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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....
Clinical Validation: The Next Level of CDI (January 2019 Update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: February 2019
This Practice Brief supersedes the 2016 Practice Brief titled “Clinical Validation: The Next Level of CDI.”
As healthcare continues to evolve and quality of care is tied to claims data and payment methodologies, payer expectations regarding what clinical documentation eleme....
Clinical Validation: The Next Level of CDI (January 2019 Update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: February 2019
This Practice Brief supersedes the 2016 Practice Brief titled “Clinical Validation: The Next Level of CDI.”
As healthcare continues to evolve and quality of care is tied to claims data and payment methodologies, payer expectations regarding what clinical documentation eleme....
Best Practices in the Art and Science of Clinical Documentation Improvement (2018 Update)
Author: AHIMA
Source: Journal of AHIMA | AHIMA practice brief
Publication Date: January 2019
Editor’s Note: This Practice Brief update supersedes the July 2015 Practice Brief titled “Best Practices in the Art and Science of Clinical Documentation Improvement.”
Clinical documentation improvement (CDI) is a discipline focused on improv....
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....
Redisclosure of Protected Health Information (PHI) (2018 Update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: November 2018
Editor’s Note: This update supersedes the 2013 Practice Brief “Redisclosure of Patient Health Information.”
Redisclosure is the act of sharing or releasing health information that was received from another source, such as an extern....
Measuring the Value of the Certified Documentation Improvement Practitioner (CDIP) Credential (2018 Update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: October 2018
Editor’s Note: This Practice Brief supersedes the January 2015 Practice Brief titled “Measuring the Value of the Certified Documentation Improvement Practitioner (CDIP) Credential.”
The role of the clinical documentation improvement (CDI) professio....
Information Governance Offers a Strategic Approach for Healthcare (2018 Update) - Retired
Author: AHIMA
Source: AHIMA practice brief
Publication Date: October 2018
Editor’s Note: This Practice Brief supersedes the November 2015 Practice Brief titled “Information Governance Offers a Strategic Approach for Healthcare.”
Information governance (IG) practices are increasingly being adopted across healthcare, according to The Pulse on Info....
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....
Guidelines for Physician Office Query Practice
Author: Bryant, Gloryanne H.; Mogbo, Chinedum
Source: AHIMA practice brief
Publication Date: July 2018
Untitled Document
Guidelines for Physician Office Query Practice
Documentation in the health record is a basic but critical component to every patient encounter, patient service, and setting. The provider is key to delivering detailed information reg....
Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories
Author: Watson, Monica M
Source: Journal of AHIMA | AHIMA practice brief
Publication Date: June 2018
Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories
Risk adjustment is a statistical process that considers the underlying health status and health spending of patients when examining their healthcare outcomes....
Managing Amendments in an HIE Environment. Appendix C AHIMA Sample Patient Statement of Disagreement
Author: AHIMA
Source: AHIMA practice brief
Publication Date: December 2017
Patient Name:_______________________________________________________________________
Date of Birth:________________________________________________________________________
Address: ____________________________________________________________________________
City:__________....
CDI Expanding Beyond the Hospital Walls through Standards
Author: Ewoterai, Okemena; Lusk, Katherine; Orlova, Anna; Young, Donna
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: November 2017
The proverbial comparison of “apples and oranges” is a well-known metaphor in casual conversation and discussion. When talking about expanding clinical documentation improvement (CDI) programs in today’s environment of electronic health records (EHRs) and information governanc....
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....
Evolution of DRGs (2017 Update)
Author: Comfort, Angie; Rugg, Donna; Ward, Maria
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2017
Editor’s Note: This update replaces the 2010 Practice Brief “The Evolution of DRGs.”
In the early 1970s Yale University developed diagnosis related groups (DRGs) to describe all types of patient care in an acute care hospital. The Yale system encompassed the Medi....
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....
Making Amendments to Health Records (2017 Update)
Author: Burton, Ben; Downing, Katherine
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: April 2017
Editor’s Note: This Practice Brief update supplants part of the 2013 Practice Brief “Patient Access and Amendment to Health Records.”
Before April 2003, a patient’s legal right to amend his or her health records was limited to those patients treated at hea....
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....
Standardizing Data and HIM Practices for Interoperability
Author: Orlova, Anna; Rhodes, Harry B.; Warner, Diana
Source: Journal of AHIMA | AHIMA practice brief
Publication Date: November 2016
Despite the many advancements in health information technology (HIT) that the industry has seen in recent years, the interoperability of HIT applications continues to present a challenge. Implementing standards—a definition, set of rules or guidelines, example format, or other document th....
Guidelines for a Compliant Business Associate Agreement (2016)
Author: AHIMA Work Group
Source: AHIMA practice brief
Publication Date: October 2016
This update supersedes the November 2013 practice brief, Guidelines for a Compliant Business Associate Agreement.
The Privacy Rule portion of the Health Insurance Portability and Accountability Act (HIPAA) defines a "business associate (BA) as a person or entity that performs....
Best Practices for Patient Matching at Patient Registration
Author: AHIMA Work Group
Source: Journal of AHIMA | AHIMA practice brief
Publication Date: October 2016
Accurate patient identification is a major challenge faced by healthcare organizations across all levels of care throughout the industry. Health information management (HIM) professionals play a critical role in collecting identifiable information and matching the patient to their health record....
Managing the Present on Admission Reporting Process (2016 update)
Author: Campbell, Angela; D'Amato, Cheryl; Rugg, Donna
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2016
Editor’s Note: This Practice Brief is an update of the March 2010 version, which replaced the November 2007 Practice Brief “Planning for Present on Admission.”
Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to report patient primary and....
Clinical Validation: The Next Level of CDI
Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2016
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
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....
EHRs Serving as the Business and Legal Records of Healthcare Organizations (2016 Update)
Author: Glondys, Barbara; Kadlec, Lesley
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: May 2016
Editor’s Note: This update supersedes the November 2010 update, EHRs as the Business and Legal Records of Healthcare Organizations that combined information from the October 2004 Practice Brief “The Strategic Importance of Electronic Health Records Management” and the Jun....
Understanding Cybersecurity: A Primer for HIM Professionals - Retired
Author: Dill, Mark W; Lucci, Susan; Walsh, Tom
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: April 2016
As protectors of patient health records, health information management (HIM) professionals are developing a keener understanding of the broad topic of cybersecurity and are becoming actively involved in organizational cybersecurity efforts. Information technology (IT) departments typically are....
HIM Best Practices for Records Management at Transitions of Care
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: March 2016
There is a significant amount of evidence that points to the existence of serious quality concerns for patients undergoing care transitions across multiple care settings. The 2001 Institute of Medicine (IOM) report “Crossing the Quality Chasm” famously described the US system as dec....
Managing Unsolicited Health Information in the Electronic Health Record (2016 update)
Author: Kadlec, Lesley
Source: AHIMA practice brief
Publication Date: January 2016
Editor’s Note: This Practice Brief supersedes the October 2013 Practice Brief titled "Managing Unsolicited Health Information in the Electronic Health Record"
Consumer engagement is developing as a key focus area in US healthcare, and patients are increasingly able&mdas....
Guidelines for Achieving a Compliant Query Practice (2016 Update)
Author:
Source: AHIMA practice brief
Publication Date: January 2016
Editor’s Note: This Practice Brief has been updated. See the latest version: http://bok.ahima.org/doc?oid=302674. This version is made available for historical purposes only.
In court an attorney can’t “lead” a witness into a....
Data Mapping Best Practices (2016 update) - Retired
Author: Maimone, Carol
Source: AHIMA practice brief
Publication Date: January 2016
This practice brief supersedes the November 2013 practice brief “Data Mapping Best Practices.”
The healthcare industry collects vast amounts of data from electronic sources. These data are captured in a wide variety of formats using various collection methods. Health d....
Using CDI Programs to Improve Acute Care Clinical Documentation to Support ICD-10-CM/PCS - Retired
Author: Combs, Tammy
Source: AHIMA practice brief
Publication Date: January 2016
Editor's note: This brief replaces the 2001 practice brief "Documentation Requirements for the Acute Care Inpatient Record, and the 2013 and 2014 versions of the practice brief "Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS."
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....
Climbing Higher: Bridging the Gap to Advanced Degrees in HIM (2016 update)
Author: Kadlec, Lesley
Source: AHIMA practice brief
Publication Date: January 2016
Editor’s Note: This Practice Brief supersedes the August 2012 Practice Brief titled “Climbing Higher: Bridging the Gap to Advanced Degrees in HIM.”
Statistics from the US Department of Labor show the field of HIM as one of today's fastest-growing occupa....
Consumer-Facing Health Information Practices (2016 update) - Retired
Author: Kadlec, Lesley
Source: AHIMA practice brief
Publication Date: January 2016
Increased adoption and use of health information technology by healthcare providers has made greater consumer access to health information possible, as well as increased general engagement in health maintenance and care. The opportunities for improving quality and efficiency afforded by this ne....
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....
Best Practices in the Art and Science of Clinical Documentation Improvement
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2015
Editor’s Note: This Practice Brief has been updated. See the latest version here. This version is made available for historical purposes only.
Clinical documentation improvement (CDI) is an entire discipline focused on improving the clinical clarity of the health record. Prac....
Electronic Documentation Templates Support ICD-10-CM/PCS Implementation (2015 update)
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2015
Editor’s Note: This Practice Brief supersedes the October 2012 Practice Brief “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation.”
Improving patient care continues to take center stage in the healthcare industry, as demonstrated by an increa....
Assessing and Improving EHR Data Quality (2015 update)
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: May 2015
Editor’s Note: This Practice Brief supersedes the March 2007 [and March 2013] Practice Brief “Assessing and Improving EHR Data Quality.”
The United States-based Institute of Medicine (IOM) reported in 1999 that “at least 44,000 people, and perhaps as many a....
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....
Including Patient-Generated Health Data in Electronic Health Records
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: February 2015
Healthcare providers and health information technology (HIT) suppliers across the country have been busy preparing for what could be one of the most significant proposals for stage 3 of the “meaningful use” EHR Incentive Program—a proposal that has wide implications for health....
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....
Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS (2014 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: December 2014
Editor's note: This practice brief has been updated. See the latest version here.
Electronic Health Record Adoption in Long Term Care (2014 update)
Author: AHIMA Longitudinal Coordination of Care Practice Council E-HIM Strategy Team
Source: AHIMA practice brief
Publication Date: November 2014
This practice brief supersedes the January 2011 “EHR Adoption in LTC and the HIM Value” practice brief.
Electronic health record (EHR) systems offer care, treatment, and communication opportunities for long-term care (LTC) facilities and their patients and residents. M....
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....
Information Governance Offers a Strategic Approach for Healthcare
Author: Kadlec, Lesley; Warner, Diana; Washington, Lydia
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: October 2014
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Transitioning to ICD-10-CM/PCS in the Classroom: Countdown to Implementation - Retired
Author:
Source: AHIMA practice brief
Publication Date: September 2014
The compliance date for the implementation of ICD-10-CM/PCS is due to take effect on October 1, 2015. Currently, academic programs are in various stages of transitioning the classroom toward this new and long-awaited classification system. This practice brief is the third in a series addressing....
Defining the Basics of Health Informatics for HIM Professionals - Retired
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2014
All data are not created equal and technology implementation alone is not enough to improve the healthcare provided to patients. Providers and organizations must be able to distinguish between an abundance of data, meaningful data, and integration of data. Healthcare organizations are challenge....
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.
Managing a Patient’s Right to Request Restrictions of Disclosures to Health Plans
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: April 2014
Covered entities should already have in place the mechanisms for limiting PHI under minimum necessary policies and procedures. This Practice Brief provides guidance to assist organizations in complying with the 2013 HITECH-HIPAA Omnibus Rule’s new disclosure restriction requirements.
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.
Laws and Regulations Governing the Disclosure of Health Information (2014 update)
Author: Hofman, Judi; Rose, Angela Dinh
Source: AHIMA practice brief
Publication Date: January 2014
This practice brief provides a general overview of the laws and regulations impacting the timely and appropriate release of PHI.
Securing Wireless Technology for Healthcare (2013 update) - Retired
Author: Evans, Brian
Source: AHIMA practice brief
Publication Date: November 2013
Editor's note: This update supplants the May 2004 practice brief "Securing Wireless Technology for Healthcare"
Overview
Wireless local area network (WLAN) environments have evolved from simple, unmanaged stand-alone access points (APs) to organizationally managed system....
Understanding Governmental Audits (2013 update)
Author: Rihanek, Theresa; Lopez, Doreen
Source: AHIMA practice brief
Publication Date: November 2013
This practice brief supersedes the July 2011 practice brief "Understanding Governmental Audits."
Today, armed with enhanced fraud and abuse laws, the federal government has launched new audits that organizations and providers must contend with on a regular basis. Recent additions....
Automated Coding Workflow and CAC Practice Guidance (2013 update)
Author: AHIMA Work Group
Source: AHIMA practice brief
Publication Date: November 2013
Editor’s Note: This update supersedes the July 2010 practice brief “Automated Coding Workflow and CAC Practice Guidance.”
Over the past decade, clinical coding has become more complex due to:
The expansion of prospective payment systems to multipl....
Security Risk Analysis and Management: An Overview (2013 update)
Author: Walsh, Tom
Source: AHIMA practice brief
Publication Date: November 2013
Editor’s note: This update replaces the January 2011 practice brief “Security Risk Analysis and Management: An Overview.”
Managing risks is an essential step in operating any business. It’s impossible to eliminate all threats; however, healthcare organizati....
Data Mapping Best Practices (2013 update) - Retired
Author: AHIMA Work Group
Source: AHIMA practice brief
Publication Date: November 2013
This practice brief has been updated. See the latest version here.
Privacy and Security Audits of Electronic Health Information (2013 update)
Author: Walsh, Tom
Source: AHIMA practice brief
Publication Date: November 2013
Editor’s note: This update supplants the March 2011 practice brief “Security Audits of Electronic Health Information (Updated).”
In a perfect world, access controls alone would ensure the privacy and security of electronic protected health information (ePHI). How....
Authorization Requirements for the Disclosure of Protected Health Information - Retired
Author: Dunn, Rose T; Rose, Angela Dinh; Wieland, LaVonne R.
Source: AHIMA practice brief
Publication Date: November 2013
Editor’s note: The following article supplants information contained in the October 2002 “Required Content for Authorizations to Disclose” Practice Brief.
The HIPAA privacy rule became effective April 14, 2003, and established standards for information disclosure....
Guidelines for a Compliant Business Associate Agreement - Retired
Author: AHIMA
Source: AHIMA practice brief
Publication Date: November 2013
This 2013 practice brief version has been retired and is retained here for historical purposes. Read the 2016 updated version of this Practice Brief here.
The Privacy Rule portion of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 defines a "business....
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 (....
Redisclosure of Patient Health Information (2013 update)
Author: Downing, Kathy; Odia, Godwin
Source: AHIMA practice brief
Publication Date: November 2013
Editor’s note: This update supplants the 2009 practice brief “Redisclosure of Patient Health Information.”
Redisclosure is the act of sharing or releasing health information that was received from another source (e.g., external facility or provider) and made part....
Authorization Requirements for the Disclosure of Protected Health Information. Appendix A: Sample Authorization Form
Author: AHIMA
Source: AHIMA practice brief
Publication Date: November 2013
Data Standards, Data Quality, and Interoperability (Updated) - Retired
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: November 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
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....
Electronic Signature Attestation and Authorship- Updated - Retired
Author: Downing, Kathy
Source: AHIMA practice brief
Publication Date: October 2013
Editor’s note: This update supersedes the November 2009 practice brief “Implementing Electronic Signatures.”
Electronic health record (EHR) systems provide the ability to sign entries electronically; however, implementing and using electronic signatures (e-s....
Notice of Privacy Practices (2013 update)
Author: McLendon, Kelly; Rose, Angela Dinh
Source: AHIMA practice brief
Publication Date: October 2013
Editor's note: This update supplants the February 2011 practice brief "Notice of Privacy Practices."
Timely, accurate, and complete health information must be collected, maintained, and made available to members of an individual's healthcare team so that members of the team can a....
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....
Sanction Guidelines for Privacy and Security Violations (2013 update) - Retired
Author: AHIMA
Source: AHIMA practice brief
Publication Date: October 2013
Editor's note: This practice brief supersedes the October 2011 practice brief "Sanction Guidelines for Privacy and Security Violations."
The HIPAA Breach Notification Rule requires healthcare providers, health plans, and other HIPAA covered entities (CEs) to notify individuals whe....
Patient Access and Amendment to Health Records (2013 update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: October 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Privacy and Security Training (2013 update) - Retired
Author: Downing, Kathy; Lucci, Susan; Lerch, Diane M
Source: AHIMA practice brief
Publication Date: October 2013
Editor's note: This update replaces the November 2010 practice brief "HIPAA Privacy and Security Training."
On January 25, 2013, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) published the long-awaited Health Insurance Portability and Accoun....
Managing Unsolicited Health Information in the Electronic Health Record
Author: AHIMA
Source: AHIMA practice brief
Publication Date: October 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
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....
Speech Recognition in the Electronic Health Record (2013 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2013
Introduction
Many technologies exist to assist with better clinical documentation and speech recognition technology (SRT) is one solution. Since SRT uses mathematic probabilities, the technology can be complicated. The goals of its use in healthcare today, however, are clear: Increase....
Understanding Publicly Available Healthcare Data (2013 update) - Retired
Author: AHIMA
Source: AHIMA practice brief
Publication Date: September 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only. This update supersedes the January 2010 practice brief "Understanding Publicly Available Healthcare Data."
Healthcare organizations increasingly ar....
Release of Information for Marketing or Fund-raising Purposes (2013 update) - Retired
Author: Schmidt, Peg; Downing, Kathy
Source: AHIMA practice brief
Publication Date: August 2013
Editor's note: This update supplants the 2002 practice brief "Release of Information for Marketing or Fund-raising Purposes."
Since its original compliance date in 2003, the HIPAA privacy rule required covered entities (CEs) to adhere to certain standards relative to the use....
Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update)
Author: AHIMA Work Group
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: August 2013
Editor’s note: This update replaces the 2007 practice brief “Guidelines for EHR Documentation to Prevent Fraud.”
Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancin....
Recruitment, Selection, and Orientation for CDI Specialists
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2013
A strong clinical documentation improvement (CDI) program begins with the proper recruitment, careful selection, and adequate orientation of CDI specialists. The purpose of a CDI program is to initiate concurrent and retrospective reviews of health records for conflicting, incomplete, or nonspe....
Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS (2013 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Telemedicine Services and the Health Record (2013 update)
Author: Johnson, Marlene L.; Warner, Diana
Source: AHIMA practice brief
Publication Date: May 2013
Editor's Note: This practice brief supersedes the April 1997 practice brief "Telemedical Records."
Telemedicine is a rapidly growing industry in the medical practice. Telemedicine is defined as telecommunications systems that link healthcare organizations and patients from d....
Regulations Governing Research (2013 update) - Retired
Author: Warner, Diana
Source: AHIMA practice brief
Publication Date: May 2013
This practice brief reviews the federal regulations that affect research and the requirements regarding the use and protection of an individual's information.
Putting the ICD-10-CM/PCS GEMs into Practice (2013 update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: May 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Rules for Handling and Maintaining Metadata in the EHR
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: May 2013
Metadata is the foundation on which information management systems are built. It is required to support the various uses of data, to manage the information and record lifecycle, to verify data integrity, authenticity, and reliability, and to evaluate the relative importance of data and informat....
The Privacy and Security of Occupational Health Records
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: April 2013
The Occupational Safety and Health Administration (OSHA) defines an “occupational medical record” as an occupation-related, chronological, cumulative record, regardless of the form or process by which it is maintained (i.e., paper document, microfiche, microfilm, or automatic data processing me....
Assessing and Improving EHR Data Quality (2013 update)
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: March 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Guidelines for Achieving a Compliant Query Practice
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: February 2013
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
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