know About the Transition

Author: AHIMA

Source: AHIMA Advocacy and Policy

Publication Date: November 2014

While many organizations see the benefits of using ICD-10, including the ability to capture more detailed information, others have concerns, including the costs of implementation. Despite the significant amount of information that has been published about ICD-10 during the last 10 years, many misconceptions persist today. The information below covers basic facts about the ICD-10 transition that are of particular interest to the physician community.

Examination of Office Visit Patient Preferences for the After-Visit Summary (AVS)

Author: Neuberger, Marolee; Dontje, Katherine; Holzman, Greg; Corser, Bill; Keskimaki, Abigail; Chant, Ericka

Source: Perspectives in Health Information Management

Publication Date: October 2014


Abstract


The federal government advocates the practice of routinely providing an after-visit summary (AVS) to patients after each office-based visit as an element of stage 1 meaningful use. A significant potential benefit of the AVS is improved patient engagement achieved by enabl....

Peer-to-Peer ICD-10 Training

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: February 2014




In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems.


The HIM Problem


Engaging the practicing physicians in the ICD-10-CM/PCS transition.


Getting physicians on-board with ICD-10-CM/PCS....

Anatomy of a Physician Coder: Small, medium, and large physician practices all feature these multi-tasking, multi-responsibility coders

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2012


An analysis of the “physician coder” anatomy would reveal a cornucopia of responsibilities nestled under this one succinct title.

They are equal parts clinical documentation improvement specialist, office manager, patient counselor, physician process tracker, coder... the list goes....

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....

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....

Role-based Model for ICD-10 Implementation: Health Plans

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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HIM in Physician Practices
: Comparing Health Information Management in Physician Practices and Hospitals


Author: Warner, Diana; Washington, Lydia

Source: Journal of AHIMA

Publication Date: August 2009


The majority of HIM professionals still practice in hospital settings and are most familiar with the HIM functions performed there.1 However, HIM professionals in hospitals frequently work with doctors in private practice, and HIM career opportunities may well grow in physician practices due t....

Preparing for ICD-10-CM in Physician Practices

Author: Kuehn, Lynn

Source: Journal of AHIMA

Publication Date: August 2009




What will change under ICD-10-CM, and what must be done to prepare? This is the year for physician practices to get their ducks in a row: become informed, assess their IT and training needs, and make a plan that leads to the October 1, 2013, deadline.



On September....

Physician Practice EHR Resources

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: August 2009



Editor's note: This article updates the February 2006 Journal of AHIMA column "Resources to Assist Physician Office EHR Selection and Implementation."


[Note: The links in this article were accurate at the time of publication.]




EHR Public and Priva....

Physician Practice Check-Up: Assessing a Practice’s Readiness for Electronic Health Records


Author: Crocker, Janice; Fahrenholz, Cheryl Gregg; Johnson, Wanda; Levinson, Stephen R; Washington, Lydia

Source: Journal of AHIMA

Publication Date: August 2009




Federal incentives will take some of the pain out of transitioning a practice to an electronic health record system, but the transformation will be monumental, nonetheless. For practices that take the leap, focusing initial efforts on a readiness assessment lays a solid foundation for....

Impact of Creating a Pay for Quality Improvement (P4QI) Incentive Program on Healthcare Disparity: Leveraging HIT in Rural Hospitals and Small Physician Offices [Commentary]

Author: Hart-Hester, Susan; Jones, Warren A.; Watzlaf, Valerie J.M.; Fenton, Susan H.; Nielsen, Carol; Madison, Mary; Arthur, Chris; Marbury, David; Rudman, LeeAnn; Patterson, Randi; Reynolds, Rebecca; Rudman, William J.

Source: Perspectives in Health Information Management

Publication Date: September 2008

Introduction

Reducing health disparities and improving healthcare quality for all Americans has become a national priority. 1–4 Approximately 16 percent (or $4 trillion) of America's gross domestic product is spent on healthcare. 5–7 Despite spending twice as much on healthcare as other i....

Tapping HIM Expertise for Physician Practice EHRs

Author: Mangin, Wendy L

Source: Journal of AHIMA

Publication Date: August 2008


Managing patient records has become more complex for medical practices. Electronic health records, quality reporting, and coding and documentation compliance all affect how a practice manages its patient information.


While improved information holds great promise for patient c....

Physicians and EHRs: a Bibliography

Author: AHIMA Work Group

Source: Journal of AHIMA

Publication Date: August 2008


The August 2008 issue of the Journal of AHIMA published a selected bibliography of research and writing on EHRs in physician practices. This is the extended version, as promised in the print issue.

"Physicians View Use of EMRs as Part of New Business Model." Capitation Management Repo....

Coding Preventive Care Services

Author: Wilkinson, Dianne

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2008


According to the Partnership for Prevention—a program-based organization of businesses, nonprofits, and government agencies—“the U.S. health care system suffers a quality deficit in part because too many patients do not get the effective preventive care they need when they ne....

Pilot Debrief: Lessons Learned Assisting Physician Practices Adopt Health IT

Author: Fergusson, Kevin; Archer, Nancy; Donnelly, Sharon; Okerson, Barbara; Parker, Charles; Weir, John

Source: Journal of AHIMA

Publication Date: June 2007


The pilot behind today’s nationwide DOQ-IT project offers early lessons on both the characteristics and assistance that help physician offices succeed with health IT.
Physician adoption of health IT has become a major policy priority in the United States. But despite the drive to g....

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