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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....
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