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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....

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....

Best Practices for Data Analytics Reporting Lifecycles: Quality in Report Building and Data Validation

Author: Clack, Lesley; Houser, Shannon H.; Kadlec, Lesley; Mikaelian, Raymound; Wendicke, Annemarie; Cain, Jeannine MSHI, RHIA, CPHI; Spears, Amanda MA, CHDA

Source: Journal of AHIMA | AHIMA practice brief

Publication Date: October 2018






While the importance of data quality in providing high-quality clinical care in today’s healthcare setting is typically well understood, the quality of data for report building and validation activities is often not well articulated—and potential data quality....

Beyond the Basics for Health Informatics Professionals - Retired

Author: Campbell, Angela; Houser, Shannon H.; Paulson, Dawn; Ryznar, Barbara; Smith, Clarice Pittillo; Woebkenberg, Jami; Hernandez, Sandra MSMIS, RHIA, CPHI, CCS, CHC; Pirie-St. Pierre, Mari RHIA, CPHI; Plimpton, Julie MSHI, RHIA, CPHI

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2018





Editor’s Note: This Practice Brief supersedes the September 2014 Practice Brief “Defining the Basics of Health Informatics for HIM Professionals.”


Data, data everywhere! We are living in the age of “Big Data” and healthcare informat....

Clinical Terminology: Expanding Career Pathways for HIM Professionals - Retired

Author: Hyde, Lynda; Casto, Anne B.; Koehler, Melissa; Lockwood, Famey; Peterson, Kathleen

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2017






Healthcare is an evolving world where data is central to all aspects of care. It is an information-intensive environment where data analysis is used to make decisions about the quality and safety of patient care, public health programs, and healthcare reform. At the core....

Impact of Physician Engagement on Clinical Documentation Improvement Programs (AHIMA Practice Brief)

Author: Combs, Tammy; Endicott, Melanie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2017


Physician engagement seems to be the buzzword in healthcare these days. Hospital administrators charged with various clinical improvement initiatives have come to realize that physician engagement is an essential element of success. While physician engagement in clinical documentation improveme....

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....

Improved Patient Engagement for LGBT Populations: Addressing Factors Related to Sexual Orientation/Gender Identity for Effective Health Information Management

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2017


One of the Healthy People 2020 objectives from the Office of Disease Prevention and Health Promotion is to improve the health, safety, and well-being of individuals in the lesbian, gay, bisexual, and transgender (LGBT) population.1 This population faces health disparities with barriers to healt....

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....

Provider’s Condensed Resource for Revenue Cycle, Coding Tools, and More

Author: Clack, Crystal; Freeman, Rae; Lewis, Laquette

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2017


A cyclone of regulatory requirements for providers has officially touched down in the United States. The Affordable Care Act (ACA), Medicare Access and CHIP Reauthorization Act (MACRA), patient-centered medical home (PCMH), and value-based purchasing (VBP) initiatives are contributing to dramat....

Clinical Validation: the Next Level of CDI (December 2016 update)

Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne

Source: AHIMA practice brief

Publication Date: December 2016


One of the more challenging tasks for both coding and clinical documentation improvement (CDI) professionals is clinical validation. This is a relatively new responsibility that has evolved as CDI programs mature and CDI and coding professionals advance their knowledge and collaboration on clin....

Managing a Data Dictionary (2016 update) - Retired

Author: Davoudi, Sion; Flanigan, Jill; Houser, Shannon H.; Kadlec, Lesley; Kirby, Annessa; VanSlyke, Daniel; Wendicke, Annemarie

Source: AHIMA practice brief

Publication Date: December 2016


This update supplants the 2012 practice brief “Managing a Data Dictionary.”


As healthcare organizations move to the electronic environment, the large volume and complexity of data collected is growing at unprecedented rates. While access to data has the potential to en....

Understanding Publicly Available Healthcare Data (2016) - Retired

Author: Buttner, Patty; Houser, Shannon H.; Flanigan, Jill; Mikaelian, Raymound; Ryznar, Barbara; Smith, Clarice Pittillo

Source: AHIMA practice brief

Publication Date: June 2016


This update supersedes the September 2013 practice brief, Understanding Publicly Available Healthcare Data, which replaced the January 2010 practice brief with the same title.


Healthcare organizations increasingly collect and utilize data for internal and external reporting on pa....

Guidelines for Achieving a Compliant ICD-10-PCS Query

Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2016



Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.




The complex and highly specific nature of ICD-10-PCS has changed....

Putting the ICD-10-CM/PCS GEMs into Practice (2016 update) - Retired

Author: Archer, Anita; Campbell, Angela; D'Amato, Cheryl; McLeod, Melissa; Rugg, Donna

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2016


Editor's Note: This Practice Brief supersedes the May 2013 and March 2010 Practice Briefs titled "Putting the ICD-10-CM/PCS GEMs into Practice."


Mappings between ICD-9-CM and ICD-10-CM/PCS will play a critical role in the successful utilization of ICD-10-CM/PCS. The Centers for Me....

Data Quality Management Model (2015 Update) - Retired

Author: Davoudi, Sion; Dooling, Julie A; Glondys, Barbara; Jones, Theresa D.; Kadlec, Lesley; Overgaard, Shauna M; Ruben, Kerry; Wendicke, Annemarie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2015


Editor’s Note: This Practice Brief supersedes the July 2012 “Data Quality Management Model (Updated),” the March 1998 “Checklist to Assess Data Quality Management Efforts,” and the June 1998 “Data Quality Management Model” Practice Briefs.


HIM Best Practices for Engaging Consumers in Their Overall Healthcare

Author: Kadlec, Lesley; Kirby, Annessa; Shaffer, Heidi; Warren, Paula

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2015


As a nation, the United States has been focused heavily on engaging consumers in their overall health and wellness. This has been propelled by federal initiatives such as the “meaningful use” Electronic Health Record (EHR) Incentive Program, mandated clinical quality measures based....

Implementation and Management of Patient Portals

Author: Baldwin, Kevin; Burton, Benjamin W; Cothran, Carey L.; DeMasters, Dana; Grady, Reginald; Halpert, Aviva M.; Hofman, Judi; Kadlec, Lesley; O'Dell, Rosann M; Pearson, Sandra; Deanna, Peterson; Rode, Dan; Rose, Angela Dinh; Schmidt, Peg

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2015


The advancement of technology has changed the practice of medicine. It has evolved the physician-patient relationship from solely a face-to-face interaction into real-time online encounters, from e-mails to virtual appointments. Patient portals represent such a technological advancement, leadi....

ICD-10-CM Coding Guidance for Long-Term Care Facilities

Author: Liebner, Carole S; Lowery, Amanda L; Maccariella-Hafey, Patricia C; Usher, Joan L; Ward, Maria; Young, Carol

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2015


Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. Come October 1, 2015, LTC facilities will assign ICD-10-CM codes to capture a resident's clinical conditions.


ICD-10-CM facilitates the collection and....

Measuring the Value of the Clinical Documentation Improvement Practitioner (CDIP) Credential - Retired

Author: Burgess, Sheila; Cooper, Sharon; Endicott, Melanie; Wallace, Susan; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2015


This Practice Brief has been updated. See the latest version here. This version is made available for historical purposes only.

The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first began in the late 1990s, the focus was almost....

Tips for Breaking into the Health Information Management Industry - Retired

Author: Camp, Michelle; Comfort, Angie; Endicott, Melanie; Howard, Artis; Kozee, Renee; Munive, Roberta; Novelli, Staci

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2014


Whether it is a first job or a career change, finding that first health information management (HIM) job following graduation is one of the biggest challenges that new graduates face. While some may find that breaking into the HIM industry takes time and persistence, it is a career choice that....

Clinical Documentation Guidance for ICD-10-CM/PCS - Retired

Author: Bielby, Judy A; Comfort, Angie; Reed, Andretta; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2014


Organizations were well on their way to an October 1, 2014 implementation of ICD-10-CM/PCS when Congress passed H.R. 4302, the Protecting Access to Medicare Act of 2014. This bill contained a section stating that the Department of Health and Human Services (HHS) could not adopt the new code set....

Navigating a Compliant Breach Management Process

Author: Downing, Katherine

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2014

The purpose of AHIMA’s new Breach Management Toolkit is to provide a comprehensive collection of resources and best practices to help healthcare organizations and health information management (HIM) professionals navigate their way through the Health Insurance Portability and Accountability Act (HIPAA) Breach Notification Rule and the overall breach management process. The toolkit is intended to raise awareness of the importance and responsibility of everyone within the organization to report HIPAA breaches to the appropriate designated personnel, as well as provide breach prevention education and training.

Managing the Integrity of Patient Identity in Health Information Exchange (2014 update)

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2014

This Practice Brief explores the complexity of patient identification integrity, including how organizations can manage patient identification systems from front end data capture to back end quality control as an ongoing process and carry local quality operations into health information exchange efforts. It urges industry stakeholders to recognize that now is a critical time to address accuracy in patient identification systems.

Privacy and Security Audits of Electronic Health Information (2014 update)

Author: Walsh, Tom; Miaoulis, William M

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2014

In a perfect world, access controls alone would ensure the privacy and security of electronic protected health information (ePHI). However, the complexities of today’s healthcare environment make it extremely challenging to limit access to the minimum information necessary that members of the workforce require in order to perform their jobs.

Enabling Consumer and Patient Engagement with Health Information - Retired

Author: Washington, Lydia

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2014

The purpose of this Practice Brief is to understand the relationship between health information management and consumer/patient engagement, and examine how HIM professionals can advance and support engagement. Its focus is on policies and practices that enable the individual’s access to and use of health information.

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.

Evolving the PPE to Meet Changing HIM Workforce Needs

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2014

This Practice Brief will educate readers on the challenges and opportunities surrounding the PPE. The desired outcome is to expand options for PPEs and increase support of the PPE throughout the healthcare industry. Providing additional options and increasing practitioner support of the PPE will result in creating a stronger and better prepared generation of new HIM professionals.

HIPAA Security Overview - Retired

Author: Miaoulis, William M

Source: AHIMA practice brief

Publication Date: November 2013


Editor’s note: This update replaces the April 2004 and the November 2010 practice briefs titled “A HIPAA Security Overview.”


The HIPAA security rule has remained unchanged since its implementation more than a decade ago. However, the Health Information Technology for Economic a....

E- Discovery Litigation and Regulatory Investigation Response Planning: Crucial Components of Your Organization’s Information and Data Governance Processes

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2013

I. What is E-Discovery?



E-discovery is defined as the pretrial legal process used to describe the method by which parties will obtain and review electronically stored information. The 2006 Federal Rules of Civil Procedure (FRCP) served to place electronically stored information (....

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....

The 10 Security Domains (Updated 2013) - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013


Editor's note: This update supersedes the February 2004, February 2010, and May 2012 practice briefs "The 10 Security Domains."


In today's healthcare environment, HIM professionals must understand basic information security principles to fully protect the privacy of information. T....

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....

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