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Ahima Practice Brief Query: A Deep Dive into Healthcare Data and Information Governance
Author: Dr. Eleanor Vance, RHIA, CHPS, FAHIMA
Dr. Eleanor Vance holds a PhD in Health Informatics and is a Registered Health Information Administrator (RHIA), a Certified Health Privacy Specialist (CHPS), and a Fellow of the American Health Information Management Association (FAHIMA). Her extensive experience includes over 20 years working in healthcare information governance, consulting for numerous hospitals and healthcare systems on compliance and data management, and significant contributions to AHIMA publications and educational initiatives. Her expertise makes her uniquely qualified to analyze the nuances of the 'ahima practice brief query' process.
Keywords: AHIMA practice brief query, healthcare data, information governance, HIPAA compliance, health information management, data privacy, query process, data integrity, medical records, AHIMA resources.
1. Introduction: Understanding the Significance of the AHIMA Practice Brief Query
The American Health Information Management Association (AHIMA) provides invaluable resources for healthcare professionals navigating the complex world of health information management (HIM). A crucial aspect of HIM is the efficient and accurate retrieval of patient data, often facilitated through a process known as the 'AHIMA practice brief query'. This process encompasses the methods used to clarify ambiguities, resolve discrepancies, and ensure the completeness and accuracy of patient medical records. This article provides a comprehensive analysis of the 'AHIMA practice brief query,' exploring its historical context, current relevance in the face of evolving technology and regulations, and its crucial role in maintaining patient safety and data integrity.
2. Historical Context of the AHIMA Practice Brief Query
The evolution of the 'AHIMA practice brief query' is intrinsically linked to the development of electronic health records (EHRs) and the increasing complexity of healthcare data. Initially, queries were primarily paper-based, relying on manual chart reviews and inter-departmental communication. The emergence of EHRs brought about significant changes, introducing the need for structured query processes to effectively navigate vast amounts of digital data. AHIMA's role has been pivotal in standardizing these processes, providing guidelines and best practices to ensure consistency and accuracy. Early AHIMA publications focused on fundamental query techniques, emphasizing clarity, specificity, and proper documentation. As technology advanced, so did AHIMA's guidance, addressing the specific challenges presented by EHR systems and the need for efficient querying methods within those systems.
3. Current Relevance and Importance of the AHIMA Practice Brief Query
The 'AHIMA practice brief query' remains incredibly relevant in today's data-driven healthcare environment. Several factors contribute to its continued importance:
HIPAA Compliance: Accurate and complete medical records are crucial for HIPAA compliance. Effective query processes are essential to ensure that all necessary information is captured and readily accessible for authorized personnel, minimizing the risk of breaches and violations. The AHIMA practice brief query process, with its focus on documentation and procedural accuracy, directly supports HIPAA compliance efforts.
Data Integrity: Maintaining data integrity is paramount in healthcare. Queries help identify and correct inconsistencies, inaccuracies, and missing data elements, ensuring the reliability of information used for clinical decision-making, research, and public health initiatives. A well-defined 'AHIMA practice brief query' process is a cornerstone of robust data governance.
Clinical Decision-Making: Timely and accurate information is essential for effective clinical decision-making. Queries facilitate the rapid retrieval of relevant data, enabling healthcare providers to make informed decisions about patient care. This contributes directly to improved patient outcomes and safety.
Improved Efficiency: Streamlined query processes improve efficiency within healthcare organizations. By standardizing methods and clarifying roles and responsibilities, unnecessary delays and confusion are minimized, freeing up valuable time for other critical tasks.
Legal and Regulatory Compliance: Beyond HIPAA, many other regulations and legal requirements necessitate accurate and complete documentation. The 'AHIMA practice brief query' process contributes to broader compliance efforts by ensuring the integrity of the medical record as a legal document.
4. The AHIMA Practice Brief Query Process: A Step-by-Step Guide
A typical 'AHIMA practice brief query' process includes the following steps:
1. Identification of the Deficiency: A healthcare professional identifies missing or unclear information in the patient's medical record.
2. Query Formulation: A well-structured query is formulated, clearly specifying the missing information and context. This includes the relevant date range and specific data elements needed.
3. Query Submission: The query is submitted through the designated channels within the EHR system or other established communication methods.
4. Response Processing: The responsible party reviews the query and responds by providing the requested information or explaining the reason for its absence.
5. Documentation: Both the query and the response are documented in the patient's medical record to maintain an audit trail.
6. Review and Follow-up: The initial requester reviews the response and takes appropriate action. Further queries may be needed if the response is insufficient.
5. Challenges and Best Practices in Utilizing AHIMA Practice Brief Queries
While the 'AHIMA practice brief query' process offers significant benefits, certain challenges exist. These include:
Workflow Integration: Seamless integration of the query process within existing workflows can be challenging, particularly in busy healthcare settings.
Staff Training: Adequate staff training is crucial to ensure consistent application of the process.
Technology Limitations: Technological limitations within EHR systems can sometimes hinder efficient query management.
Query Response Time: Delayed responses can impact clinical care and data integrity.
Best practices include:
Implementing standardized query forms and templates.
Establishing clear roles and responsibilities for query submission and response.
Utilizing automated query systems to improve efficiency.
Regularly monitoring response times and identifying areas for improvement.
Providing ongoing training and education to staff.
6. The Future of AHIMA Practice Brief Queries
With the increasing adoption of artificial intelligence (AI) and machine learning (ML) in healthcare, the 'AHIMA practice brief query' process is likely to evolve. AI could automate parts of the process, such as identifying potential data deficiencies or suggesting appropriate queries. However, human oversight will remain crucial to ensure accuracy and address complex situations requiring clinical judgment. Future AHIMA guidelines will likely address these advancements, providing best practices for integrating AI and ML into query processes while preserving data integrity and patient privacy.
7. Conclusion
The 'AHIMA practice brief query' is a vital component of effective health information management. Its importance extends beyond mere data retrieval; it contributes significantly to HIPAA compliance, data integrity, clinical decision-making, and overall efficiency within healthcare organizations. By adhering to AHIMA's guidelines and best practices, healthcare professionals can ensure the accuracy and completeness of patient medical records, leading to improved patient care and organizational success. Continuous adaptation to technological advancements and evolving regulatory requirements will be essential to maintaining the relevance and effectiveness of the 'AHIMA practice brief query' process in the future.
8. FAQs
1. What is the purpose of an AHIMA practice brief query? To clarify ambiguities, resolve discrepancies, and ensure the completeness and accuracy of patient medical records.
2. Who can submit an AHIMA practice brief query? Authorized healthcare professionals, such as physicians, nurses, coders, and HIM professionals.
3. What information should be included in an AHIMA practice brief query? Clear and concise description of the missing or unclear information, relevant date range, and specific data elements needed.
4. How are AHIMA practice brief queries documented? Both the query and the response are documented in the patient's medical record to maintain an audit trail.
5. What happens if a response to an AHIMA practice brief query is unsatisfactory? Further queries may be needed, or escalation to a supervisor or other appropriate personnel may be required.
6. How does the AHIMA practice brief query process support HIPAA compliance? By ensuring the accuracy and completeness of medical records, minimizing the risk of breaches and violations.
7. What are some best practices for managing AHIMA practice brief queries? Standardized forms, clear roles and responsibilities, automated systems, regular monitoring of response times, and ongoing staff training.
8. How might AI impact the future of AHIMA practice brief queries? AI could automate aspects of the process, but human oversight will remain crucial.
9. Where can I find more information about AHIMA practice brief queries? AHIMA's website, publications, and educational resources.
9. Related Articles
1. "Improving Query Response Time in EHR Systems": This article explores strategies to reduce delays in receiving responses to queries, focusing on workflow optimization and technology solutions.
2. "The Role of AI in Automating Medical Record Completion": This article examines how artificial intelligence can be used to identify and address missing data elements in patient records, potentially reducing the need for manual queries.
3. "Best Practices for Query Resolution in a Multi-Specialty Clinic": This article provides specific guidance for managing queries in settings with multiple medical specialties, emphasizing clear communication and standardized processes.
4. "HIPAA Compliance and the Importance of Accurate Medical Records": This article discusses the link between HIPAA compliance and the need for accurate and complete medical records, highlighting the role of query processes in maintaining compliance.
5. "Data Integrity in Healthcare: A Comprehensive Overview": This article provides a broader perspective on data integrity in healthcare, emphasizing the importance of accurate data for clinical decision-making, research, and public health initiatives.
6. "The Impact of EHR Systems on Query Processes": This article analyses the influence of electronic health records on the evolution of query processes, discussing both the advantages and challenges posed by EHR technology.
7. "Standardizing Query Forms and Templates for Improved Efficiency": This article details best practices for designing standardized query forms to ensure clarity, consistency, and efficient information retrieval.
8. "Training Healthcare Professionals on Effective Query Techniques": This article outlines effective training methods for healthcare professionals to ensure they can accurately formulate and submit queries and appropriately handle responses.
9. "Legal and Regulatory Implications of Incomplete Medical Records": This article explores the legal and regulatory consequences of maintaining incomplete or inaccurate medical records, highlighting the role of proper query management in mitigating risk.
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| ahima practice brief query: ICD-10-CM/PCS Coding: Theory and Practice, 2019/2020 Edition E-Book Elsevier Inc, 2018-07-31 Learn facility-based coding by actually working with codes. ICD-10-CM/PCS Coding: Theory and Practice provides an in-depth understanding of in-patient diagnosis and procedure coding to those who are just learning to code, as well as to experienced professionals who need to solidify and expand their knowledge. Featuring basic coding principles, clear examples, and challenging exercises, this text helps explain why coding is necessary for reimbursement, the basics of the health record, and rules, guidelines, and functions of ICD-10-CM/PCS coding. - UPDATED ICD-10 codes and coding guidelines revisions ensure you have the most up-to-date information available. - 30-day access to TruCode® encoder on the Evolve companion website gives you realistic practice with using an encoder. - UPDATED codes for Pancreatitis, Diabetic Retinopathy, Fractures, GIST Tumors, Hypertension and Myocardial Infarctions. - ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting provide fast, easy access instruction on proper application of codes. - Coverage of both common and complex procedures prepares you for inpatient procedural coding using ICD-10-PCS. - Numerous and varied examples and exercises within each chapter break chapters into manageable segments and help reinforcing important concepts. - Illustrations and examples of key diseases help in understanding how commonly encountered conditions relate to ICD-10-CM coding. - Strong coverage of medical records provides a context for coding and familiarizes you with documents you will encounter on the job. - Illustrated, full-color design emphasizes important content such as anatomy and physiology and visually reinforces key concepts. |
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| ahima practice brief query: ICD-10-CM/PCS Coding: Theory and Practice, 2016 Edition Karla R. Lovaasen, 2015-08-12 With this comprehensive guide to inpatient coding, you will 'learn by doing!' ICD-10-CM/PCS Coding: Theory and Practice, 2016 Edition provides a thorough understanding of diagnosis and procedure coding in physician and hospital settings. It combines basic coding principles, clear examples, plenty of challenging exercises, and the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting to ensure coding accuracy using the latest codes. From leading medical coding authority Karla Lovaasen, this expert resource will help you succeed whether you're learning to code for the first time or making the transition to ICD-10! Coding exercises and examples let you apply concepts and practice coding with ICD-10-CM/PCS codes. Coverage of disease includes illustrations and coding examples, helping you understand how commonly encountered conditions relate to ICD-10-CM coding. ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting provide fast, easy access to examples of proper application. Full-color design with illustrations emphasizes important content such as anatomy and physiology and visually reinforces key concepts. Integrated medical record coverage provides a context for coding and familiarizes you with documents you will encounter on the job. Coverage of common medications promotes coding accuracy by introducing medication names commonly encountered in medical records. Coverage of both common and complex procedures prepares you for inpatient procedural coding using ICD-10-PCS. MS-DRG documentation and reimbursement details provide instruction on proper application of codes NEW! 30-day trial access to TruCode? includes additional practice exercises on the Evolve companion website, providing a better understanding of how to utilize an encoder. UPDATED content includes icd-10 code revisions, ensuring you have the latest coding information. |
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| ahima practice brief query: ICD-10-CM/PCS Coding: Theory and Practice, 2016 Edition - E-Book Karla R. Lovaasen, 2015-07-16 With this comprehensive guide to inpatient coding, you will ‘learn by doing!’ ICD-10-CM/PCS Coding: Theory and Practice, 2016 Edition provides a thorough understanding of diagnosis and procedure coding in physician and hospital settings. It combines basic coding principles, clear examples, plenty of challenging exercises, and the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting to ensure coding accuracy using the latest codes. From leading medical coding authority Karla Lovaasen, this expert resource will help you succeed whether you’re learning to code for the first time or making the transition to ICD-10! Coding exercises and examples let you apply concepts and practice coding with ICD-10-CM/PCS codes. Coverage of disease includes illustrations and coding examples, helping you understand how commonly encountered conditions relate to ICD-10-CM coding. ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting provide fast, easy access to examples of proper application. Full-color design with illustrations emphasizes important content such as anatomy and physiology and visually reinforces key concepts. Integrated medical record coverage provides a context for coding and familiarizes you with documents you will encounter on the job. Coverage of common medications promotes coding accuracy by introducing medication names commonly encountered in medical records. Coverage of both common and complex procedures prepares you for inpatient procedural coding using ICD-10-PCS. MS-DRG documentation and reimbursement details provide instruction on proper application of codes NEW! 30-day trial access to TruCode® includes additional practice exercises on the Evolve companion website, providing a better understanding of how to utilize an encoder. UPDATED content includes icd-10 code revisions, ensuring you have the latest coding information. |
| ahima practice brief query: ICD-10-CM/PCS Coding: Theory and Practice, 2018 Edition E-Book Karla R. Lovaasen, 2017-07-12 With ICD-10-CM/PCS Coding: Theory and Practice, 2018 Edition, you will learn facility-based coding by actually working with codes. This comprehensive guide provides an in-depth understanding of inpatient diagnosis and procedure coding if you’re just learning to code, or are an experienced professional who needs to solidify and expand your knowledge. It combines basic coding principles, clear examples, plenty of challenging exercises, and the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting to ensure accuracy using the latest codes. From leading medical coding authority and AHIMA-approved ICD-10 Trainer Karla Lovaasen, this expert resource offers all a well-rounded understanding of the necessity and functions of ICD-10-CM/PCS coding. ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting provide fast, easy access instruction on proper application of codes. 30-day access to TruCode® encoder on the Evolve companion website provides you with realistic practice with using an encoder. Coverage of both common and complex procedures prepares you for inpatient procedural coding using ICD-10-PCS. Illustrations and examples of key diseases help in understanding how commonly encountered conditions relate to ICD-10-CM coding. Coding examples and exercises let you apply concepts and practice coding with ICD-10-CM/PCS codes. Illustrated, full-color design emphasizes important content such as anatomy and physiology and visually reinforces key concepts. Coverage of medical records provides a context for coding and familiarizes you with documents you will encounter on the job. Coverage of common medications promotes coding accuracy by introducing medication names commonly encountered in medical records. NEW! Zika virus coverage, NIHSS codes, and coding tips ensure you’re learning the most up-to-date coding information. UPDATED The latest ICD-10 codes and coding guidelines revisions ensure that you have the most up-to-date information available. UPDATED Coding Medical and Surgical Procedures chapter includes enhanced coverage and revised information. UPDATED! codes for Pancreatitis, Diabetic Retinopathy, Fractures, GIST Tumors, Hypertension and Myocardial Infarctions. |
| ahima practice brief query: Health Information Management Margaret A. Skurka, 2017-04-10 The Updated and Extensively Revised Guide to Developing Efficient Health Information Management Systems Health Information Management is the most comprehensive introduction to the study and development of health information management (HIM). Students in all areas of health care gain an unmatched understanding of the entire HIM profession and how it currently relates to the complex and continuously evolving field of health care in the United States. This brand-new Sixth Edition represents the most thorough revision to date of this cornerstone resource. Inside, a group of hand-picked HIM educators and practitioners representing the vanguard of the field provide fundamental guidelines on content and structure, analysis, assessment, and enhanced information. Fully modernized to reflect recent changes in the theory and practice of HIM, this latest edition features all-new illustrative examples and in-depth case studies, along with: Fresh and contemporary examinations of both electronic and print health records, data management, data privacy and security, health informatics and analytics, and coding and classification systems An engaging and user-friendly pedagogy, complete with learning objectives, key terms, case studies, and problems with workable solutions in every chapter Ready-to-use PowerPoint slides for lectures, full lesson plans, and a test bank for turnkey assessments A must-have resource for everyone in health care, Health Information Management, Sixth Edition, puts everything you need at your fingertips. |
| ahima practice brief query: Foundations of Health Information Management - E-Book Nadinia A. Davis, 2023-05-15 **Selected for Doody's Core Titles® 2024 with Essential Purchase designation in Health Information Management** Foundations of Health Information Management, 6th Edition is an absolute must for anyone beginning a career in HIM. By focusing on healthcare delivery systems, electronic health records, and the processing, maintenance, and analysis of health information, this engaging, easy-to-understand text presents a realistic and practical view of technology and trends in healthcare. It readies you for the role of a Registered Health Information Technician, who not only maintains and secures accurate health documentation, but serves as a healthcare analyst who translates data into useful, quality information that can control costs and further research. This edition is organized by CAHIIM competencies to prepare you for the RHIT® credentialing exam, as well as EHR samples, critical-thinking exercises, and expanded coverage of key issues in HIM today. - Clear writing style and easy reading level make reading and studying more time efficient. - Organized for CAHIIM competencies to assure that you are prepared to sit for the exam. - Competency Check-in Exercises at the end of every main section in each chapter encourage you to review and apply key concepts. - Competency Milestone feature at the end of each chapter hosts ample assessments to ensure your comprehension of the CAHIIM competencies. - Ethics Challenge links topics to professional ethics with real-world scenarios and critical-thinking questions. - Critical-thinking questions challenge you to apply learning to professional situations. - Mock RHIT® exam provides you with the opportunity to practice taking a timed, objective-based exam. - Specialized chapters, including legal, statistics, coding, and performance improvement and project management, support in-depth learning. - Professional Profile highlights key HIM professionals represented in chapter discussions. - Patient Care Perspective illustrates the impact of HIM professionals on patients and patient care. - Career Tip boxes instruct you on a course of study and work experience required for the position. - Chapter summaries and reviews allow for easy review of each chapter's main concepts. - SimChart® and SimChart® for the Medical Office EHR samples demonstrate electronic medical records in use. |
| ahima practice brief query: The CCDS Exam Study Guide , 2010 |
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| ahima practice brief query: ICD-10-CM/PCS Coding: Theory and Practice, 2014 Edition - E-Book Karla R. Lovaasen, Jennifer Schwerdtfeger, 2013-08-15 - Updated content includes the icd-10 code revisions released in Spring 2013, ensuring you have the latest coding information available. |
| ahima practice brief query: Conquer Medical Coding Jean Jurek, Stacey Mosay, Daphne Neris, 2016-01-25 Conquer Medical Coding. Take a real-world approach to coding that prepares you for the AAPC or AHIMA certification exams and for professional practice in any health care setting. The book is also a handy resource you can turn to throughout your career. Unique decision trees show you how to logically assign a code. It's the only text that breaks down the decision-making process into a visual and repeatable process! You’ll learn exactly how to select the correct ICD-10, CPT, and HCPCS codes. Each section parallels the Official Coding Guidelines, with a special emphasis on commonly used codes. A wealth of learning tools and tips, along with critical-thinking exercises and real-life case studies, provide the practice you need to master coding. Brief reviews of A&P and pathophysiology put the codes into perfect context. |
| ahima practice brief query: The Clinical Documentation Improvement Specialist's Handbook, Second Edition Heather Taillon, 2011-01-21 The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's Managing an Effective Query Process and Guidance for Clinical Documentation Improvement Programs. CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards |
| ahima practice brief query: The Coder's Guide to Physician Queries Adrienne Commeree, Rose T. Dunn, 2017-11-27 This book is for new and established coders who are looking to expand their knowledge of queries. |
| ahima practice brief query: Acdis Answers , 2016-12-16 ACDIS Answers: Clinical Documentation Improvement FAQs ACDIS Answers: Clinical Documentation Improvement FAQs is a quick reference guide for the most common questions faced by CDI specialists. Organized by Major Diagnostic Categories and broken down into specific topics of concern, ACDIS Answers provides information not only on documentation needs but also on issues related to the CDI profession. This compendium of commonly asked CDI questions is an essential reference book and office companion, valuable for new CDI specialists as well as those experienced in concurrent medical record review. Whether you're wondering about sequencing guidelines, staff productivity, escalation policies, diabetes coding, or documentation requirements for acute kidney injury, ACDIS Answers provides quick, easily understandable information from respected experts in CDI, including ACDIS' own Boot Camp instructors and Advisory Board members. |
| ahima practice brief query: ICD-9-CM Coding: Theory and Practice with ICD-10, 2013/2014 Edition - E-Book Karla R. Lovaasen, Jennifer Schwerdtfeger, 2012-08-20 Learn to code effectively with ICD-9-CM medical coding and gain a thorough introduction to ICD-10-CM/PCS coding with one book! ICD-9-CM Coding, 2013/2014 Edition combines basic coding principles with proven, practical insight and the ICD-9-CM and ICD-10-CM/ICD-10-PCS Official Guidelines for Coding and Reporting to prepare you for the upcoming implementation of ICD-10-CM/PCS. Whether you're learning to code for the first time or making the transition from ICD-9-CM to ICD-10-CM/PCS, leading medical coding authors Karla Lovaasen and Jennifer Schwerdtfeger deliver the fundamental understanding you need to succeed in hospital and physician settings. Both ICD-9-CM codes and ICD-10-CM/ICD-10-PCS codes are shown in all coding exercises and examples (including answer keys). Emphasis on ICD-10-CM and ICD-10-PCS coding prepares you for the upcoming implementation of ICD-10. MS-DRG documentation and reimbursement details guide you through this key component of the coding process. Line coding exercises and activities challenge you to apply concepts to solve problems. ICD-10 Official Guidelines for Coding and Reporting (OGCR) are included in each coding chapter, immediately following the ICD-9-CM coding guidelines. Full-color A&P content, disease coverage, procedure guidelines, and drug data ensure that you’re familiar with key topics affecting medical coding. Medical record coverage introduces the records and documents you’ll encounter on the job. Updated Coding Clinic references direct you to the definitive coding resource from the American Hospital Association (AHA). A companion Evolve website provides convenient online access to the OGCR, medical and surgical root operations definitions, a MS-DRG list, partial answer keys, and more. |
| ahima practice brief query: The Coding Manager's Handbook Rose T. Dunn, 2010-03-12 Provides a comprehensive and detailed look at coding managers' and supervisors' responsibilities and explains how to: allocate resources and structure the coding function to maximize productivity; select, develop, retain, and motivate staff; and establish a coding quality review program to ensure accuracy and compliance. |
| ahima practice brief query: The Complete Guide to CDI Management Cheryl Ericson, Stephanie Hawley, RN, Bsn, ACM, Anny Pang Yuen, 2016-01-28 The Complete Guide to CDI Management Cheryl Ericson, MS, RN, CCDS, CDIP Stephanie Hawley, RN, BSN, ACM Anny Pang Yuen, RHIA, CCS, CCDS, CDIP Managing a CDI department can be a daunting task for new and seasoned managers alike. The Complete Guide to CDIManagement provides CDI program managers and directors with insight into the most common issues associated with implementing, staffing, running, and growing a CDI department. The book also covers core skills such as auditing and metrics, and it provides strategies for overcoming challenges related to electronic records, changing regulatory landscapes, and resource limitations. The Complete Guide to CDI Management incorporates the deep expertise of multiple authors with varied backgrounds who have come together to share their firsthand knowledge. From reporting structures and productivity measurement to defining a mission and physician engagement, this definitive resource addresses the wide array of issues facing CDI managers and directors in today's hospital environment. Table of Contents About the Authors Introduction Chapter 1: An Introduction to CDI for the New Manager History of Coded Data The Medical Coder The Prospective Payment System Adding Severity Into the DRG Methodology CDI Basics Summary Chapter 2: Growing a CDI Department The Traditional Role of CDI CDI Review Population Principal Diagnosis Assignment Types of DRG Reviews Quality Focus Summary Chapter 3: Developing Relationships Sharing the Mission Physician Engagement Obstacles to Developing a Physician Relationship Leveraging Queries as an Educational Tool The Art of Clinical Validation The Query Format Query Templates Fostering a Relationship With Coding Networking Summary Chapter 4: Department Structures and Staffing Expectations Department Structures Staffing/Hiring Physician Advisor Creating a Career Ladder Continuing Education CDI Department Meetings Evaluations Credentialing Initialing vs. Revitalizing Summary Chapter 5: Demonstrating the Return on Investment Measuring Success Productivity and Sample Metrics Summary Chapter 6: Challenges and How to Overcome Them Organization Issues Resource Issues Summary Appendixes Appendix A: Resources |
| ahima practice brief query: Clinical Documentation Improvement Pamela Carroll Hess, 2015 |
| ahima practice brief query: Optimizing Widely Reported Hospital Quality and Safety Grades Armin Schubert, Sandra A. Kemmerly, 2022-07-26 This practical, engaging book provides concise, real life-tested guidance to healthcare teams concerned with widely reported and incentivized hospital quality and safety metrics, offering both a conceptual approach and specific advice and frameworks for reviewing quality and safety numerator events, from the perspective and experience of clinicians and administrators working within the Ochsner Health System. The text opens with the rationale for closely managing widely (including publicly) reported hospital patient quality and safety measures. Attention is given to the financial implications of quality performance, with respect to both penalties and payment incentives used by payer organizations. It then reviews the major public ratings and their relevant methodologies, including CMS, AHRQ and NSHN. In addition, it addresses ratings by proprietary organizations that have a large member clientele, such as Vizient, USNews, Leapfrog, Healthgrades, CareChex and others. Each metric - for example, the AHRQ Patient Safety Indicators (PSIs), and other metrics such as readmission rate, risk adjusted complications, hospital-acquired conditions and mortality - is addressed in a stand-alone chapter. For each, the importance, approach to review, opportunity for optimization, and engagement of healthcare staff are reviewed and discussed. Overall, this book forefronts the benefits of a collaborative approach within a health system. The concurrent review process, multidisciplinary collaboration among quality improvement, clinical documentation, coding and medical staff personnel are all emphasized. Also described in detail is the approach to and specific opportunities for medical staff education and engagement. Additional key topics include Engagement of the Medical Staff and House Staff (i.e., residents and other trainees), Futile Care, Surgical Quality Improvement (NSQIP), Nursing Provider Partnership, and Translation of Data Review to Successful Performance Improvement. Specialty chapters on pediatric, neurologic and transplant quality metrics are also included. |
| ahima practice brief query: Registries for Evaluating Patient Outcomes Agency for Healthcare Research and Quality/AHRQ, 2014-04-01 This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews. |
| ahima practice brief query: Coding and Reimbursement for Hospital Inpatient Services Karen S. Scott, 2006 The most comprehensive resource for hospital inpatient coding and reimbursement! Provides educators, students, and healthcare practitioners with the most authoritative guidance available for managing inpatient coding and reimbursement issues. This must-have resource was developed to give you easier access to the most up-to-date information you need for inpatient coding and reimbursement. You'll save time and make more effective decisions with this one-of-a-kind resource.Covers reimbursement methodologies for hospital inpatient services, the structure and organization of hte Medicare Inpatient Acute Care Prospective Payment System, the relationship between coding and DRG assignment, and data quality and coding compliance processes related to coding and reimbursement for inpatient services. |
| ahima practice brief query: RHIT Exam Secrets Study Guide Rhit Exam Secrets Test Prep, 2018-04-12 ***Includes Practice Test Questions*** RHIT Exam Secrets helps you ace the Registered Health Information Technician Exam without weeks and months of endless studying. Our comprehensive RHIT Exam Secrets study guide is written by our exam experts, who painstakingly researched every topic and concept that you need to know to ace your test. Our original research reveals specific weaknesses that you can exploit to increase your exam score more than you've ever imagined. RHIT Exam Secrets includes: The 5 Secret Keys to RHIT Exam Success: Time is Your Greatest Enemy, Guessing is Not Guesswork, Practice Smarter, Not Harder, Prepare, Don't Procrastinate, Test Yourself; A comprehensive General Strategy review including: Make Predictions, Answer the Question, Benchmark, Valid Information, Avoid Fact Traps, Milk the Question, The Trap of Familiarity, Eliminate Answers, Tough Questions, Brainstorm, Read Carefully, Face Value, Prefixes, Hedge Phrases, Switchback Words, New Information, Time Management, Contextual Clues, Don't Panic, Pace Yourself, Answer Selection, Check Your Work, Beware of Directly Quoted Answers, Slang, Extreme Statements, Answer Choice Families; A comprehensive Content review including: Health Data Management, Electronic Health Record, Sequencing, Jukebox, Cache Memory, Progress Notes, Physical Examination Thorax, Patient Chart Order, Diagnosis-Related Groups, Levels of Interoperability, Soap Progress Note, Discharge and Follow-Up Plans, Calculating Autopsy Rates, Census Statistics, Discuss Interval Data, Frequency Polygon, Pearson Correlation Co-Efficient, Chi-Square Test, Life-Table Analysis, Experimental Epidemiology, Patient Safety Measurements, Risk Management, HIPAA, Patient Rights, Transplant, Trauma Data, Anesthesia Report, Pathology Report, Recovery Room Record, Operating Report, Postpartum, Progress Notes, Electrocardiographic, Diagnostic Imaging, Joint Commission, Long-Term Care Facilities, Home Healthcare, and much more... |
| ahima practice brief query: Ethical Health Informatics Laurinda B. Harman, Frances Cornelius, 2017 Preceded by: Ethical challenges in the management of health information / [edited by ] Laurinda Beebe Harman. 2nd edition. 2006. |
| ahima practice brief query: ICD-9-CM Official Guidelines for Coding and Reporting , 1991 |
| ahima practice brief query: ICD-10-CM Official Guidelines for Coding and Reporting - FY 2021 (October 1, 2020 - September 30, 2021) Department Of Health And Human Services, 2020-09-06 These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. |
| ahima practice brief query: Health Informatics: Practical Guide for Healthcare and Information Technology Professionals (Sixth Edition) Robert E. Hoyt, Ann K. Yoshihashi, 2014 Health Informatics (HI) focuses on the application of Information Technology (IT) to the field of medicine to improve individual and population healthcare delivery, education and research. This extensively updated fifth edition reflects the current knowledge in Health Informatics and provides learning objectives, key points, case studies and references. |
| ahima practice brief query: The Clinical Documentation Improvement Specialist's Complete Training Guide Laurie L. Prescott, 2014-10-23 Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures |
| ahima practice brief query: The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition Jennifer Avery, Cheryl Ericson, 2013-05-07 The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition Now in its second edition, The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. In it you'll find the specific documentation requirements to appropriately code a variety of conditions. The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors--an ICD-10 certified coder and CDI specialist--collaborated to create a comprehensive selection of ICD-10 sample queries that facilities can download and use to jumpstart their ICD-10 documentation improvement efforts. Develop the expertise and comfort level you need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition, is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools TABLE OF CONTENTS Chapter 1: ICD-10 primer Chapter 2: Conventions and Guidelines Chapter 3: Physician queries Chapter 4: CDI target areas Chapter 5: ICD-10-CM/PCS Provider Education |
| ahima practice brief query: 2022 CDI Pocket Guide Pinson & Tang LLC, 2021-10-15 |
| ahima practice brief query: Beyond the HIPAA Privacy Rule Institute of Medicine, Board on Health Care Services, Board on Health Sciences Policy, Committee on Health Research and the Privacy of Health Information: The HIPAA Privacy Rule, 2009-03-24 In the realm of health care, privacy protections are needed to preserve patients' dignity and prevent possible harms. Ten years ago, to address these concerns as well as set guidelines for ethical health research, Congress called for a set of federal standards now known as the HIPAA Privacy Rule. In its 2009 report, Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research, the Institute of Medicine's Committee on Health Research and the Privacy of Health Information concludes that the HIPAA Privacy Rule does not protect privacy as well as it should, and that it impedes important health research. |
| ahima practice brief query: Clinical Documentation Improvement Rn Phn Nkwuaku, Msn Cphq, 2015-12-17 Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The book is a compendium of sound clinical knowledge and experience, clinical documentation expertise, and quality, which will help the CDIS/CDIP and others maximize their potentials in performing their core duties. Whether you are a new CDIS trying to learn CDI or an experienced CDIS hoping to stay current with CDI world, or involved in the CDI, this book will be very valuable to you. Remember, accurate and quality documentation is a reflection of great patient care. If it wasn't documented, and documented accurately, it never happened. This book clearly explained various query opportunities by Major Disease Classifications (MDCs) with some sample queries. It defines and analyses different disease processes, creates CDIS awareness and what to look for under various MDCs, ICD-10-CM/PCS, explained current CMS Pay for Performance (P4P), and the CDI responsibility under P4P, explained some pertinent coding guidelines, 2016 Official Coding Guidelines for Coding and Reporting, AHIMA/ACDIS practice brief for queries and compliance, and much more. I have no doubt in my mind that this book is a concise but a comprehensive tool and reference that anyone involved in CDI should always have at his/her side. The Author Anthony O Nkwuaku, RN, PHN, MSN, CPHQ, CCDS is very knowledgeable and experienced as a clinician, clinical instructor, and Clinical Documentation Improvement Specialist. |
| ahima practice brief query: Conditions of Participation for Hospitals United States. Social Security Administration, 1966 |
| ahima practice brief query: First Steps in Outpatient CDI Anny Pang Yuen, Page Knauss, 2017-06-22 First Steps in Outpatient CDI: Tips and Tools for Building a Program Anny P. Yuen, RHIA, CCS, CCDS, CDIP Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO Find best practices and helpful advice for getting started in outpatient CDI with First Steps in Outpatient CDI: Tips and Tools for Building a Program. This first-of-its-kind book provides an overview of what outpatient CDI entails, covers industry guidance and standards for outpatient documentation, reviews the duties of outpatient CDI specialists, and examines how to obtain backing from leadership. Accurate documentation is important not just for code assignment, but also for a variety of quality and reimbursement concerns. In the past decade, outpatient visits increased by 44% while hospital visits decreased by nearly 20%, according to the Medicare Payment Advisory Commission. However, just because physicians are outside the hospital walls doesn't mean they're free from documentation challenges. For these reasons, CDI programs are offering their assistance to physician practices, ambulatory surgical centers, and even emergency rooms. This book will explore those opportunities and take a look at how others are expanding their record review efforts in the outpatient world. This book will help you: Target the outpatient settings that offer the greatest CDI opportunities Understand the quality and payment initiatives affecting outpatient services Understand the coding differences between inpatient and outpatient settings Identify data targets Incorporate physician needs to ensure support for program expansion Assess needs by program type |
| ahima practice brief query: Effective Management of Coding Services Lou Ann Schraffenberger, 2002 This is a resource for coding managers across the continuum of health care settings, with a special emphasis on acute-care and hospital-based ambulatory settings. Addresses the scope and organization of clinical coding data, including standards for electronic record systems, coding practice issues, recruitment and retention of coding staff, chargemaster, management, quality control issues, compliance reporting issues, and financial issues. Contains numerous examples and case studies to illustrate issues and demonstrate how coding decisions affect other areas in the health care organization. |
| ahima practice brief query: Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee on the Review of the Department of Veterans Affairs Examinations for Traumatic Brain Injury, 2019-05-20 The Veterans Benefits Administration (VBA) provides disability compensation to veterans with a service-connected injury, and to receive disability compensation from the Department of Veterans Affairs (VA), a veteran must submit a claim or have a claim submitted on his or her behalf. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans reviews the process by which the VA assesses impairments resulting from traumatic brain injury for purposes of awarding disability compensation. This report also provides recommendations for legislative or administrative action for improving the adjudication of veterans' claims seeking entitlement to compensation for all impairments arising from a traumatic brain injury. |
| ahima practice brief query: Medical Coding Shelley C. Safian, 2017-11 Updated for 2018 ICD-10 guidelines, this 6 page laminated guide covers core essentials of coding clearly and succinctly. Author Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer used her knowledge and experience to provide the largest number of valuable facts you can find in 6 pages, designed so that answers can be found fast with color coded sections, and bulleted lists. A must for students seeking coding certification and a great desktop refresher for professionals. 6-page laminated guide includes: General Coding & Legal Guidelines Coding Tips Conditions & Diagnoses Diagnosis Coding Pathology & Laboratory Reimbursement & Billing Tips Coding Evaluation & Management Services ICD-10 Terms, Notations & Symbols Wounds & Injuries Important Resources Anesthesia, Surgery & Radiology Diagnostic Coding |
| ahima practice brief query: DRG Expert Ingenix, 2010-09 THE DRG EXPERT has been a trusted and comprehensive reference to the DRG classification system for over 25 years. Organized by major diagnostic category (MDC), the convenient and innovative book layout follows the logical MS-DRG decision process. This is a must-have reference for those who need to verify DRG information and accurately assign MS-DRGs concurrently or retrospectively. |
Wiki AAPC vs AHIMA Credential
Oct 26, 2017 · Also, AHIMA approved college degree programs (RHIA and RHIT) are widely recommended if you are going to be working in an HIM department at a hospital. Coders and …
AAPC Credential Verification, CPC Certification Verification
Validate the credentials of a Certified Professional Coder (CPC). AAPC helps you with medical coding credential verification.
Wiki - Anyone have AAPC and AHIMA credentials?
Aug 2, 2012 · I have heard that the CPC-H is an equivalent certification to the CCS. Is this the case? Would I have the same opportunities as a CCS with the CPC-H credential? I have my …
Medical Coding Continuing Education Unit Policy, CEU Policy
AAPC does not accept CEUs from other entities that offer "AHIMA approved" CEUs. These organizations must apply separately for AAPC CEUs and receive an AAPC index number and …
How to get CPC certified? - AAPC
The Certified Professional Coder (CPC) credential is the most recognized medical coding certification in the healthcare industry.
CIC Certification- Hospital Coding - Certified Inpatient Coder
Prepare for CIC certification and earn 40% more than non-credentialed coders for inpatient & hospital coding. AAPC helps you with CIC certification exam.
Wiki - AHIMA CEU's count for AAPC credit?
Apr 18, 2013 · My employer is also giving us training for ICD 10 w/ the AHIMA product. When I brought up this same scenario to them because about half of the Coding Dept is AHIMA and …
Medical Coding - Medical Billing - Medical Auditing - AAPC
The nation's largest medical coding training and certification association for medical coders and medical coding jobs.
The 5 KPIs of a Great CDI Team - AAPC Knowledge Center
Apr 1, 2025 · Heather Greene, MBA, RHIA, CDEI, CIC, RCMS, CDIP, CPC, CPMA, CDEO, CRC, CPC-I, AHIMA Approved CDI Trainer, has over 20 years of experience in a variety of health …
AHIMA compared to CPC ? | Medical Billing and Coding Forum
Jan 6, 2012 · Experiences are subjective, Lilit. I know for a fact there are hospitals and similar health networks that hire coders without their carrying AHIMA credentials. I have nothing …
Wiki AAPC vs AHIMA Credential
Oct 26, 2017 · Also, AHIMA approved college degree programs (RHIA and RHIT) are widely recommended if you are going to be working in an HIM department at a hospital. …
AAPC Credential Verification, CPC Certification Verification
Validate the credentials of a Certified Professional Coder (CPC). AAPC helps you with medical coding credential verification.
Wiki - Anyone have AAPC and AHIMA credentials?
Aug 2, 2012 · I have heard that the CPC-H is an equivalent certification to the CCS. Is this the case? Would I have the same opportunities as a CCS with the CPC-H …
Medical Coding Continuing Education Unit Policy, CEU Policy
AAPC does not accept CEUs from other entities that offer "AHIMA approved" CEUs. These organizations must apply separately for AAPC CEUs and receive an AAPC index …
How to get CPC certified? - AAPC
The Certified Professional Coder (CPC) credential is the most recognized medical coding certification in the healthcare …
