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The

JANUARY 2015

Year Ahead

THE M
OST
IM
TO W PORTAN
ATCH
T
FOR HIM TOP
ICS
IN 20
15
I
CD10

-CM

/PC
S
Priv
acy
and
S ec
Info
u r it y
rma
t io n
Gov
Da t a
er na
nc e
A na
l ys i s

Welcome
TO THE DIGITAL EDITION OF THE

JOURNAL AHIMA
OF

Tips on Passing the CCS Exam

Jo Santos, RHIA, senior manager, certification services at


AHIMA/CCHIIM, gives quick tips on how to prepare for the CCS
exam in this video.

JOURNAL OF AHIMA

JOURNAL OF AHIMA

JOURNAL OF AHIMA

JOURNAL OF AHIMA

NOVEMBERDECEMBER 2014
JULY 2014

APRIL 2014

Top

TIPS FOR TACKLING EVERCHANGING ELECTRONIC


AUDITS, E-DISCOVERY, AND
E-MEASURES

HEALTHCARE DIY

BE E-PREPARED

REINVENTING CDI

TOP HITECH-HIPAA COMPLIANCE OBSTACLES EMERGE

BEHealthcare
g on
e-PREPARED
DIY epin ati
Ke formn
In lea
C

NOVEMBER/DECEMBER 2013

HITECHHIPAA

Compliance
Obstacles
Emerge

SEPTEMBER 2014

TS
OR A
FF AT
EE YD
NC IRT
NA T D
R
E U
OV T O
N G S OR
TIO O
MA T
OR HIM
INF NGE
W E
NE H A L L
C

Analyzing lessonsARE
learned
from six
ORGANIZATIONS
RELAUNCHING
AND REWORKING
of Omnibus
Privacy AND
Rule CODING ROLES, WITH
DATA months
INTEGRITY
EFFORTS,
implementation efforts
CLINICAL DOCUMENTATION
IMPROVEMENT PROGRAMS

SEPTEMBER 2014 - 85/9

NOVEMBERDECEMBER 2014 - 85/11

JULY 2014 - 85/7

APRIL 2014 - 85/4

EMPOWERING CONSUMERS TO OPTIMIZE THEIR


HEALTHCARE THROUGH HEALTH INFORMATION

Miss an Issue of the Journal in 2014?

Read all of the Journals 2014 issues by clicking on the back issues
tab in the menu tray at left.

Remember, you can always access tips and help


from the Help tab in the menu tray on the left.

WHOS GUARDING YOUR


PHI DISCLOSURE?
Ensure compliance
with privacy and
security regulations
through MRO.
HIM leaders are challenged to keep pace in a
rapidly evolving environment. Feel secure and
confdent while disclosing PHI by leveraging
MROs expertise, specialized services and
leading-edge technology, for:

Release of Information
Payer Audit Compliance
and Tracking
Accounting of Disclosures
esMD for CMS Audits
Social Security Portals for DDS
Meaningful Use and Patient
Portal Solutions
Direct Secure Messaging and
HISP Services

Get all your ducks in a row.


888.252.4146 www.mrocorp.com

Contents January 2015

Cover

20

The Year Ahead

The most important HIM


topics to watch for in 2015
By Mary Butler

Vol. 86, no. 1


Departments

10

Presidents Message
Now is the Time: Realizing Our Vision

12

Bulletin Board

pg. 26
Features

A lack of time management and unfamiliarity with code books


are two CCS exam challenges.

26

Top Ten Challenges of Passing the CCS


Examination (And How to Overcome Them)
By Kelli Horn, RHIT, CCS

32

mHealths Role in Consumerism


and Connectivity
By David Levin, MD, and Debra Gordon, MS

38

A Foot in the Door


How post-graduate apprenticeship
programs can help organizations
prepare for ICD-10

16

Word from Washington


ICD-10 Coalition Cautions Capitol Hill
Against Further Implementation Delay

19

Inside Look
Get Ready for 2015s Unique
Challenges, Opportunities

64

Calendar

65

Keep Informed

66

Volunteer Leaders

By Kayce Dover, MSHI, RHIA, and Chloe Phillips, MHA, RHIA

70

AHIMA Career Center

72

Addendum
This is Going on Your
Permanent Record

Contents January 2015


Working Smart

42

46

By Don Asmonga

By Beth Acker Moodhard, RHIA, and Reed Gelzer,


MD, MPH

44

48

Navigating Privacy and Security


Industry Awaits Phase 2 of
HIPAA Audit Program

e-HIM Best Practices


HIM Engaging the New Frontier
of Patient Portals
By Lesley Kadlec, MA, RHIA; Angela Dinh Rose,
MHA, RHIA, CHPS, FAHIMA; and Diana Warner,
MS, RHIA, CHPS, FAHIMA

Standards Strategies
Are We There Yet?

Quality Care
Obtaining Quality Healthcare
through Patient and Caregiver
Engagement
By Vera Rulon, MS, RHIT, FAHIMA

Coding Notes

Quizzes

56

AHIMA members may earn continuing


education credits by successfully completing
the following quizzes at www.ahimastore.org

By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS; William E. Haik, MD, FCCP,
CDIP; and Heidi Hillstrom, MS/HSA, MBA, RN, PHN, CCDS, CCS

31

CDI Tips Developed to Maximize ICD-10-CM/PCS

60

GEMs: Buyers Beware


By Diana Reed, RHIT, CCS-P

Practice Brief

52

Measuring the Value of the Clinical Documentation


Improvement Practitioner (CDIP) Credential

4/Journal of AHIMA January 15

Top Ten Challenges of Passing the CCS Examination


Domain: External Forces

37

mHealths Role in Consumerism and Connectivity


Domain: Technology

62

GEMs: Buyers Beware


Domain: Clinical Data Management

Contents January 2015

http://journal.ahima.org
ICD-10: Cutting Through
the Noise Physicians
have been bombarded with
opinions, information, and
misinformation about ICD-10.
This makes it challenging for
them to cut through the noise
and focus exclusively on how
best to deal with the new
coding system.

Tips on Passing the CCS Exam

Jo Santos, RHIA, senior manager, certification


services at AHIMA/CCHIIM, gives quick tips on
how to prepare for the CCS exam in this video.

Visit Our New Website

The Journal of AHIMA website, journal.ahima.org, has a


whole new look. Visit today for web exclusive content.

Share and Connect with AHIMA


Follow AHIMA and Journal of AHIMA on these social media outlets.
tinyurl.com/AHIMAFacebook

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feeds.feedburner.com/JournalOfAhima

6/Journal of AHIMA January 15

For the treatment of toxic plasma methotrexate


concentrations (>1 micromole per liter) in patients
with delayed methotrexate clearance due to impaired
renal function

Ad Space

Voraxaze New Technology Add-on Payment (NTAP) Extended

BTG
(Front)

Receive up to an additional 50% payment on your MS-DRG submission.*


When you report a claim for Voraxaze you can be reimbursed up to half the cost of Voraxaze
in addition to the current MS-DRG payment

USE VORAXAZE
ICD-9-CM CODE 00.95
TO BE ELIGIBLE FOR NTAP

Payers may require the national drug code (NDC) to be submitted on the claim
Product

Voraxaze

Injection or infusion of glucarpidase

NDC Number

50633021011 (11 digit)

Call 1-866-369-9290 or email Voraxaze@thepinnaclehealthgroup.com with questions


Indication and Limitations of Use
Voraxaze is indicated for the treatment of toxic plasma methotrexate concentrations (>1 micromole per liter) in patients
with delayed methotrexate clearance due to impaired renal function1

Voraxaze is not indicated for use in patients who exhibit the expected clearance of methotrexate (plasma methotrexate
concentrations within 2 standard deviations of the mean methotrexate excretion curve specic for the dose of methotrexate
administered) or those with normal or mildly impaired renal function because of the potential risk of subtherapeutic exposure
to methotrexate1

Selected Safety Information


Serious allergic reactions, including anaphylactic reactions, may occur
The most common adverse reactions (incidence 1%) with Voraxaze are paresthesias, ushing, nausea and/or vomiting,
hypotension, and headache

Please see brief summary of prescribing information on adjacent page.


Please see full prescribing information, including important safety information, at www.voraxaze.com.
References: 1. Voraxaze [prescribing information]. Brentwood, TN: BTG International Inc. March 2013. 2. New Medical Services and New Technologies. February 2014. http://cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.html.

DISCLAIMER
*Procedure coding should be based upon medical necessity and procedures and supplies provided to the patient. Coding and reimbursement information is provided for educational purposes and does
not assure coverage of the specic item or service in a given case. This information makes no guarantee of coverage or reimbursement of fees. Contact a local Medicare Fiscal Intermediary, Carrier, or
CMS for specic information regarding coverage, coding, and payment. To the extent that cost information is submitted to Medicare, Medicaid, or any other reimbursement program to support claims for
services or items, there is an obligation to accurately report the actual price paid for such items, including any subsequent adjustments.
ICD-9-CM=International Classication of Diseases, Ninth Revision, Clinical Modication.
NTAP=New Technology Add-on Payment policy provides additional payments for cases with high costs involving eligible new technologies while preserving some of the incentives under the averagebased payment system. The payment mechanism is based on the cost to hospitals for the new technology and is determined on a case-by-case basis. Under 42 CFR 412.88 Medicare pays the
lesser of 50 percent of the cost in excess of the full DRG payment or 50 percent of the cost of the technology. If the actual costs of a NTAP case exceed the DRG payment by more than the estimated
costs of the new technology, Medicare payment is limited to the DRG payment plus 50 percent of the estimated costs of the new technology. 2

BTG International Inc.


All rights reserved US-VX-2014-1091 August 2014
BTG and the BTG roundel logo are registered trademarks of BTG International Ltd.
Voraxaze is a registered trademark of Protherics Medicines Development Ltd.,
a BTG International group company.

VORAXAZE (glucarpidase)
For Injection, for intravenous use
Initial U.S. Approval: 2012
Brief Summary of Prescribing Information.
For complete Prescribing Information,
consult offcial package insert.
INDICATIONS AND USAGE
Indication
VORAXAZE (glucarpidase) is indicated for
the treatment of toxic plasma methotrexate
concentrations (>1 micromole per liter) in
patients with delayed methotrexate clearance
due to impaired renal function.
Limitation of Use
VORAXAZE is not indicated for use in
patients who exhibit the expected clearance
of methotrexate (plasma methotrexate
concentrations within 2 standard deviations
of the mean methotrexate excretion curve
specifc for the dose of methotrexate administered) or those with normal or mildly impaired
renal function because of the potential risk of
subtherapeutic exposure to methotrexate.
CONTRAINDICATIONS
None
WARNINGS AND PRECAUTIONS
Serious Allergic Reactions
Serious allergic reactions occurred in less than
1% of patients [see Adverse Reactions].
Monitoring Methotrexate Concentration/
Interference with Assay
Methotrexate concentrations within 48
hours following administration of VORAXAZE
can only be reliably measured by a
chromatographic method. DAMPA (4deoxy-4-amino-N10-methylpteroic acid) is an
inactive metabolite of methotrexate resulting
from treatment with VORAXAZE. DAMPA
interferes with the measurement of
methotrexate concentration using
immunoassays resulting in an erroneous
measurement which overestimates the
methotrexate concentration. Due to the long
half-life of DAMPA (t1/2 of approximately
9 hours), measurement of methotrexate
using immunoassays is unreliable for samples
collected within 48 hours following VORAXAZE
administration.
Continuation and Timing of Leucovorin
Rescue
Continue to administer leucovorin after
VORAXAZE. Do not administer leucovorin
within 2 hours before or after a dose of
VORAXAZE because leucovorin is a substrate
for VORAXAZE [see Drug Interactions].
For the frst 48 hours after VORAXAZE,
administer the same leucovorin dose as
given prior to VORAXAZE [see Warnings
and Precautions]. Beyond 48 hours after
VORAXAZE, administer leucovorin based on
the measured methotrexate concentration. Do
not discontinue therapy with leucovorin based
on the determination of a single methotrexate
concentration below the leucovorin treatment
threshold. Therapy with leucovorin should be
continued until the methotrexate concentration
has been maintained below the leucovorin
treatment threshold for a minimum of 3 days.
Continue hydration and alkalinization of the
urine as indicated.
ADVERSE REACTIONS
Serious allergic reactions, including
anaphylactic reactions, may occur. The most
common adverse reactions (incidence >1%)
with VORAXAZE are paraesthesias, fushing,
nausea and/or vomiting, hypotension, and
headache.
Clinical Trials Experience
Because clinical trials are conducted under
controlled but widely varying conditions, adverse reaction rates observed in clinical trials
of VORAXAZE cannot be directly compared to

rates in the clinical trials of other drugs and


may not refect the rates observed in practice.
The evaluation of adverse reactions in patients
treated with VORAXAZE is confounded by the
population in which it was studied, patients
with toxic plasma methotrexate levels due to
impaired renal function. Adverse reactions
related to toxic methotrexate levels due to
prolonged methotrexate clearance include
myelosuppression, mucositis, acute hepatitis,
and renal dysfunction and failure.
The safety of VORAXAZE is based on data from
290 patients who were treated in 2 single-arm,
open-label, multicenter trials enrolling patients
who had markedly delayed methotrexate
clearance secondary to renal dysfunction.
Patients with osteosarcoma were eligible
for these studies if the plasma methotrexate
concentration was greater than 50 mol/L at
24 hours, greater than 5 mol/L at 48 hours,
or greater than 2 standard deviations above
the mean methotrexate elimination curve at
least 12 hours after methotrexate administration and there was a 2-fold or greater increase
in serum creatinine above baseline. All other
patients were eligible for these studies if the
plasma methotrexate level was greater than
10 mol/L more than 42 hours after the start
of the methotrexate or the plasma level was
greater than 2 standard deviations above the
mean methotrexate excretion curve at least 12
hours following methotrexate and the serum
creatinine was greater than 1.5 times the upper limit of normal or the creatinine clearance
was less than 60 mL/min at least 12 hours
following methotrexate administration.
Study 1, conducted by the National Cancer
Institute (NCI), enrolled 184 patients; safety
information is available for 149 patients.
VORAXAZE was given at a dose of 50 Units/
kg as an intravenous injection over 5 minutes.
Patients with pre-VORAXAZE methotrexate
concentrations >100 mol/L were to receive a
second dose of VORAXAZE 48 hours after the
frst dose. The protocol specifed that patients
continue receiving intravenous hydration,
urinary alkalinization and leucovorin, and
that leucovorin administration be adjusted to
ensure that it was not administered within two
hours before or after VORAXAZE.
In Study 1, VORAXAZE-related adverse
reactions were collected on a fow sheet with
a daily log of adverse reactions characterized
as glucarpidase toxicity. Additional safety
information was collected from clinical records submitted by treating physicians. This
information was abstracted and categorized
using the National Cancer Institute (NCI)
Common Terminology Criteria for Adverse
Events (CTCAE) version 3 scale.
The Study 1 population enrolled patients with
a median age of 18 years (1 month to 85
years); 63% were male, and the underlying
malignancies were osteosarcoma/sarcomas
in 32%, and leukemia or lymphoma in 63%
of patients. One (n=106) or 2 (n=30) doses of
VORAXAZE were administered intravenously;
the number of doses was not specifed in 13
patients. Doses ranged from 18 to 98 Units/
kg, with a median dose of 49 Units/kg.
Study 2 is an ongoing expanded access
program. At the time of data cut-off, 243
patients were enrolled and safety data was
available for 141 patients. VORAXAZE was
given at a dose of 50 Units/kg as an intravenous injection over 5 minutes. The criterion for
allowing patients to receive a second glucarpidase dose was not specifed in the protocol.
The protocol specifed that patients continue
receiving intravenous hydration, urinary alkalinization and leucovorin, and that leucovorin
administration be adjusted to ensure that it
was not administered within two hours before
or after VORAXAZE.
Study 2 enrolled patients with a median age
of 17 years (6 months to 85 years); 64% were
male, and the underlying malignancies were
osteogenic sarcoma in 32%, and leukemia or
lymphoma in 62% of patients. One (n=122) or 2
(n=18) doses of VORAXAZE were administered
intravenously; the number of doses was not

specifed for 1 patient. Doses ranged from


6 to 189 Units/kg, with a median dose of
50 Units/kg.
In Study 2 only VORAXAZE-related adverse
reactions were collected and severity was
graded according to NCI CTCAE version 3.
Among the 290 patients included in the
safety evaluation of VORAXAZE, there were 8
deaths within 30 days of VORAXAZE exposure
that were not related to progressive disease.
Twenty-one of 290 patients (7%) experienced
adverse reactions that were assessed as
related to VORAXAZE. Most were Grade 1 or 2
events. One patient experienced related Grade
3 fushing. The most common related adverse
reactions that were not hematologic, hepatic
or renal events were paresthesia, fushing, and
nausea and/or vomiting, which each occurred
in 2% of patients (Table 1).
Table 1: Per Patient Incidence of Grade
1 and 2 Adverse Reactions Assessed as
Possibly, Probably, or Defnitely Related
to VORAXAZE Excluding Hematologic,
Hepatic, or Renal Adverse Reactions
Adverse Reaction

N= 290
n (%)

Paresthesias

7 (2%)

Flushing1,2

5 (2%)

Nausea/Vomiting

5 (2%)

Headache

2 (1%)

Hypotension

2 (1%)

Blurred Vision

1 (<1%)

Diarrhea

1 (<1%)

Hypersensitivity

1 (<1%)

Hypertension

1 (<1%)

Rash

1 (<1%)

Throat irritation/
Throat tightness

1 (<1%)

Tremor

1 (<1%)

This incidence includes the following terms: fushing,


feeling hot, burning sensation.

One of these reactions was classifed as Grade 3


in severity.

Immunogenicity
As with all therapeutic proteins, there is
potential for immunogenicity. In clinical trials,
121 patients who received one (n=99), two
(n=21), or three (n=1) doses of VORAXAZE
were evaluated for anti-glucarpidase
antibodies. Twenty-fve of these 121 patients
(21%) had detectable anti-glucarpidase antibodies following VORAXAZE administration, of
which 19 received a single dose of VORAXAZE
and 6 received two doses of VORAXAZE.
Antibody titers were determined using a
bridging enzyme-linked immunosorbent assay
(ELISA) for anti-glucarpidase antibodies.
Neutralizing antibodies were detected in 11
of the 25 patients who tested positive for
anti-glucarpidase binding antibodies. Eight of
these 11 patients had received a single dose
of VORAXAZE. However, the development of
neutralizing antibodies may be underreported
due to lack of assay sensitivity.
The detection of antibody formation is highly
dependent on the sensitivity and specifcity of
the assay. Additionally, the observed incidence
of antibody (including neutralizing antibody)
positivity in an assay may be infuenced by
several factors, including assay methodology,
sample handling, timing of sample collection,
concomitant medications, and underlying
disease. For these reasons, comparison of
incidence of antibodies to VORAXAZE with the
incidence of antibodies to other products may
be misleading.

DRUG INTERACTIONS
Use of VORAXAZE with Leucovorin
Leucovorin is a substrate for VORAXAZE.
Do not administer leucovorin within 2 hours
before or after a dose of VORAXAZE. No dose
adjustment is recommended for the continuing leucovorin regimen because the leucovorin
dose is based on the patients pre-VORAXAZE
methotrexate concentration [see Warnings
and Precautions].
Other Substrate Interference
Other potential exogenous substrates of
VORAXAZE may include reduced folates and
folate antimetabolites.
USE IN SPECIFIC POPULATIONS
Pregnancy
Pregnancy category C.
There are no adequate and well controlled
studies with VORAXAZE in pregnant women
and animal reproduction studies have not
been conducted with VORAXAZE. Therefore, it
is not known whether VORAXAZE can cause
fetal harm when administered to a pregnant
woman. VORAXAZE should be given to a
pregnant woman only if clearly needed.
Nursing Mothers
It is not known if VORAXAZE is excreted in human milk. Because many drugs are excreted
in human milk, caution should be exercised
when VORAXAZE is administered to a nursing
woman.
Pediatric Use
The effectiveness of VORAXAZE in pediatric
patients was established in Study 1. Of the
22 patients in the effcacy dataset in Study 1,
12 were pediatric patients with ages ranging
from 5 to 16 years. Three of the six pediatric
patients with a pre-VORAXAZE methotrexate
concentration of 1-50 mol/L achieved a rapid
and sustained clinically important reduction
(RSCIR) in plasma methotrexate concentration,
while none of the six pediatric patients with a
pre-VORAXAZE methotrexate concentration
>50 mol/L achieved a RSCIR.
The pooled clinical safety database for
VORAXAZE included data for 147 patients
from 1 month up to 17 years of age. No overall
differences in safety were observed between
these patients and adult patients.
Geriatric Use
Of the total number of 290 patients in clinical
studies of VORAXAZE, 15% were 65 and
over, while 4% were 75 and over. No overall
differences in safety or effectiveness were
observed between these patients and younger
patients.
Renal Impairment
No dose adjustment of VORAXAZE is
recommended for patients with renal
impairment.
Hepatic Impairment
No specifc studies of VORAXAZE in patients
with hepatic impairment have been conducted.
OVERDOSAGE
There are no known cases of overdose with
VORAXAZE.

Manufactured by:
BTG International Inc.
Brentwood, TN 37027
U.S. License No. 1861
Distributed by:
BTG International Inc.
West Conshohocken, PA 19428
VORAXAZE is a registered trademark of
Protherics Medicines Development Ltd.
BTG and the BTG roundel logo are registered
trademarks of BTG International Ltd.

The Journal of AHIMA is an official publication of AHIMA

AHIMA CEO

EDITORIAL DIRECTOR

EDITOR-IN-CHIEF

Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA


Anne Zender, MA
Chris Dimick


ASSISTANT EDITOR/
ADVERTISING COORDINATOR Sarah Sheber

ASSOCIATE EDITOR

Mary Butler


CONTRIBUTING EDITORS
Sue Bowman, MJ, RHIA, CCS, FAHIMA

Patricia Buttner, RHIA, CDIP, CCS

`
Angie Comfort, RHIT, CDIP, CCS

Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA

Julie Dooling, RHIA, CHDA

Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, CDIP,

FAHIMA

Katherine Downing, MA, RHIA, CHP, PMP

Deborah Green, MBA, RHIA

Jewelle Hicks

Lesley Kadlec, MA, RHIA

Carol Maimone, RHIT, CCS

Paula Mauro

Anna Orlova, PhD

Kim Osborne, RHIA, PMP

Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA

Maria Ward, MEd, RHIT, CCS-P

Diana Warner, MS, RHIA, CHPS, FAHIMA

Lydia Washington, MS, RHIA

Lou Ann Wiedemann, MS, RHIA, CHDA, CDIP, CPEHR,

FAHIMA

ART DIRECTOR Graham Simpson

EDITORIAL ADVISORY BOARD


Linda Belli, RHIA

Gerry Berenholz, MPH, RHIA

Carol A. Campbell, DBA, RHIA

Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FAHIMA

Teri Jorwic, RHIA, CCS

Diane A. Kriewall, RHIA

Frances Wickham Lee, DBA, RHIA

Glenda Lyle, RHIA

Susan R. Mitchell, RHIA

Daniel J. Pothen, MS, RHIA

Cheryl Tabatabai Stachura, RHIA

Tricia Truscott, MBA, RHIA, CHP

Carolyn R. Valo, MS, RHIT, FAHIMA

Valerie Watzlaf, PhD, RHIA, FAHIMA

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Journal of AHIMA (ISSN 1060-5487) is published monthly, except for the combined issue of November/December, by the American Health Information Management Association, 233 North Michigan
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Copyright 2014 American Health Information Management Association Reg. US Pat. Off.

Journal of AHIMA January 15/9

Presidents Message

Now is the Time: Realizing Our Vision


By Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA

AS I ENTER my 35th year as an AHIMA


leader, educator, practitioner, and volunteer, I am excited to celebrate AHIMAs
86 years of accomplishments and to
have a role in paving the way for a bright
future for HIM professionals everywhere.
I look forward to the months ahead,
building on AHIMAs strategic foundation as we lead the healthcare industry in
ensuring data integrity through groundbreaking information governance practices, health informatics, leadership,
public good, and innovative practices
that drive the power of knowledge. I am
proud of our collaborative approach to
demonstrating the value proposition
achieved by early ICD-10 adopters following last years delay. As disruption
changes the healthcare industry, the
organizations that will continue to thrive
will be those best able to adjust their
business models and practices to industry changes and external threats.
Health information and informatics
professionals are poised to act as the
conduit that ensures technology develops as a tool that improves an organizations ability to both tell and correctly
interpret the patients story. AHIMAs
work in health informatics will provide
a blueprint to seamlessly convert data
into health intelligence to propel the improvement of population health.
To mark the occasion of my transition
to AHIMA President, I launched an endowed research scholarship in memory of my brother, Joel Nagorner, who
passed away during my first term with
AHIMAs Board of Directors. My goal
and vision is to enhance the HIM communitys applied research pathway to
promote the achievement of a better
healthcare system through leveraging
technology, HIM standards, and best
practices to provide access to trusted
information.
10/Journal of AHIMA January 15

Joel would be proud that he is the inspiration for a gift that keeps on giving
as the scholarship supports research
that will tackle the challenges he experienced during his 20-year battle with
cancer, furthering efforts that will enable
quality healthcare information to be securely accessed anywhere and anytime.
This ability is at the core of AHIMAs
public good strategic pillar.
Over the past year I have heard from
our members about the challenges they
face, from changing roles, relevancy,
and influence to new opportunities to
shape their professional destiny. I encourage all AHIMA members to jump in
the front seat when it comes to navigating our initiatives through the changing
healthcare landscape.
The path ahead wont be easy, nor will it
always be straightforward. It is critical for
HIM professionals to continuously work
to build leadership skills and knowledge
in the new competencies that have been
defined by our educational community
as we transition to our 2020 vision.
In order to meet all of our strategic initiatives, we need to really push ourselves
to the next level, outside of our respective comfort zones, align with multiple
stakeholders both inside and outside of
our association, fine tune our skills, and
even reinvent ourselves as we strive for
excellence in the execution of HIM duties. Together as an engaged HIM community I know that we can realize our
vision and motivate our members to
achieve their full potential while advancing the practice of HIM.
Weve dreamed big, believed, and
stepped up to lead. Now it is time to realize our vision!
Cassi Birnbaum (cassi.birnbaum@ahima.org)
is senior vice president of HIM and consulting at
Peak Health Solutions.

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Bulletin Board whats happening in healthcare

IOM Panel Recommends EHRs Collect More Social, Behavioral Data


Electronic health records (EHRs)
should be used to capture additional
social and behavioral data on patients
in order to better facilitate research,
according to a study developed by an
Institute of Medicine (IOM) subcommittee. The study, Capturing Social
and Behavioral Domains and Measures in Electronic Health Records:
Phase 2 also recommended that the
stage 3 meaningful use EHR Incentive Program require the collection of
12 specific social and behavioral data
categories through certified EHRs.
The subcommittee was convened
by the Centers for Medicare and Medicaid Services (CMS), the Centers for
Disease Control and Prevention (CDC),
and other government and private enti-

ties to identify domains and measures


that capture the social and behavioral
determinants of health to inform the
development of recommendations for
the meaningful use of EHRs.
Over the past few decades, substantial empirical evidence points to
the contribution of social and behavioral factorssuch as living conditions and physical activity levelsto
functional status and the onset and
progression of disease, the study
stated. Research and interventions
on social and behavioral determinants
of health have largely fallen under
the purview of public health, and until recently, these determinants have
not been linked to clinical practice or
health care delivery systems.

The 12 data categories the subcommittee says EHRs should capture are:
Alcohol use
Race and ethnicity
Residential address
Tobacco use and exposure
Census tract-median income
Depression
Education
Financial resource strain
Intimate partner violence
Physical activity
Social connections and social
isolation
Stress
The first four categories are already
routinely collected in clinical settings,
though the value of the information

Consumer Concerns About EHR Privacy


and Security Declining

CMS Names First


Chief Data Officer

As electronic health record (EHR)


adoption increases, consumer concern about the privacy and security
of digital records compared to paper
records is becoming statistically insignificant, new studies have found.
In a two-year long study conducted
by the Office of the National Coordinator for Health IT, investigators compared consumer privacy concerns
over electronic records with concerns
about paper records. In findings published by Bloomberg BNA, 69 percent
of respondents whose providers used
EHRs were very or somewhat concerned about privacy, compared with
75 percent of respondents whose
providers used paper records.
Whats more, 74 percent of respondents whose providers used EHRs
were very or somewhat concerned
about security, compared with 83
percent of respondents whose providers used paper records, according
to iHealthBeat.
The same study also revealed that

The Centers for Medicare and Medicaid


Services (CMS) has named Niall Brennan the agencys first chief data officer,
in charge of running its new Office of
Enterprise Data and Analytics (OEDA),
according to a CMS press release.
Brennan will be tasked with overseeing
improvements in data collection and
dissemination as the agency strives to
be more transparent.
OEDA will help CMS better harness
its vast data resources to guide decision-making and develop frameworks
promoting appropriate external access
to and use of data to drive higher quality, patient-centered care at a lower
cost, read a CMS statement on the
new appointment and department.
The move builds on the steps CMS
has recently taken to better harness its
data resources. CMS is now routinely
analyzing claims data in real time and
applying predictive analytics to proactively identify fraud and abuse and
track key metrics such as hospital readmissions, the release said.

12/Journal of AHIMA January 15

10 percent of patients withheld information from providers who used


EHRs, while six percent of patients
withheld information from providers
who used paper records.
A National Public Radio (NPR)Truven Health Analytics Health Poll
yielded similar results. The survey
found that consumers were most
concerned about the security of their
data in the hands of insurers, with 16
percent expressing concern about
the integrity of insurer data. Only 11
percent were worried about the privacy of their health data with physicians, and 14 percent were worried
about data stored by hospitals. According to the NPR poll, five percent
of consumers had been told that they
were part of a security breach.
Both sets of studies concluded that
consumers want healthcare organizations to use EHRs and are willing to
trade perceived privacy and security concerns for the benefit of having
their information collected.

would be increased if standard measures were used in capturing these


data as part of stage 3 meaningful
use, the study stated. The addition of
the other eight data areas, together
with the four regularly collected areas,
would constitute a coherent panel
that will provide valuable information
on which to base problem identification, clinical diagnoses, treatment,
outcomes assessment, and population health management.
The recommendations shouldnt
pose significant technical difficulties
for vendors to institute, according to
William Stead, co-chairman of the
13-member subcommittee that created the study and professor of medicine and biomedical informatics at

Vanderbilt University, who was quoted in a Modern Healthcare article.


Providers may have issues collecting the information, however, which
could be gathered from patients using patient portals or mobile devices.
Trust is another issue that must be
addressed by providers, Stead said.
Practices will need to consider
workflow design, Stead said. Who
its going to be shared with and why
its essential to maintain trust. Twoway consent from patients to share
their information between providers
and outside agencies may be required, though Stead said in the article that the benefits of addressing
these concerns outweigh the problems collecting it.

Consumers Look to Web for Objectivity in


Health Information
While the vast majority of individuals consult medical professionals for healthcare advice (95 percent), a comparable majority also consult health websites
(89 percent), according to a recent survey by Accenture. Internet searches (87
percent) and family and friends (74 percent) were the next most popular, with
health plans (67 percent) bringing up the rear. According to Accenture, threefourths of consumers reported that they value lack of bias over accuracy when
searching for medical information. Even though most consumers believe the
Internet yields inaccurate information, they also believe the information to be
unbiased, pushing Internet sources past health plans in popularity.

Top Sources for Medical Information Among US Consumers


95%

Medical Professionals
89%

Health Websites

87%

Internet Searches
74%

Family and Friends


Health Plans

0%

67%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

A report from the Office of the National


Coordinator for Health IT found that a
lack of interoperability among electronic health record systems used
by participants in accountable care
organizations inhibits progress toward
a value-based care environment.
A study in the Journal of General Internal
Medicine finds that less than a third of
Americans ages 65 and over use the
Internet for health information.
A report from Juniper Research predicts
that electronic health records will deliver a cumulative cost savings of $78
billion over the next five years.
Recent data from the Department of
Health and Human Services shows that
nearly five percent of eligible hospitals
failed post-payment meaningful use
EHR Incentive Program audits.
Baptist Memorial Health Care has deployed an electronic health record
platform that creates a single patient
record, which is expected to decrease
the number of duplicate tests.
Robert Wood Johnson University Hospital
has announced plans to implement a
single electronic health record system
for all its facilities.
A former hospital employee of Parkland
Memorial Hospital in Dallas, TX that
accessed confidential patient data in
the hospitals electronic health record
is facing up to five years in prison and
a fine up to $250,000 after pleading
guilty to identity theft.
Eligible providers in Massachusetts
were overpaid by $2.1 million in
Medicaid EHR incentives in 2011 and
2012, according to a report from the
Department of Health and Human Services
Office of Inspector General.
A former chief financial officer at Shelby
Regional Medical Center is facing up
to five years in prison after pleading
guilty to submitting false statements to
Medicare regarding the meaningful use
of electronic health records.

Source: Accenture. Building Trust Using Patient Engagement and the Wisdom of the Crowd. October 15, 2014.
www.accenture.com/us-en/Pages/insight-building-trust-using-patient-engagement-wisdom-crowd.aspx.

Journal of AHIMA January 15/13

Bulletin Board whats happening in healthcare

Big Data Key to Preventing Military Suicides


ECRI INSTITUTE 2015 TOP 10 HEALTH
TECHNOLOGY HAZARDS
www.ecri.org/Forms/
Pages/2015hazards.aspx
A report from the ECRI Institute
analyzes 10 technology safety topics
that warrant particular attention for
the coming year and includes additional resources and guidance on each
topic. The topics include data integrity,
patient-handling device use errors, and
cybersecurity.
USE OF SOCIAL MEDIA ACROSS US
HOSPITALS: DESCRIPTIVE ANALYSIS OF
ADOPTION AND UTILIZATION
www.jmir.org/2014/11/e264
A study offers a preliminary investigation of social media adoption and
utilization among US hospitals, providing the framework for future studies
investigating the effect of social media
on patient outcomes, including links
between social media use and the
quality of hospital care and services.
REASONS AND BARRIERS FOR USING A
PATIENT PORTAL: SURVEY AMONG PATIENTS
WITH DIABETES MELLITUS
www.jmir.org/2014/11/e263
A study explores the opinions of patients with diabetes and identifies perceived barriers to using a Web portal
to optimize its use. Current Web portal
adoption rates among diabetes mellitus patients is slow, despite the fact
that portal use may result in improved
diabetes outcomes.
BUSINESS STRATEGY: THWARTING
CYBER THREATS AND ATTACKS AGAINST
HEALTHCARE ORGANIZATIONS
www.idc.com/getdoc.
jsp?containerId=HI251775
A new report from IDC Health Insights
features findings from the 2014 IDC
Insights Cross Industry Cyber Threat
Survey, designed to gauge how financial services, healthcare provider organizations, and retailers are responding
to increasing cyber threats and the impact of successful attacks on business
operations. The report highlights how
healthcare organizations are investing
in their cyber strategy to protect their
most valuable electronic assets.
14/Journal of AHIMA January 15

Predictive analyticsand the data


used to drive itis making impressive
strides for predicting hospital readmission risk and warning signs of major
illnesses. The US Department of Veterans Affairs (VA) has developed an
approach to reducing military suicides
that leverages this innovation.
In recent years, the military has lowered the enlistment standards that
have kept some would-be soldiers with
mental illness risk factors from entering
the system. The result has been higher
rates of suicides among veterans. To
combat this, the VA has implemented
screening systems to help flag individuals with a high risk for suicide and depression, the New York Times recently
reported.
A computer system takes nearly 300
actuarial factors such as age at enlistment, history of violence, and prescription drug use into account, and uses

data mining processes to determine


risk. A Harvard-led research team,
which mined the data of over 40,000
soldiers hospitalized for mental health
reasons, found that five percent of the
sample were 15 times as likely to commit suicide in the year after being discharged from the hospital as the rest
of the group, according to the Times.
The risk model could help practitioners
identify vulnerable soldiers earlier on
and employ interventions to prevent
suicides, the researchers deduced.
This would be unparalleled, compared to almost any other intervention
we could make in medicine, Lt. Gen.
Eric B. Schoomaker, a former surgeon
general of the US Army, told the New
York Times.
This study begins to show the positive effects big data can have, when
combined with administrative health
records.

Hospital Puts Patient Portal Access at


Patients Bedside
A pilot program at a Boston hospital is
putting tablet computers at patients
bedside to help the patients and their
family members better engage with the
care team.
Funded by a $2 million grant from the
Gordon and Betty Moore Foundation
and $700,000 from the oncology and
intensive care units at Brigham and
Womens Hospital, the tablets come
loaded with an application that allows
patients to interact with their medical
record.
According to the Boston Business
Journal, the app was created with the
patients needs in mind rather than
physicians.
Designed with the help of patient advocacy groups, the tablets and the app
let patients and their proxies review a
patients status, look up medications,
or communicate questions to a patients doctors and clinicians in a chat

room-like setting, according to Boston


Business Journal. Over 100 oncology
patients have used the technology so
far.
Care was also taken to make the devices and app HIPAA-compliant. Only
the patient and a proxy are given login
information and the tablet becomes inoperable if taken beyond the hospitals
IP address. Only one of the 55 iPads
has gone missing since the pilot started in July.
The care team owning the medical
recordthose days are over, Patricia
Dykes, program director for the Center for Patient Safety Research and
Practice and also program director for
the Center for Nursing Excellence, told
the publication. The patient knows its
their information, they want access,
and we believe if patients have access
in a way they understand, that they can
partner with us for better outcomes.

Unique Naming System Reduces NICU Errors


Errors made when entering clinical orders for neonatal intensive care unit
(NICU) patients may be prevented via
the implementation of more sophisticated identification systems, according to researchers.
Patient identity confusion in the
NICU environment has been an ongoing issue for years, said Jason Adelman, MD, patient safety officer at Montefiore Medical Center, in an interview
with MedPage Today. Part of the issue
is that most hospitals have a temporary
naming system for newborns such as
BabyBoy or BabyGirl, which can
increase the chances of confusion
between patient charts, according to
Adelman.
In a survey of over 300 NICUs, 80
percent indicated that they used a
similar non-specific temporary naming
system for all the newborns delivered
at their facility.
Adelman and research colleagues
developed an algorithm to identify

when a healthcare provider quickly


cancels orders from one patient in the
EHR and reorders the same orders for
another patient within 10 minutes.
In previous research, Adelman and
his team identified 382 of these nearmiss errors, called Retract-and-Reorder (RNR), out of 341,408 total orders
from 2007 to 2010.
For the teams second study, a function was added to the EHR system that
required providers to enter the patients initials, age, and gender before
being able to start an order entry session. This identity verification function
provided a 50.6 percent reduction in
RNR errors.
In a third study, researchers developed a formula to create a first name
for neonatal patients. This naming formula led to a 49.9 percent RNR reduction for individual orders, and a 25.1
percent reduction for each ordering
session, according to the MedPage
Today article.

Patient Access to EHRs May Improve


Accuracy
Providing patients with the ability to
access and provide feedback on their
health information may improve the
accuracy of medication lists, a recent study suggests. According to the
study, published in eGems, patients
requested changes to shared medication lists in 89 percent of all cases, and
pharmacists responded positively to
68 percent of patient requests.
Patients were eager to provide feedback in the study, and potential benefits extended beyond the accuracy of
the medication list alone. Most participants saw benefits in having medication feedback available online, the researchers wrote. The benefits include
convenience of electronic access,
enhanced ability to track and monitor
medications for themselves and their
family, and being better prepared for

their doctors visits. Many participants


indicated that they used their enhanced
access to prepare questions and discussion points ahead of physician office visits, and reduced the amount of
time in appointments spent reconciling
medications, according to the study.
All patient feedback in the study was
routed through a pharmacist, who followed up with the patient before changing the medication list shared between
the patient and clinicians.
A recent study published in the Journal of the American Medical Informatics Association found similar benefits
in an exploration of the experience of
early patient adopters who access their
clinical notes online using the Blue Button feature of My HealtheVet, the online
patient portal for the US Department of
Veterans Affairs.

ADVANCED ICD-10-PCS SKILLS WORKSHOPS


www.ahimastore.org
This three day workshop is designed
for individuals that already have basic
ICD-10-PCS education and want to
enhance their skills. Workshop attendees practice the code set with complex
cases commonly encountered in an
inpatient setting, and use the Centers
for Medicare and Medicaid Services
electronic code set file. Each attendee
also receives a copy of the book ICD10-PCS: An Applied Approach.
COMBATING FAKE DRUGS
http://preventfaking.com/
A mobile technology tool has been designed to help prevent the proliferation
of fake drugs in West Africa. The tool
is part of an initiative from the Pharmaceutical Society of Ghana, which will
allow participating companies to add
special labeling to their products when
dispensed at the retail level. People
purchasing the products will be able
to scratch off a hidden area to reveal
a unique 12-digit numeric code, then
text the code to a unique toll-free short
code. A response arrives within 10 seconds to tell the consumer whether the
medicine is original or fake.
VIDEO CONSULTATION VIA MOBILE APP
www.touchcare.com
A new mobile app from start-up vendor TouchCare connects patients and
physicians for video consultations on
smartphones and tablets. The app is
being used by physicians in primary
and emergency care settings, as well
as accountable care organizations and
specialty practices, according to the
TouchCare website.
AHIMA PRODUCTS AND CATALOG APP
https://itunes.apple.com/us/app/ahima-products/id904979366?ls=1&mt=8
AHIMA has launched a new free app,
available in the iTunes store and on
Google Play, which offers an interactive catalog to users. The app provides
detailed information that helps HIM instructors evaluate AHIMA Press books
and materials for classroom and professional use.

Journal of AHIMA January 15/15

Word from Washington

ICD-10 Coalition Cautions Capitol Hill


Against Further Implementation Delay
By AHIMAs Advocacy and Policy Team

AHIMA IS NOT the only industry voice


advocating for the transition to ICD-10CM/PCS. At a Capitol Hill briefing sponsored by the Coalition for ICD-10, Sue
Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance at AHIMA, was joined by many
other industry leaders who echoed AHIMAs position that relying on the current
ICD-9 coding system compromises the
value of healthcare data.
At the September 2014 briefing, leaders
representing physician practices, hospitals, and payers urged policymakers to
adhere to the scheduled transition to
ICD-10 on October 1, 2015. The following are interviews with several speakers
at the event on why the healthcare industry cannot afford another delay.

Providers Have Been Ready


According to a February 2014 survey by
the Healthcare Financial Management
Association (HFMA), nearly three quarters of hospitals and health systems said
they were ready for ICD-10 just weeks
before another yearlong delay was announced on April 1, 2014.
The hospital sector had put in the
time and effort, so providers could have
made it work, says Sandra J. Wolfskill,
FHFMA, director of healthcare finance
policy, revenue cycle MAP, at HFMA. If
we have another delay, we would lose
even more momentum, not to mention
the lost dollars that we have spent trying to maintain skills and tread water because of the current delay.
What is at risk is perhaps as much as
$6.8 billion, the estimated cost of a single one-year delay, according to the US
Department of Health and Human Services. Also at risk are the job prospects
for more than 25,000 HIM students and
recent graduates, many of whom learned
to code exclusively in ICD-10.
16/Journal of AHIMA January 15

Wolfskill believes ICD-10 adoption is


needed in 2015 because the new coding systems granularity will allow providers to capture the data they require
for population health management and
new value-based payment models. For
example, ICD-10 provides four levels of
asthma disease severityunlike ICD-9,
which does not include a severity measure.
Severity coding allows providers to
develop interventions and strategies
to appropriately treat asthma patients
at either end of the spectrum, whereas
now we are dealing with a one-size-fitsall approach, she says.

Effects on the Bottom Line


The delayed transition means that hospitals across the country will need to respend millions of dollars that they have
already spent on staffing, education,
and IT resources. For example, Inspira
Health Network, located in Bridgeton,
NJ, will need to reinvest $1.2 million in
2015 that they spent in 2014 to prepare
for the ICD-10 transition.
We absolutely cannot afford another
delay, says Thomas Pacek, vice president of information systems and CIO at
Inspira. We are trying to reduce costs
in healthcare, and this is not helping us.
Inspira originally had $2.8 million earmarked for the ICD-10 transition, a figure
that Pacek believes is on the low side
compared with other organizations. We
spent millions to get software upgraded
to be compliant, to test systems, and
to test claims with payers. We even did
some preliminary tests with [the Centers
for Medicare and Medicaid Services]
CMS at one point before they had the
delay. So we were in a really good spot,
Pacek says.
Inspira also made significant investments in education for coders, office

Word from Washington

managers, and physicians.


Pacek says the delay has had a ripple effect on other technology initiatives at Inspira, which has been named a Most
Wired organization by Hospitals & Health Networks. In particular, the delay has made it difficult to assign resources to
other projects, including the deployment of a common IT
platform with a recently merged hospital. If there is another
delay of ICD-10-CM/PCS implementation in 2015, Inspira
may need to postpone its planned rollout of a common ambulatory platform until 2016.
Based on Inspiras market, Pacek believes physicians are
motivated to move to ICD-10. If you really listen to physicians, they are ready, he says. We have done a lot to support our community physicians through education, and we
are not going to let them fail.

Training Costs are Not an Obstacle


The cost of training clinicians on ICD-10-CM is not a valid
excuse to delay the transition another year, says Jeffrey
F. Linzer Sr., MD, professor of pediatrics and emergency
medicine at Emory University School of Medicine, located
in Atlanta, GA. Some groups have claimed it will cost thousands and thousands to train physicians on I-10 [ICD-10],
says Linzer, who is leading ICD-10-CM training at Childrens
Healthcare of Atlanta. In my healthcare system with 2,000
physicians, we have estimated that it costs less than $1,000
per physician to train on I-10. So the costs are not that substantial. And a fair number of health systems with EHRs are
already using ICD-10 terminology, so physicians are getting
used to it.
Linzer says the industry needs to adopt the ICD-10-CM
coding standard this coming October because the current
coding system is 35 years old and does not reflect current
medical thought. Ask your own physician when was the last
time he or she purposely made the diagnosis of intrinsic or
extrinsic asthma. That terminology is archaic and way out of
date, he says.
In addition to using more current terminology, ICD-10-CM
is more flexible to update and allows for greater specificity,
Linzer says. This specificity is critical for reporting quality
metrics, tracking health resource utilization, and helping uncover fraud and abuse, he says.
To take advantage of this greater specificity, medical societies like the American Academy of Pediatrics and the
American Academy of Orthopaedic Surgeons contributed
to the development of the US clinical modification of ICD10, known as ICD-10-CM. The medical societies asked
for specific codes because they wanted to track conditions more closely, Linzer says. As a result, the number of
codes increased from just over 14,000 in ICD-9 to more than
69,000 in ICD-10-CM.
Because of this input from medical societies, ICD-10-CM
is really tailored to help physicians document the services
they provided and why certain resources were utilized.

Telling the Patients Story


Like hospitals and health systems, physician practices also
must reinvest time and energy to prepare for ICD-10. The
longer we delay, the more we have to redo the work we have
already done, says Gail Eminhizer, CMM, CGCS, HITCMPP, practice administrator at Digestive Health Associates of
Northern Michigan, P.C., a 10-provider private practice in
Traverse City, MI.
As an office manager, Eminhizer believes the adoption of
ICD-10 is needed to reduce the number of rejected or pended
claims from payers requesting further documentation. We
simply do not have codes that can tell the whole story, says
Eminhizer, who is president of the Traverse City Chapter of
the Professional Association of Health Care Office Management (PAHCOM). This has implications for timely payment as
well as accurate quality reporting in specialty practices that
see complex patients. There is nothing in ICD-9 that fully
explains how complicated a patients condition can be.
Eminhizer urges other small to mid-sized practices to recognize that the new coding system may not be as difficult as
they perceive. She recommends taking advantage of transition tools available online from CMS and specialty organizations. As Eminhizer puts it, People need to step back and
recognize that they are really already where they need to be.

Payers Offer Support


To help support small practices and individual physicians
that may be anxious or unprepared for the ICD-10 transition,
several payers in Michigan have formed a unique consortium. Confirmed members include Blue Cross Blue Shield of
Michigan, United HealthCare, Humana, and Priority Health.
Together, they will meet with specialty groups to present a
framework for provider readiness.
The framework helps specialties understand how they can
map their current ICD-9 codes to the corresponding codes
in ICD-10 so they can focus their preparedness activities on
their particular book of business, says Dennis Winkler, technical program director of program management and ICD-10
at Blue Cross Blue Shield of Michigan, based in Detroit, MI.
The framework also gives practices access to free or lowcost industry resources and testing environments to practice
ICD-10 coding. By doing this type of outreach, payers hope
to debunk some of the myths about ICD-10. Some in the
professional community have heard that it costs an average
of $80,000 to get ready for ICD-10, but it is our contention
that for small practices, the costs could be much lower,
Winkler says. Payers in Michigan hope to replicate this collaborative approach in other states across the country.
As Winkler says, ICD-10 is good for the industry, and it is in
everyones best interest to work together and ensure readiness across the board.
The AHIMA Advocacy and Policy Team (advocacyandpolicy@ahima.org)
is based in Washington, DC.
Journal of AHIMA January 15/17

ICD-10 Online Clinical Documentation Training


for Physicians and Clinicians
AHIMAs Clinical Documentation for ICD-10
by Specialty training provides interactive, online
training addressing the documentation needed by
physicians and clinicians to support ICD10CM/
PCS coding specificity. Written by physicians,
CDI specialists, and medical coding experts, this
program provides relevant and targeted clinical
documentation training and support for physicians,
clinicians, and physician practices.

Online. Self-Paced. Specialty-Specific.


40 Specialties Available, Including:

Clinical Documentation for ICD-10 by Specialty

Internal Medicine

Psychiatry

Family Practice

Pulmonary

Bitesized, ondemand, three to fiveminute


training modules

Pediatrics

Rheumatology

Targeted top conditions

Cardiology

Cardiothoracic Surgery

Computer, tablet, or smartphone access

Dermatology

General Surgery

Specialtyspecific training

Endocrinology

Neurosurgery

iOS and Android Mobile App

Gastroenterology

OB/GYN Surgery

Case studies with quizzes to enhance recall

Hematology

Orthopedic Surgery

Interactive learning for greatest recall

Nephrology

Otolaryngology

CM and PCS modules available

Neurology

Urolgy

CMEs

See website for additional specialties.


Accreditation Statement

This activity has been planned and implemented in


accordance with the Essential Areas and Policies of the
Accreditation Council for Continuing Medical Education
(ACCME) through the joint sponsorship of Interstate
Postgraduate Medical Association (IPMA) and the
American Health Information Management Association
(AHIMA). IPMA is accredited by the ACCME to provide
continuing medical education for physicians.

Credit Designation

The IPMA designates this enduring material for a


maximum of 20 AMA PRA Category 1 Credit(s)TM .
Physicians should claim only the credit commensurate
with the extent of their participation in the activity.
MX10355

To view sample skills, go to ahima.org/clinicianicd10


To request a demo, contact sales@ahima.org

Inside Look

Get Ready for 2015s Unique


Challenges, Opportunities
By Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA, chief executive officer

AS I WRITE this column in November, I


hope that the autumns top healthcare
story, Ebola, will be out of the headlines
by January. But the emergence of the disease in the United States in 2014 gave
many people in the health IT community
pause, particularly the initial misdiagnosis in Texas that was briefly blamed on
the organizations electronic health record (EHR).
While the incident was later attributed
to failures in miscommunication, authors
of an article in the journal Diagnosis suggested that the problem may have originated in the design and workflows of the
EHR itself, making the situation more vulnerable to misdiagnosis. These highlyconstrained tools are optimized for data
capture, but at the expense of sacrificing
their utility for appropriate triage and diagnosis, leading users to miss the forest
for the trees, they wrote.1
The Ebola anecdote is a scary one, but
it illuminates the need for a renewed focus on the importance of public health.
The outbreak has brought home to many
the importance of accurate information
where and when it is neededthe very
thing HIM professionals are working to
achieve.
As EHRs continue to evolve, HIM professionals are well positioned to encourage workflows that facilitate critical
thinking and communication, while at
the same time discouraging damaging
practices such as heavy use of copy and
paste. And the example that there is no
specific ICD-9 code for Ebola (it shares a
code with multiple viral diseases) whereas there is a specific code for the disease
in ICD-10 illustrates the value of ICD-10s
increased specificity.
In 2015, AHIMA will continue its work
advocating for the development of health
IT interoperability standards, both nationally and internationally. Well continue

to provide resources on data analytics


and applied informatics. Well continue
to advocate for the implementation of
ICD-10 this fall. And we will leverage the
knowledge of our colleagues from the
non-profit Public Health Data Standards
Consortium, which joined its forces to
AHIMAs in 2014. All of these are ways to
ensure that HIM has a greater impact on
public health.
This months features highlight important issues for the coming year. In The
Year Ahead, Mary Butler describes the
most important topics to watch for in
2015, including ICD-10, information governance, and data standards and interoperability. Authors David Levin and Debra
Gordon advise the healthcare industry to
get on board with the advancement of
mHeath in mHealths Role in Consumerism and Connectivity. Finally, to meet
the challenges of the future, the profession needs a well-prepared workforce.
Kelli Horn offers exam preparation advice in Top Ten Challenges of Passing
the CCS Examination, while Kayce Dover and Chloe Phillips reveal how postgraduate apprenticeship programs can
help employers grow talented coders in
A Foot in the Door.
What are your big challenges for the
new year? AHIMA is here to help. Contact us at journal@journal.ahima.org.
Wed love to hear your thoughts.

Note
1. Upadhyay, Divvy K., Dean F. Sittig,
and Hardeep Singh. Ebola US Patient Zero: Lessons on Misdiagnosis and Effective Use of Electronic
Health Records. Diagnosis 1, no.
4 (December 2014). Published online Oct. 23, 2014. www.degruyter.
com/view/j/dx.ahead-of-print/
dx-2014-0064/dx-2014-0064.
xml?format=INT.
Journal of AHIMA January 15/19

The

Year Ahead

By Mary Butler

THE
MOS
T
TO W IMPORT
A
ATC
H FO NT HIM
TO
R IN
2015 PICS

ICD

20/Journal of AHIMA January 15

-10CM

/PC
S
Priv
acy
and
S ec
Info
u r it y
rma
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The Year Ahead

HUMAN BEINGS HAVE been fascinated by birdstheir flight patterns, colors,


and songsfor centuries. In the ancient world, augurs, Roman practitioners of
augury, looked for clues about the past and future by observing birds in flight,
hoping for omens. Modern bird watchers, sometimes known as birders, study
them for less mystical purposes, such as the chance of spotting a rare one, identifying which winged creatures might be creeping toward becoming endangered,
or just for the sake of observing their beauty. Every diligent birder carries with
them a list, binoculars, and a field guide to help document proof of every discovery and keep score.
Though it might seem at first that birders and health information management
(HIM) professionals dont have a lot in common, they face many of the same
challenges. Both need to be vigilant about speciesor job roles and technologiesfacing extinction and both operate in environments where regulation is a
fact of life. Birders and HIM professionals have to be constantly mindful of habitats and whether those habitats offer protection from invasive species.
Like birders, HIM professionals accept that change, regulation, and growth
have a natural progression, even when Mother Natureor the hand of governmentgets in the way. In the HIM world, 2014 was a tumultuous yearanother
delay in ICD-10-CM/PCS implementation; stumbling blocks and technical challenges in implementing the meaningful use Electronic Health Record (EHR)
Incentive Program; the ever-present threat of government audits; continuing the
implementation of new HITECH-HIPAA protocols; and realizing that information governance (IG) is going to become a huge priority.
Thats why HIM folks need to take a cue from birders: grab a checklist, a field
guide, and let the Journal of AHIMA be your augur.
Journal of AHIMA January 15/21

The Year Ahead

ICD-10-CM/PCS

HIM Fights for Implementation in 2015


Non-birders loathe the nuisance that is
the common grackle, which are characterized by their shiny black metallic and
purple sheen. They can carry disease and
foment fears of avian flu, but most people hate them for unattractively decorating their cars. Like any species, however, their
existence is vital to maintain harmony in the ecosystem. And
while the ecosystem can adapt to stressors, too many hits can
cause it to collapse.
The same can be said for ICD-10-CM/PCS. In order to maintain the modern healthcare ecosystem, which needs accurate
disease and coded billing data to keep up with regulations and
monitor public health, a more sophisticated code set is a must.
For many providers and payers who had spent millions of dollars getting ready for the expected October 1, 2014 implementation date, the ICD-10 delay enacted by Congress in April was a
major setback.
In a letter to the Centers for Medicare and Medicaid Services
(CMS), AHIMA and other organizations reminded the agency
that the cost of a one-year delay to the healthcare industry could
be as much as $6.6 billion.
Angie Comfort, RHIA, CDIP, CCS, AHIMAs senior director of
HIM practice excellence, coding services, says payers and providers are weary and fearful of another delay, especially those
who have already spent their budgeted training dollars in preparation for the 2014 deadline.
Hospitals and physician practices dont have a lot of budget
when it comes to education. If they spend their entire education
budget in 2013 with an expectation of going live in 2014, then
they arent going to have anything to spend in 2014, Comfort
says.
In the year ahead, provider organizations must spend the extra
time on doing end-to-end testing with as many of their biggest
payers as they can, keep training physicians on documentation
improvement, and dual code claims as much as time allows.
Comfort encourages hospital and physician practice staff to
once a week, once every two weeks, code some charts with
ICD-9 and ICD-10. Just to see what you may be missing down
the road, as far as documentation goes dual coding not only
provides those coders with hands on education, but it also helps
the physicians, she says.
Comfort says she expects to see the use of computer-assisted
coding (CAC) programs pick up speed during the delay. She
also dismisses speculation within the industry that coders are
going to be replaced by technology, namely CAC systems.
Coders role is evolving. Theyll still need to know the guidelines, they will still need to code, theres not any type of computer system that can replace an individual with that knowledge,
Comfort says. If you can offset your productivity decrease from
ICD-10, too, with CAC, it should come out in the wash.

22/Journal of AHIMA January 15

Privacy and Security


Hunting Down HIPAA Compliance

As hunters and birders know, there are strict


rules regulating water fowl such as ducks,
geese, and game such as pheasants, grouse,
and woodcocks. Hunters face fines and penalties for exceeding the maximum number
of animals theyre allowed to kill. In the HIM
world, privacy and security officers know all
too well the burden of complying with myriad regulationsand
the significant penalties if they dont.
Privacy and security professionals spent 2014 continuing efforts to ensure compliance with the HITECH-HIPAA Omnibus
Final Rule, which for the first time in September 2013 required
business associates of covered entities to be compliant with
HIPAA, changed breach notification protocols, and extended
individuals rights to obtain restrictions on certain disclosures
of protected health information to health plans if services are
paid for out-of-pocket, among other requirements.
In 2012 covered entities responded to audits under Phase 1
of the HIPAA audit program, which centered on their compliance with the law. The about-to-begin Phase 2 audits will have
auditors for the first time looking into organizations business
associates as well.

Targets for OCR scrutiny have


been chosen at random, but
some are done in response to
complaints, particularly if news
of a big data breach makes it
into the media.
Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA, director of
HIM practice excellence at AHIMA, says that Phase 2 audits
conducted by the US Department of Health and Human Services Office for Civil Rights (OCR)is one of the highly anticipated
privacy and security stories for 2015.
Phase 2 of OCR HIPAA audits are going to be important in
2015, Rose says, especially because it is the very first time business associates will be audited.
Rose noted that at the September 2014 AHIMA Convention
and Exhibit in San Diego, CA, officials from OCR said they have
identified the organizations that they plan to audit in 2015, but
as of press time had not officially notified the organizations.
For the most part, targets for OCR scrutiny have been chosen
at random, but some are done in response to complaints, particularly if news of a big data breach makes it into the media. That
might spark an audit. Organizations should make sure they have
a complete list of all of their business associates with whom they
share PHI, should they be subject to an audit.

The Year Ahead

Information Governance
Healthcare Moving from the Why of IG to
the How

The Eurasian collared dove, notable for its


mocha feathers and a dark narrow band
across the back of their neck, is considered
an invasive species in some birding circles.
Transported by humans from the Bahamas to the United States
in the mid-1970s, the birds quickly made their homes here,
threatening to overtake the population of native doves. Hunters
are encouraged to shoot the birds to keep their numbers low.
Information governance (IG) in the healthcare world has the
same task as these hunters. With so much healthcare data being generated and stored, and becoming hard to access, HIM
professionals are well-positioned to keep information and data
from becoming invasive in its own way.
AHIMA took a major step in helping HIM leaders take charge
of IG in their organizations with the 2014 release of its Information Governance Principles for Healthcare (IGPHC), as well as
a benchmarking white paper exploring the state of IG readiness
across healthcare organizations. According to AHIMA, IGPHC
is a set of comprehensive principles that can be applied in all
types of organizations across the healthcare ecosystem.
Lydia Washington, MS, RHIA, CPHIMS, a senior director of
HIM practice excellence at AHIMA and a member of AHIMAs
IG Task Force, says IG is really picking up momentum in that
HIM leaders clearly see the need for it. At AHIMAs most recent
convention in September 2014, Washington says the IG-related
sessions were packed, and several HIM leaders volunteered to
be pilot sites once the IG Task Force develops their forthcoming
IG maturity model this year.
The maturity model, according to Washington, will help interested organizations complete a self-assessment to figure out
their current IG capabilities and improve their processes.
We want to see where people are, have people able to assess
where they are, and ideally from that assessment develop a plan
as to how they move into governance within their organization,
Washington says.
Part of whats driving the need for IG, Washington says, is a
recognition among providers that they implemented electronic
health records (EHRs) too quicklythey put a lot of data into
the EHR, but are struggling to get it back out in a meaningful
way due to a lack of standards.
Conditions change, the practice of medicine changes, payment changes, almost anything, the EHR has got to be a little
more malleable in order to meet those requirements, Washington says. That requires a governance process as well. Youve
got to have a [governance] body somewhere that makes adjustments as needs come up.

Data Analysis

Data Analyst Skills Increase in Demand


Wood ducks, extremely common and abundant in number, are a favorite of hunters and
birdwatchers alike due to the sheer beauty of
their colorful, iridescent plumage. This water fowl saw a decline
in the late 19th century, but preservation efforts have made
them more popular and prevalent than ever.
Likewise, the preservation of data, in the eyes of health informaticians and health data analysts, is rapidly becoming more
important than ever as they find ways to harness the beautiful
and abundant data for improvements in healthcare.
Julie Dooling, RHIA, CHDA, a director of HIM practice excellence at AHIMA, says that the industry has long been saying
that data is king and its all about the data, but the current
healthcare environment is finally putting these calls to action
to the test.
Now youve got the Affordable Care Act, youve got the payment bundling and youve got the value-based purchasing
(VBP) and the accountable care organizations (ACOs) Healthcare organizations are trying to figure out how they can find the
value in their data, Dooling says. She adds that organizations
are generating so much data these days it can be very challenging to know what needs to be analyzed.
Because of this, interest in AHIMAs certified health data analyst (CHDA) credential has gone way up. While its still largely
HIM professionals seeking the credential, says Dooling, who
teaches CHDA exam preparation courses, shes seeing more interest from those who work in the role of analyst across many
different healthcare sectors.
But HIM practitioners have the upper hand when it comes to
deciding how and where data are analyzed in healthcare settings.
When it comes to knowing where the data originated, where
it gets populated, where it gets managed and archived, and
where it lives for its final dispositionthats the HIM professional, and theres nobody that knows that information like we
do, Dooling says.
She adds that jobs for data analysts are increasingly in demand, which has spurred interest in the CHDA credential. A
recent Department of Labor report confirmed this. According
to analysis of a Department of Labor report titled Hospital recruiting efforts shift to data and outpatient services published
in Healthcare Finance in September 2014, when hospitals are
hiring, they are looking for more techies and analysts to help
crunch the data required by accountable care models.

Journal of AHIMA January 15/23

The Year Ahead

Additional Checklist Items for 2015


BIRDERS OFTEN HAVE multiple checklists operating at
the same timeone for birds in the backyard, one for birds
theyve spotted in their own state, city, or even North America. Successful HIM professionals, likewise, must keep lists
in order to juggle and respond to competing priorities.
Additional checklist items that every HIM professional
should be tracking in 2015 are:
Clinical Documentation Improvement (CDI). At
AHIMAs most recent convention, the CDI Roundtable,
which normally attracts 40 attendees, brought in 120
attendees. Lou Ann Wiedemann, MS, RHIA, CHDA,
CDIP, CPEHR, FAHIMA, AHIMAs vice president of
HIM practice excellence, says its a misnomer that interest in CDI is being driven by documentation needs
for ICD-10. Truly, if you do CDI for the right reasons,
CDI is about quality of care and patient safety, Wiedemann says. Accurate reimbursement will follow. If
youre trying to sell CDI as a reimbursement tool, as a
profit margin, its never going to go.
The return of Recovery Audit Contractor (RAC)
audits will require extensive documentation improvement, especially in light of CMS issuing new criteria
for a two-midnight hospitalization. This is a potential
game changer for HIM professionals who have to produce patient records for an audit.
Patient matching. In February 2014, ONC released
a report on the current state of patient identification
and matching system programs. The findings in the
report drew on information provided by AHIMA representatives involved in an environmental scan. Patient
matching best practices are key to ensuring patient
safety, as well as reducing medical identity theft. Wiedemann noted that healthcare fraud is one of the
leading types of white collar crime. This type of fraud
is often perpetrated when an individual uses a family
member or friends insurance card to receive services. Theres almost a 40 percent chance that someone
who commits healthcare fraud has already committed
credit card fraud, Wiedemann says. AHIMA is currently developing a white paper on patient matching in
response to ONCs ongoing efforts.
Copying and pasting in EHRs. In March 2014, AHIMA released a position statement on the practice of
copying and pasting information in an EHR, a practice that can lead to medical errors or perpetuate
fraud. AHIMAs Diana Warner, MS, RHIA, CHPS, FAHIMA, says AHIMA is working on another white paper
about copying and pasting, also known as cloning,
to recommend standards that EHRs should integrate
to prevent copy/paste from occurring. Warner is working with the international community, via the International Standards Organization Technical Committee
215 (ISO/TC 215) on Health Informatics on developing
a standard for the appropriate use of copy and paste
functionality in EHRs.
24/Journal of AHIMA January 15

Data Standards and


Interoperability
Interoperability Remains a Struggle,
Standards Needed

The snowy owl has achieved celebrity


status among avid birders. The snowy
owl migration pattern reaches far into
the US, making this regal raptor something of a ubiquitous
winter resident of the northern statesand an enthusiastically
welcomed, though less frequent, sight in some not-so-northern
states.
HIM professionals are working hard to build a health IT infrastructure that makes health data exchange ubiquitous across
the country. But right now, as the country continues learning
how to flap its wings, the coverage of that infrastructure remains
inconsistent.
In a report to Congress from the Office of the National Coordinator for Health IT (ONC), provider participation in meaningful
usethe federal incentive program that encourages interoperability of EHRs across statesis robust, but interoperability is
lagging.
According to the report, 42 percent of hospitals electronically
shared clinical care summaries outside their systems, an increase of 68 percent since 2008. Fifty-five percent of hospitals
shared radiology reports outside of their systems, and 57 percent shared laboratory reports. Four in 10 physicians reported
electronically sharing any patient health information with other
providers, with 14 percent indicating that they share patient information with providers outside their organization.
Authors of the report called on the industry to promote existing technical standards and developing new standards critical
to the development and success of an operational and connected health system.
To that end, AHIMA members and staff will be sitting on ONC
committees designed to address the interoperability problems
the industry faces.
Michelle Dougherty, MA, RHIA, CHP, the senior director of research and development for the AHIMA Foundation, has been
appointed to ONCs Health IT Policy Committees Implementation, Usability and Safety Workgroup. Linda Kloss, MA, RHIA,
FAHIMA, a consultant and former CEO of AHIMA, was recently
appointed to ONCs newly convened Privacy and Security Workgroup, which is a subgroup of the Health IT Policy Committee
and is replacing the previous Privacy and Security Tiger Team.
According to Diana Warner, MS, RHIA, CHPS, FAHIMA, a
director of HIM practice excellence at AHIMA, all eyes will be
on these groups to see how they tackle current interoperability
challenges.
One of the barriers to true interoperability, Warner says, is a
patchwork of laws across states. Laws governing health issues
such as sexually transmitted diseases, mental illness, or pregnancy among emancipated minors, have different privacy protection state to state. Thats some of the stuff that they [members of the ONC workgroups] have to look at or well never get
interoperability, Warner says.

The Year Ahead

Healthcare Reform

New Care Models Take Flight in 2015


The Affordable Care Act has forced the
healthcare industry to adapt to an influx of
new patients while at the same time preparing to meet the needs of aging Baby Boomers. The industry is
responding the same way thatmany grassland species of birds
such as Bairds sparrow, Henslows sparrow, and Grasshopper
Sparrows have had to adapt to grassland farming practices and
federal regulations.
One of the most closely watched parts of US healthcare reform
has been the implementation of Medicares ambitious accountable care organizations (ACOs), the medical home model, and
value-based purchasing (VBP) initiatives. The programs are intended to lower costs by better coordinating care and carefully
monitoring the health of individuals enrolled in these programs.
The programs success is largely reliant on the capabilities of
health information exchanges (HIEs) and the interoperability of
the data being exchanged.
The Social Security Act requires that ACOs define processes
that promote evidence-based medicine and patient engagement; report on quality and cost measures; coordinate care;
employ telehealth; conduct remote patient monitoring; and be
fully EHR capable. All of these responsibilities fall right into the
HIM professionals wheelhouse.

Sustainability is clearly possible


and we see that with a third of
the survey respondents, so there
is a light at the end of the tunnel
for those who can transition
over. Jennifer Covich Bordenick

success of these groups, particularly as they try to find funding


for interoperability, said eHI CEO Jennifer Covich Bordenick,
in a press release.
The challenge for HIM professionals in the era of health information exchange and care coordination efforts is working to increase interoperability and make sure the data being generated
are safe and reliable.
All of these records they [HIOs] are collecting from patients in
ACOs, medical homes, and VBP, youre going to have to protect
all that stuff along with all the other stuff youve got to protect,
says Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA, a director of HIM practice excellence at AHIMA.

References
Dimick, Chris. HITECH Omnibus Rule Compliance Begins
Today. Journal of AHIMA. September 23, 2013. http://
journal.ahima.org/2013/09/23/hitech-omnibus-rulecompliance-begins-today/.
Evans, Melanie. CMS posts long-awaited Pioneer ACO quality
and financial results. Modern Healthcare. October 8, 2014.
www.modernhealthcare.com.
Office of the National Coordinator for Health IT. Report to
Congress: Update on the Adoption of Health Information
Technology and Related Efforts to Facilitate the Electronic
Use and Exchange of Health Information. October 2014.
www.healthit.gov/sites/default/files/rtc_adoption_and_
exchange9302014.pdf.
Mary Butler (mary.butler@ahima.org) is associate editor at the Journal of
AHIMA.

In October 2014, both the Centers for Medicare and Medicaid


Services (CMS) and the eHealth Initiative (eHI) released financial and quality results reflecting ACO programs performance.
According to results posted by CMS about the Pioneer ACOs
and the state of HIE development, during the first year of the
ACO program health spending slowed as much as seven percent among some ACOs and accelerated as much as five percent
for others. In the second year, health spending dipped as much
as 5.4 percent among those that reduced patients medical
bills and accelerated as much as 5.6 percent where costs grew,
according to an analysis by Modern Healthcare. Nine ACOs
exited the program, however, after recording increased costs.
The eHI report Post HITECH: The Landscape of Health Information Exchange, which surveyed 106 US health information
exchange organizations (HIOs), paints a more upbeat picture of
ACOs. According to the report, 64 respondents (51 percent) are
supporting an ACO, 52 HIOs are supporting a patient-centered
medical home (41 percent), 21 HIOs are supporting a state innovation model (SIM) grant (17 percent), and 12 HIOs are supporting a bundled payment initiative (9 percent).
However, the federal funding that helps support these initiatives will be running out. Next year [2015] will be critical to the
Journal of AHIMA January 15/25

TOP
TEN
CHALLENGES of

PASSING the CCS

EXAMINATION

(And How to Overcome Them)


By Kelli Horn, RHIT, CCS

26/Journal of AHIMA January 15

Top Ten Challenges of


Passing CCS Examination

HUNDREDS OF CODERS and students desire to take the next


step in their career by obtaining the Certified Coding Specialist (CCS) credential. This examination represents high-level
achievement and proficiency in inpatient and outpatient coding and associated concepts. Benefits of certification include a
potential growth opportunity in ones coder career path, a possible salary increase, heightened employer confidence in skills
and knowledge, and future unforeseen opportunities.
But the benefits of passing the exam dont come easily. The
test covers 97 multiple choice questions and eight medical
scenarios adding up to a four-hour rigorous examination. Preparing for the examination while striving to balance work and
family requires much energy. And it is challenging enough in its
present ICD-9-CM form.
With the transition to an ICD-10-CM/PCS examination in the
future, a whole new level of stress will be added to the equation.
This move has led some potential test-takers to delay sitting for
the exam. However, with the exam still reflecting ICD-9 content until ICD-10 has officially been implemented, coders have
bought more unexpected time to take the exam.
Coding experts say that now is not the time for up-and-coming coders to hold back on becoming credentialed. ICD-10 has
created a high demand for credentialed coders, and the workforce needs individuals with the CCS credential more than ever.
While test-takers cannot control the ICD-9 or ICD-10 factor of
the examination, they can concentrate on overcoming 10 specific challenges of taking the exam. Follow these guidelines, and
one can breathe a little easier before hitting the exam room.

Some Lack Outpatient Coding Experience


Many inpatient coders feel very competent coding inpatient
accounts and answering questions related to inpatient-related
concepts. However, since these coders primarily code only inpatient accounts, many lack the coding knowledge and experience related to outpatient encounters.
To help combat this and get their coders the experience they
need to sit for the CCS exam, some healthcare providers have
offered to cross-train inpatient and outpatient coders. Ardent
Health Services, a healthcare organization based in Nashville,
TN, that owns and operates 12 acute care hospitals in Albuquerque, NM (Lovelace Health System), Tulsa, OK (Hillcrest
HealthCare System), and Amarillo, TX (BSA Health System), has
shown their strong commitment to their coders by currently offering on-the-job cross-training for outpatient coders who feel
they lack inpatient coding skills. As a result, these coders have
expanded their coding knowledge and skills, improved their
versatility in being able to code more visit types, and have effectively prepared to pass a national coding exam. Ardent also
provides cross-training opportunities for their inpatient coders
to obtain outpatient coding knowledge and skills.
It is valuable to have coders with both inpatient and outpatient coding experience to help with coverage, says Terri Walker,
RHIT, CCS, the MS-DRG manager of shared coding services at
Ardent Health Services. Through the program, coders have the
opportunity to complete outpatient coding education modules,
pass a test, and then be promoted to Inpatient Coder II, which

State HIM Associations Offer Training


SEVERAL STATE HEALTH information management associations have taken the lead in hosting CCS exam review
courses for their members. Three of the state associations
doing this include the Oklahoma Health Information Management Association (OkHIMA), with courses in Tulsa and
Oklahoma City; the Arkansas Health Information Management Association (ArHIMA), with courses in Ft. Smith and
Little Rock; and the New York Health Information Management Association (NYHIMA), offering courses in New York
City and Syracuse.
Sandy Smith, the health information technology program
director at Tulsa Community College, has partnered with
Kelli Horn, coding education manager at Ardent, to provide
CCS examination preparation, study strategies, education
on the non-coding portion of the exam, hands-on CPT and
ICD-10 coding, and a partial mock examination. In addition,
Smith and Horn provide ongoing follow-up support and
host a Facebook group called Pursuing the CCS, RHIT,
and CCA Exam, where members can post questions as
they embark on their certification journey.
The benefit for an organization that has its coders participate in a review course is that it exposes the coders to
inpatient and outpatient coding concepts and coding exercises, simulates the mock examination experience, creates
a networking atmosphere with others who are also preparing to take their exam, and provides further education regarding the non-coding concepts on the examination.
Vanessa McCool, RHIA, the OkHIMA specialty workshop
coordinator, has been instrumental in providing these workshops for OkHIMA. I think its important for OkHIMA to continue to offer concurrent education for its healthcare members in an effort to keep up with the rapid changes of the
industry, not only for coders, but for all healthcare related
employees in Oklahoma. The OkHIMA board strives to offer
the best and most affordable education for members and
non-members, McCool says. We value their healthcare
and want to give our members and non-members learning
opportunities that they can use to aid their careers.

also modifies their job description and increases their salary.


This would easily present an opportunity for the coders to gain
the hands-on practice they need to pass the CCS examination.
Therefore, inpatient coders must use creativity to discover ways
to obtain this experience. If hands-on experience is not possible
at a coders facility, they could use printed tools to practice with
outpatient coding, such as the Clinical Coding Workout with
Answers book published by the AHIMA Press.
Not only do inpatient coders need to develop their outpatient
coding skills, they need to become more familiar with outpatient-related concepts, including Outpatient Prospective Payment System (OPPS), Current Procedural Terminology (CPT),
Healthcare Common Procedure Coding System (HCPCS), Evaluation and Management (E/M), Correct Coding Initiative (CCI),
Medicare Code Editor (MCE), Outpatient Code Editor (OCE),
Journal of AHIMA January 15/27

Top Ten Challenges of


Passing CCS Examination

medical necessity, modifiers, and clinical laboratory service requirements.


There are some outpatient coders who have experience coding only ancillary visits, and lack the skills to code a variety of
outpatient encounters including endoscopy and surgical procedures. These coders will also need to practice coding the full
spectrum of outpatient visits either by purchasing a resource or
obtaining on-the-job training experience.

Outpatient coders may feel comfortable coding ancillary and


outpatient surgery accounts. However, many outpatient coders are lacking inpatient coding experience. Workplaces that
provide on-the-job cross-training are the best option for coders preparing to take their exam. However, if this option is not
available, coders may need to take the initiative and purchase
resources that contain sample inpatient coding exercises and
work beginning, intermediate, and advanced exercises, along
with case studies, to develop inpatient coding skills.
These coders will also need to learn more about concepts associated with inpatient coding, including the Inpatient Prospective Payment System (IPPS) overview and definitions, Diagnosis
Related Groups (DRGs), major complications or comorbidities
(MCC), complication or comorbidity (CC), clinical documentation improvement (CDI), present on admission (POA), compliant physician queries, and discharge disposition. Furthermore,
they will need to be prepared to code eight medical scenarios,
which will include some inpatient cases.

portion of the exams. Many had been coding for several years,
however, they had not been exposed to many of the domains
included in the examination.
Data Quality and Management (three percent of the test),
Information and Communication Technologies (two percent),
Privacy/Confidentiality/Legal/Ethical Issues (three percent),
and Compliance (three percent) are the indirect domains contained in the CCS examination. Topics include reimbursement
methodologies, documentation rules and regulations, abstracted data elements for database integrity and claims processing,
using technology to ensure data collection, analysis, storage, reporting of information, and use in HIM work processes. Privacy
and security concerns, protection of data integrity, access and
disclosure of personal health information, accuracy and completeness of the patient record, monitoring organization-wide
compliance, and ethical coding standards are additional topics.
These sections comprise 11 percent of the overall score on the
examination.
Recommendations for overcoming this challenge include:

Research selected health information topics, such as
OPPS, clinical documentation, HIPAA, and general information technology issues within the AHIMA HIM Body of
Knowledge, available at www.ahima.org.

Initiate interactive conversations on AHIMAs Engage
Communities of Practice, available at engage.ahima.org/
home, on topics such as Coding, Classification and Reimbursement; Confidentiality, Privacy, and Security; and
Health Information Technologies and Processes.

Many Get Overwhelmed by the Coding Guidelines

Beating the Dreaded Clinical Scenarios

Many coders feel overwhelmed by the Official Coding Guidelines developed by the Centers for Medicare and Medicaid
Services (CMS) and the National Center for Health Statistics
(NCHS). While many coders reference them, as needed, when
they are coding their visits each day, some coders struggle at
comprehending the material as a whole.
Things get especially tough for some when they are asked to
recall and apply the material quickly on the CCS test, and many
run out of time or barely have sufficient time to complete the
exam. When the guidelines reflect ICD-10 instead of ICD-9, this
will be one major area of concern for coders preparing to take
the CCS. But this should not be a deterring factor in taking the
exam, coding experts say. Coders are expected to become familiar with these guidelines in their daily workplace coding duties,
which should serve as extra motivation to become familiar with
ICD-10 at a higher level. Coders should read through the guidelines at least once, but preferably twice, before taking the exam.

The clinical scenario portion of the CCS exam will probably


present the biggest challenge for coders once the exam moves
to include ICD-10, which wont occur until after the new code
set is implemented in the US. Coders must code eight medical
record cases, which includes inpatient and outpatient encounters. Even before the code set changes to ICD-10, many coders
feel nervous about this section. Since most coders have not had
much exposure to hands-on ICD-10 coding, this is the area that
could potentially become the biggest obstacle once ICD-10 is
implemented. For clarification, while there can be questions
regarding ICD-10 on the multiple choice section of the exam,
there are no coding exercises that would involve ICD-10 until
that code set has officially been implemented.
There are several steps coders can take to face their fear of this
exam portion. Attending an ICD-10 workshop to become more
familiar with ICD-10-CM and ICD-10-PCS concepts will make
a significant difference. Furthermore, coders can purchase resources from AHIMA and other publishers to gain practice
coding exercises using ICD-10. The Journal of AHIMA website,
journal.ahima.org, also offers free weekly ICD-10-CM/PCS coding quizzes each Monday that can help coders become familiar
with the new code set.
Anna Reynolds, CPC, CCS, a clinical coding specialist at Integris Health, based in Oklahoma, passed her CCS examination on
her second attempt. When asked what she worked on between
exams, she said I took a CPT class, got a study buddy, and con-

Some Lack Inpatient Coding Experience

Handling the Non-Coding Parts of the Exam


Between October 2013 and January 2014, an informal CCS examination preparation survey was conducted with CCS Exam
Review Course participants from Oklahoma, Arkansas, New
York, and students from Tulsa Community College. Several of
the respondents surveyed at the New York Health Information
Management Association (NYHIMA) review course were concerned about being able to successfully pass the non-coding
28/Journal of AHIMA January 15

Top Ten Challenges of


Passing CCS Examination

centrated more on cases. Practicing case studies cannot be overemphasized. Practice, then practice, then practice some more.

Not Using the Code Books Effectively


Several participants of the CCS Exam Review Course hosted
by NYHIMA, the Oklahoma Health Information Management
Association (OkHIMA), and the Arkansas Health Information
Management Association (ArHIMA) have communicated their
discomfort level of being able to assign codes effectively and efficiently using their code books. As a result, they have an opportunity to get to know their code books as they invest much
time and effort in becoming familiar with it in preparation for
the CCS exam. Future test-takers will benefit greatly from scanning over the Index to Diseases and the Tabular List, as well as
other sections in the ICD-9 and ICD-10 code books, including
V Codes, E codes, Appendices, Table of Drugs and Chemicals,
Hypertension Table, Official Coding Guidelines, the Procedures
section, and other sections. Becoming familiar with the index,
guidelines, and chapters of the CPT coding book is also a must.

Effectively Managing Test Time Very Difficult


At a recent NYHIMA CCS Exam Review Course in New York City,
12 participants were asked what their greatest concerns were in
taking the examination. The number one concern reported was
running out of time. Following time, participants reported concerns with the low pass rate, not having ample on-the-job cross-

D I S C E R N I N G

training opportunities to gain knowledge and skills in coding


outpatient surgeries, not having sufficient time in the workplace
to keep current with Coding Clinics and CPT Assistants, and, finally, test anxiety. The overlying fear factor for all participants
was having to take the examination with the ICD-10 code set
sections included, as most indicated they were attending the
review course in order to take the examination before the CCS
examination will reflect ICD-10 codes.
The time factor is a valid concern for many reasons. Completing the test in four hours reflects that test-takers have mastered
the material at a high cognitive level and can apply that information at a recall, application, or analysis level. Some test questions will require participants to identify facts, basic concepts,
theories, processes, and principles. Other questions will require
test-takers to apply principles and concepts to situations, recognize data relationships, and solve specific problems integrating
various concepts into the solution. Therefore, it is imperative
that test-takers have thoroughly studied the concepts listed on
the CCS Examination Content Outline to increase their chances of answering questions accurately and quickly. Test-takers
should simulate the timed test experience before the exam.

Attending Formal Coding Education


Students who have completed their formal coding education
at a local community college, university, or through online distance learning have a great opportunity to pass the CCS exami-

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nation. However, they may want to start with the CCA examination to build up to the mastery level of knowledge and skill
required to pass the CCS exam.
I encourage students without coding experience to start out
with the CCA exam, says Ellen Shakespeare Karl, MBA, RHIA,
CHDA, FAHIMA, academic director of the health information
management program at the City University of New York. This
will get their feet wet and give them a sense of accomplishment
before even attempting the CCS exam. She encourages her
students to take the CCA exam during their tenure as a student
soon after completing the programs coding classes. Karl previously worked at a community college in New Jersey and had
many students pass their CCA exam in this manner as well.
However, a few students are able to immediately take and
pass the CCS exam. Those students who received above average
grades in their ICD-9 and CPT coding classes, and other classes,
including reimbursement, statistics, legal, and management,
are typically able to combine their classroom learning with an
excellent study strategy and successfully pass the examination
on the first try.
Sandy Smith, MEd, RHIA, CCS, the health information technology program director at Tulsa Community College, reported
that one of her colleges recent graduates passed the CCS exam
within several months after graduation. The graduates advice
to those preparing to take the examination is to buy as many
coding workbooks as you can afford and code everything you
can find, even from different registering agencies.
Coding is the only way to build up speed, the graduate said.
And dont believe all the answers. Look them up in the references that are listed to see if the author is correct.

Keeping Up on Coding Clinic, CPT Assistant Content


One area of the exam listed on the CCS Examination Content
Outline is to select the appropriate diagnosis and procedure
codes according to the Coding Clinic and CPT Assistant, and
according to UHDDS definitions. Therefore, coders should become familiar with these resources. Several sources suggest
that test-takers familiarize themselves with the last three to five
years worth of material. Others choose to study only the last
one to two years worth of material.
OkHIMA has recently taken the lead in this area and plans to
offer quarterly Coding Clinic Update workshops. Members in
the Tulsa and Oklahoma City area will receive education from
this publication and will have the opportunity to ask questions
and receive feedback from an instructor and other participants.
OkHIMA has been proactive in offering education, evident in
their selection as the AHIMA Core Services Achievement Winner in 2013 for their commitment to continuing education programs relating to HIM practice topics.
Benefits of keeping up with each Coding Clinic and CPT Assistant go far beyond preparation for the CCS exam. Given that
Coding Clinic is official advice used by outside regulators to challenge query and coding appropriateness, CDI specialists and
coders alike must familiarize themselves with its logic in order
to successfully defend their coded output, says James Kennedy,
MD, CCS, director of FTI Healthcare, based in Atlanta, GA. Ken-

Top Ten Challenges of


Passing CCS Examination

nedy says that ignoring the two publications is a big mistake.

Improvement Opportunities Exist for Test-Takers


and Test Encouragers
Even though ICD-10 is not a part of the CCS exam now, the
exam will test using ICD-10 upon its official implementation
for reporting and billing in the US. Coders must be proactive in
gaining ICD-10 knowledge and skills, despite their ICD-10 fear
and unfamiliarity, in order to take and pass the CCS exam in the
future. State associations, workplaces, and possibly educational
institutions also have opportunities to host ICD-10 workshops,
Coding Clinic and CPT Assistant workshops, CCS exam review
courses, and inpatient/outpatient cross-training webinars for
their employees and students to help them gain the knowledge, experience, and confidence needed to successfully pass
the CCS examination. Coders can also own their certification
journey by subscribing to coding publications and newsletters,
like AHIMAs CodeWrite, where certification preparation information can be found, and participating in the AHIMA Engage
Certification Preparation Communities of Practice for further
support and resources.
Follow these and the other recommended steps, and coders

Journal of AHIMA Continuing Education Quiz


Quiz ID: Q1518601 | EXPIRATION DATE: JANUARY 1, 2016
HIM Domain Area: External Forces
ArticleTop Ten Challenges of Passing the CCS Examination

will feel more comfortable sitting for the examinationand


hopefully successfully pass it.

References
AHIMA. CCS Recommended Resources. www.ahima.org/~/
media/AHIMA/Files/Certification/CCS_Recommended_
Resources.ashx.
AHIMA. Certified Coding Specialist (CCS) Examination
Content Outline. www.ahima.org/~/media/AHIMA/Files/
Certification/ICD-10%20CCS%20Content%20Outline.ashx.
AHIMA. Certification Examination Preparation. www.
ahima.org/certification/CCS.
HCPro. Tip: Stay up to date with quarterly Coding Clinic
releases. CDI Strategies. October 1, 2009. www.hcpro.com/
HIM-239829-5707/Tip-Stay-up-to-date-with-quarterlyCoding-Clinic-releases.html.
Kelli Horn (kelli.horn@hillcrest.com) is the coding education manager at
Ardent Health Services and an AHIMA-approved ICD-10-CM/PCS trainer. Horn is also an author, conducts CCS examination review courses for
OkHIMA, ArHIMA, and NYHIMA, and is an adjunct coding instructor at
Tulsa Community College.

TAKE THE QUIZ AT WWW.AHIMASTORE.ORG


NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED

REFER TO THE ARTICLE for the one best answer to each question. Questions are based solely on the content of the article.
1. How long is the CCS exam?

a. four hours

b. five hours

c. eight hours

d. 12 hours

6. W hen will the CCS exam will be based on ICD-10?



a. after the new code set is implemented

b. is currently part of the CCS exam

c. is currently part of the CCA exam

d. none of the above

2. What is the number one concern in taking the CCS exam?



a. running out of time

b. discrepancies between ICD-9 and ICD-10

c. locating a review course

d. purchasing Coding Clinic

7. One organization that approves the Official Coding Guidelines is:



a. CMS

b. OkHIMA

c. AMA

d. WHO

3. How many multiple choice questions are on the CCS exam?



a. 97

b. 100

c. 105

d. 197

8. Students who have completed formal coding education may want


to start with which exam to build up to the mastery level of coding
knowledge?

a. RHIA

b. RHIT

c. CCA

d. CDI

4. How many scenario cases are on the CCS exam?



a. six

b. eight

c. 10

d. 12
5. The official advice used by outside regulators to challenge query
and coding appropriateness is:

a. Coding Clinic

b. CodeWrite

c. CPT Assistant

d. 
Clinical Coding Workout

9. The best way to build up speed is:



a. practice coding

b. read Coding Clinic

c. attend coding workshops

d. participate in a cross-training webinar
10. In one section of the CCS exam, appropriate diagnoses and
procedures are selected according to:

a. Coding Clinic

b. CPT Assistant

c. UHDDS definitions

d. all the above

Journal of AHIMA January 15/31

mHealths Role in
Consumerism and
Connectivity
By David Levin, MD, and Debra Gordon, MS

CONSUMERISM IN HEALTHCARE is not coming. It is already


here, affecting every aspect from the clinical setting to the health
information management (HIM) office to the health information
technology (HIT) department. Or at least it should be. Unfortunately, too few healthcare systems in the US have integrated the
consumer into their HIT, let alone put them at the center.
The consumerization of healthcare is driven by the perfect
storm of aging Baby Boomerswho are used to getting what
they want, when they want it, how they want itthe shift from
volume-based to value-based carewhich requires greater patient engagement for successand the explosion of mobile devices that put the power of information and connectivity in consumers hands. It is also propelled by the transactional society
in which we live where technology allows us to bank, shop, reserve travel, even turn on the heat and lights in our house from
1,500 miles away with just a few keystrokes. So consumers are
asking, Why isnt healthcare transactional? Why is it still technologically stuck in the 20th century? The answer is technical
limitations, such as a lack of interoperability, in combination
with inadequate leadership and decision-making, a lack of vision, and a traditionally paternalistic system.
The advent of mobile health (mHealth) coupled with the patient engagement movement will increasingly accelerate the
changes already underway in healthcare. Health IT entities in
turn have two options: Jump aboard while the consumer-focused train is still rolling relatively slowly; or find themselves
running after a disappearing caboose.
32/Journal of AHIMA January 15

Patient Engagement: The Cornerstone of HIT


Consumerism
According to the American Medical Associations 2014 paper
Improving Care: Priorities to Improve Electronic Health Record
Usability, effective communication and engagement between
patients and physicians should be of central importance in EHR
design. An engaged patient is one who takes the necessary actions to obtain the greatest benefit from the healthcare services
available to them, and who is an active participant in finding,
purchasing, engaging in, and taking care of their own health.1,2
Studies find that engaged patients are more motivated to take
care of themselves, make better day-to-day decisions about
their health, are more likely to keep appointments, tend to be
more satisfied with their care, experience fewer complications,
andmost importantlyhave an improved quality of life.3,4,5
Thats why patient engagement has been called the blockbuster drug of the century.6
Engaging patients should be a foundational philosophy in any
electronic health record (EHR) or other HIT system. Indeed,
stage 2 of the meaningful use EHR Incentive Program requires
it, and stage 3 will expand upon it. This, in turn, requires healthcare organizations to provide the Three Ts of patient engagement: transparency, transactions, and trust.

Transparency
Can consumers get the information they need? This includes
providing access to the patients entire health record, including

mHealths Role in
Consumerism/Connectivity

medical notessomething an emerging body of research finds


is not only possible but can improve patient satisfaction and
outcomes.7,8,9
One study published in the Annals of Internal Medicine reported the outcomes of the OpenNotes project, in which 13,564
patients in 105 primary care practices in three states were able
to view their entire medical record. After one year, 87 percent
of patients had opened at least one note, with the vast majority
(77 percent to 87 percent) reporting that the notes helped them
feel more in control of their care. They were also more adherent
to their medications. Just one percent to eight percent reported
confusion, worry, or offense at the notes.10
Participating physicians initially worried that providing access
to the notes would disrupt workflow and confuse or worry their
patients. Instead, they reported that the open notes strengthened their relationships with patients by enhancing trust, transparency, and communication, and that their patients seemed
more activated or empowered. Between 85 percent and 91
percent of doctors supported making the notes available to patients.
Transparency also means pricing transparency, including letting consumers know the cost of the procedure based on insurance contracts, and the out-of-pocket cost to the patient based
on their insurance benefit. This is becoming more important
given the increased prevalence of high-deductible health plans,
which require that patients pay considerably more out-of-pocket for services.

Transactions
Transactions must be interactive. Patients should be able to go
online to make appointments, communicate with healthcare
professionals, renew prescriptions, complete paperwork and
medical histories, register for admission, procedures, and tests,
and pay their bills. They should also be able to populate their
health record with their own data and notes.
Some of this is already required in stage 2 meaningful use,
and stage 3 is expected to require healthcare providers to receive provider-requested, electronically submitted, patientgenerated health information, including information submitted
through mobile devices.11
Despite growing adoption of EHRs at the physician practice
level, however, one recently published study found that just
a third of physicians used the EHR for secure messaging with
their patients, and just a fourth enabled patients to routinely
view, download, or transmit their records online.12 A National
Research Council Report highlighted the fact that EHRs did not
adequately provide cognitive support for healthcare providers, patients, and caregivers.13
Limiting patient interactivity creates an unnecessary barrier
to improved outcomes. Patient-generated information provides
valuable information about the patients activities outside of the
provider office, including emotional and physical status, medication adherence, and side effects. Health systems like Group
Health, Kaiser Permanente, and the Cleveland Clinic recognize
this, and are pulling information from the patient into the EHR
with questionnaires, patient summary forms, and e-mail com-

Figure 1: MyOwnMed

municationall in structured data formatsto improve patient


satisfaction, quality outcomes, physician engagement and satisfaction, and costs.14
There are also a plethora of apps today that link mobile devices
with the EHR and transmit data directly into the health record.
Gregory Abowd, PhD, a professor at the Georgia Institute of
Technology, predicted during his keynote speech at the American Medical Informatics Associations 2011 Annual Symposium
that the majority of clinically relevant data would be collected
outside of clinical settings by 2016.15
Of course, there are numerous concerns about an interactive
EHR. Providers fear the additional time required to review patient entries in a timely manner. Patients worry that providers
will not see or value the information. The information must be
collected using standardized methods so it can be searched.
And privacy and security issues must be addressed. In addition,
systems must find new ways to encourage patients to access
their personal health record, perhaps by instituting opt-out
approaches rather than opt-in policies.
Another concern is the veracity of the data. Studies already
found that patient-entered data are, by and large, accurate, and
provide significant clinical value to providers.16,17 Conversely,
there is a growing body of evidence that clinicians themselves
enter errors into the clinical record, in part because of technological challenges but also because of human error.18,19,20

Trust
Patients must believe that the information in their health record
(and from other sources) is from a trusted source and is accurate. The system must also be reliable, secure, and private.
While the Three Ts are critical to consumer-based HIT, they
wont mean a thing unless health systems use the information
in meaningful ways beyond meeting meaningful use. That includes considering how patient-entered data can improve the
patient/clinician experience, joint decision-making, and outcomes; how greater pricing transparency can improve decisions regarding appropriateness and cost of care, as well as patient collections; and how educating patients through the EHR
and mHealth applications can drive engagement. The answers
Journal of AHIMA January 15/33

mHealths Role in
Consumerism/Connectivity

Table 1: Key Components of Quality Apps


QUALITY APPS CONTAIN the following characteristics:
Secure and private
Interactive
Intuitive to use
Portable across platforms
Integrated into the EHR/Personal Health Record
Able to transmit data wirelessly
Designed from the user perspective to meet personal
needs
Designed to accept information from and provide information to consumers
Tested with intended audience
Developed to be integrated with the users ecosystem
(Facebook, Twitter, Pinterest, etc.)

to these questions should be built into any HIT systems infrastructure and ecosystem.
The potential benefits are significant. A 2014 report from the
Agency for Healthcare Research and Quality noted that making the patient the ultimate owner of his/her electronic health
information places increased responsibility on the patient for
health maintenance, including becoming educated and staying
informed about their condition, making good lifestyle choices,
and playing an active role in data gathering through web-based
reporting, wireless sensors, and other electronic communications. This engagement also aids patients in following preventative care and seeking early intervention for adverse conditions,
as well as complying with medical treatments.21

Caregivers as Consumers
The first generation of consumer-facing applications took the
form of patient portals or simple mobile applications. Heavyweights like Google, Microsoft, and major EHR vendors such as
Epic Systems as well as a growing number of smaller startups
now provide limited ways for patients and healthcare workers to
connect and share information. While this is a good start, there
is a much greater opportunitycaregiver engagement.
About one in three adults are currently providing care for a
family member or friend, according to the Family Caregiver Alliance.22 Most are in the Panini generation, squeezed between
caring for children and aging parents. They are sometimes called
secondary patients who need as much guidance and support as the patients they care for. However, caregivers get very
little support or training, a significant barrier to their ability to
provide quality care. For instance, they often feel abandoned
when their loved one is discharged from the hospital because
they receive little information on how to copy that care in the
coming days and weeks.23 Yet studies find that greater preparedness and a sense of mastery can protect caregiver health and
increase satisfaction with their role.24, 25, 26
Thus, caregivers need to be part of the consumerization of
34/Journal of AHIMA January 15

healthcare and given access to the health system and the patients health record, as well as the ability to input data. Increasingly, caregivers can find applications that allow them to do just
that. One example is MyOwnMed (see Figure 1 on page 33), a
customizable digital platform and mobile health app designed
to capture health data submitted by patients and their caregivers. Information from a platform like MyOwnMed can be fed
into the EHR, improving clinical decision-making and knowledge and providing practices and healthcare systems with the
data necessary to manage the health of populations. This system also allows patients, caregivers, and healthcare workers the
ability to communicate with each other to coordinate care.

Barriers to Consumer-Based HIT


There are significant barriers to successful HIT, no matter how
or to whom it is delivered. One of the most significant is privacy
and security, particularly in light of the numerous breaches recently occurring in the retail, banking, and healthcare worlds.
Others include poor design and infrastructure of mobile health
applications and devices, cultural issues in the environment in
which they will be used, challenges integrating mobile apps, remote monitoring, and medical devices with the patients EHR,
andmost importantlythe need to deliver real value based
on health-related outcomes. For example, Table 1 highlights the
key components of quality mobile applications.
Overcoming those barriers requires robust leadership
at both the clinical and IT level. Table 2 demonstrates key
strengths chief medical information officers and chief information officers must have in order to be successful. As the
table notes, technical skill is really the least important component of a successful HIT leader. Too often, however, HIT leaders are low in the other necessary strengths and high only in
technical knowledge.

Patients Must Be in the Center of Healthcare


The development of HIT has traditionally been clinician-focused, not patient-focused. An age of patient empowerment
and greater consumerism in health requires that systems shift
from an emphasis on clinician-controlled data and information
to one that puts the patient and caregiver at the center of the
healthcare experience.
That means opening the EHR to the consumer, enabling mobile health applications, remote monitoring, and implantable
devices to feed data into the EHR, and developing systems to
monitor that additional data and provide value through actions
designed to improve outcomes. It also means greater transparency and sharing of clinical information as well as cost and access-to-care data. Most importantly it means designing systems
that are trustworthy and secure so that all participants, clinicians, patients, caregivers, and HIT specialists, can be confident
and willing adopters of these transformative technologies.

Notes
1. Center for Advancing Health. A New Definition of Patient

mHealths Role in
Consumerism/Connectivity

Table 2: Key Traits CMIOs/CIOs Need to Achieve HIT Benefits


Overall Benefits/Frustration Level

*ROI/VOI = Low
Frustration Level High

*ROI/VOI = Low
Frustration Level High

Technical IQ

High

Low

Operations IQ

Low

High

Strategic IQ

Low

High

Ability to manage challenges

Low

High

Emotional intelligence

Low

High

Skill/demand

*ROI=return on investment; VOI=value on investment

Engagement. 2010. www.cfah.org/engagement/research/


snapshot.
2. Institute of Medicine. Partnering with Patients to Drive
Shared Decisions, Better Value, and Care Improvement.
2013. http://iom.edu/Reports/2013/Partnering-with-Patients-to-Drive-Shared-Decisions-Better-Value-and-CareImprovement.aspx.

PJ &A

3. Lorig, Kate and Sonia Alvarez. Community-based diabetes education for Latinos. Diabetes Educator 37, no. 1
(2011): 128.
4. Lorig, Kate, Philip L. Ritter, Diana D. Laurent et al. Online
diabetes self-management program: A randomized study.
Diabetes Care 33, no. 6 (2010): 1275-1281. http://care.diabetesjournals.org/content/33/6/1275.full.

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Journal of AHIMA January 15/35

mHealths Role in
Consumerism/Connectivity

Comprehensive, Role-Based eLearning


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36/Journal of AHIMA January 15

5. Dentzer, Susan. Rx for the blockbuster drug of patient


engagement. Health Affairs 32 no. 2 (2013): 202. http://
content.healthaffairs.org/content/32/2/202.full.
6. Ibid.
7. Delbanco, Tom et al. Inviting Patients to Read Their
Doctors Notes: A Quasi-experimental Study and a Look
Ahead. Annals of Internal Medicine 157, no. 7 (2012): 461470. http://annals.org/article.aspx?articleid=1363511.
8. Vodicka, Elisabeth et al. Online Access to Doctors Notes:
Patient Concerns About Privacy. Journal of Medical Internet Research 15, no. 9 (2013): e208. http://www.jmir.
org/2013/9/e208/.
9. Woods, Susan et al. Patient experiences with full electronic access to health records and clinical notes through
the My HealtheVet Personal Health Record Pilot: qualitative study. Journal of Medical Internet Research 15, no. 3
(2013): e65.
10. Delbanco, Tom et al. Inviting Patients to Read Their
Doctors Notes: A Quasi-experimental Study and a Look
Ahead.
11. Dimick, Chris. Preliminary Stage 3 Meaningful Use Recommendations Released. Journal of AHIMA. March 11,
2014. http://journal.ahima.org/2014/03/11/preliminarystage-3-meaningful-use-recommendations-released/.
12. Furukawa, Michael F. et al. Despite Substantial Progress
in EHR Adoption, Health Information Exchange and Patient Engagement Remain Low In Office Settings. Health
Affairs 33, no. 9 (2014): 1672-1679. http://content.healthaffairs.org/content/33/9/1672.abstract.
13. Stead, William and Herbert Lin. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. National Research Council. 2009. www.
nlm.nih.gov/pubs/reports/comptech_prepub.pdf.
14. Deering, Mary Jo. Issue Brief: Patient-Generated Health
Data and Health IT. Office of the National Coordinator for
Health Information Technology. 2013. www.healthit.gov/
sites/default/files/pghd_brief_final122013.pdf.
15. Abowd, Gregory D. Keynote address to American Medical
Informatics Association Annual Conference on Biomedical and Health Informatics. October 24, 2011. www.amia.
org/amia2011/keynotes.
16. Wuerdeman, Lisa et al. How accurate is information that
patients contribute to their Electronic Health Record?
AMIA Annual Symposium proceedings. 2005. www.ncbi.
nlm.nih.gov/pmc/articles/PMC1560697/.
17. Schneider, Joseph H. Online Personal Medical Records:
Are They Reliable for Acute/Critical Care? Critical Care
Medicine 29, no. 8 (2001): 196-201. http://journals.lww.
com/ccmjournal/Abstract/2001/08001/Online_personal_
medical_records__Are_they_reliable.9.aspx.
18. Thornton, J. Daryl et al. Prevalence of copied information
by attendings and residents in critical care progress notes.
Critical Care Medicine 41, no. 2 (2013): 382-388. http://
journals.lww.com/ccmjournal/Abstract/2013/02000/
Prevalence_of_Copied_Information_by_Attendings_
and.2.aspx.

mHealths Role in
Consumerism/Connectivity

19. Wrenn, Jesse O. et al. Quantifying clinical narrative redundancy in an electronic health record. Journal of the
American Medical Informatics Association 17, no. 1 (2010):
49-53.
20. Sparnon, Erin and William Marella. The Role of the Electronic Health Record in Patient Safety Events. Pennsylvania Patient Safety Advisory 9, no. 4 (2012): 113-121. www.
patientsafetyauthority.org.
21. The MITRE Corporation. A Robust Health Data Infrastructure. Agency for Healthcare Research and Quality.
April 2014. http://healthit.ahrq.gov/sites/default/files/
docs/publication/a-robust-health-data-infrastructure.
pdf.
22. Family Caregiver Alliance. Selected Caregiver Statistics.
December 31, 2012. https://caregiver.org/selected-caregiver-statistics.
23. Reinhard, Susan et al. Chapter 14: Supporting Family
Caregivers in Providing Care. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville,
MD: Agency for Healthcare Research and Quality, April
2008. www.ahrq.gov/professionals/clinicians-providers/
resources/nursing/resources/nurseshdbk/ReinhardS_

Journal of AHIMA Continuing Education Quiz


Quiz ID: Q1528601 | EXPIRATION DATE: JANUARY 1, 2016
HIM Domain Area: Technology
ArticlemHealths Role in Consumerism and Connectivity

FCCA.pdf.
24. Picot, Sandra J. Rewards, costs, and coping of African
American caregivers. Nursing Research 44, no. 3 (1995):
147-152.
http://journals.lww.com/nursingresearchonline/pages/articleviewer.aspx?year=1995&issue=05000&a
rticle=00004&type=abstract.
25. Picot, Sandra J., JoAnne Youngblut, and Richard Zeller.
Development and testing of a measure of perceived caregiver rewards in adults. Journal of Nursing Measurement
5, no. 1 (1997): 33-52.
26. Archbold, Patricia G. et al. The PREP system of nursing interventions: a pilot test with families caring for older members. Preparedness (PR), enrichment (E) and predictability (P). Research in Nursing and Health 18, no. 1 (1995):
3-16.
David Levin (dave@amatihealth.com) is co-founder and partner at Amati
Health, a healthcare professional services consulting firm that provides advice to healthcare providers, technology companies, and investors. Amati
Health has provided advisory services to MyOwnMed. Debra Gordon (debra@debragordon.com) is president of GordonSquared, Inc., a healthcare
communications firm specializing in the changing healthcare system.

TAKE THE QUIZ AT WWW.AHIMASTORE.ORG


NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED

REFER TO THE ARTICLE for the one best answer to each question. Questions are based solely on the content of the article.
1. The advent of mobile health coupled with the patient engagement
movement will accelerate the changes already underway in
healthcare.

a. true

b. false

6. One study published in the Annals of Internal Medicine reported


patients were more adherent to their medication regimes as one
outcome of the OpenNotes project.

a. true

b. false

2. Name the Three Ts of patient engagement.



a. truth, transparency, and trust

b. transparency, transactions, and trust

c. transactions, trust, and timeliness

d. transparency, transactions, and truth

7. Pricing
includes letting consumers know the cost of
the procedure based on insurance contracts and the out-of-pocket
cost to the patient based on their insurance benefit.

a. definition

b. transparency

c. renewal

d. equality

3. According to the Family Caregiver Alliance, about how many adults


are providing care for a family member or friend?

a. one in four

b. one in 10

c. one in three

d. one in five
4. Particularly in light of the numerous breaches recently occurring
in the retail, banking, and healthcare worlds, one of the most
significant barriers to successful HIT is
.

a. credit cards

b. mobile apps

c. transparency

d. privacy and security
5. The development of HIT has traditionally been

a. clinician

b. laboratory

c. paper

d. future

-focused.

8. Systems must find new ways to encourage patients to access their


personal health record, perhaps by instituting opt-in approaches
rather than opt-out policies.

a. true

b. false
9. Engaging the patient by making them the ultimate owner of
his/her electronic health information aids patients in following
preventative care and seeking early intervention for adverse
conditions, as well as complying with medical treatments.

a. true

b. false
10. Despite growing adoption of EHRs at the physician practice level,
one recently published study found that just
of
physicians used the EHR for secure messaging with their patients.

a. one-fourth

b. one-third

c. one-half

d. one-fifth

Journal of AHIMA January 15/37

A FOOT IN
THE DOOR
HOW POST-GRADUATE
APPRENTICESHIP PROGRAMS
CAN HELP ORGANIZATIONS
PREPARE FOR ICD-10
By Kayce Dover, MSHI, RHIA, and Chloe Phillips, MHA, RHIA

38/Journal of AHIMA January 15

A Foot in the Door

ITS A CONSTANT dilemmanew health information management (HIM) graduates struggle to find jobs because they lack
experience, yet its difficult to get that coveted experience without having a job. Even despite an increasing demand for coders, many new graduates cannot find employers willing to hire
them. Lack of experience is the biggest barrier. However, as the
industry moves toward ICD-10-CM/PCS, organizations must
find a way to incorporate these knowledgeable and capable individuals into the workforce in order to avoid further aggravating the current coding shortage.

Supply and Demand


The US Department of Labor estimates that more than 41,000
new HIM and health IT (HIT) jobs will be created between
2015 and 2022. This is an average of 350 new jobs per month.
The good news is that more than 5,000 individuals graduated
with an associates or baccalaureate degree in HIM during the
2011-2012 academic year, according to the 2012 annual report
by the Commission on Accreditation for Health Informatics and
Information Management Education (CAHIIM). The bad news
is that many employers arent willing to hire inexperienced professionals even though they have completed an oftentimes rigorous HIM program.
If new professionals cant find work upon graduation, they
will likely move into other non-HIM fields. This will create an
even bigger challenge for organizations during a time when
the integrity and exchange of health information is paramount.
Educators have called on seasoned HIM professionals in hiring
positions to look to new graduates to support the ever-growing
demand for HIM skills. Some employers have heeded this call,
but the move is not just symbolic or charitablethey see real
value in investing in the next generation of HIM professionals
due in part to the upcoming switch to ICD-10.

Impact of ICD-10 Change


Although some organizations are reluctant to hire new graduates, ICD-10 may change all of this. This is because coding productivity is expected to take a hit with ICD-10, given the added
specificity of the codes and the documentation required to support this specificity. It has been reported that many Canadian
healthcare organizations, for example, experienced a 50 to 60
percent loss in productivity while transitioning to ICD-10.
Organizations in the US must prepare for the worst and hope
for the best with their ICD-10 transition. Working with the largely untapped pool of talented new HIM professionals could be
something an increasing number of organizations consider to
fill staffing gaps, ensure coverage, and offset productivity losses.
Many organizations are starting to implement post-graduate
apprenticeship programs to prepare for all of the uncertainties associated with ICD-10. These programs provide hospitalspecific training to new graduates who, in turn, are available
and fully trained to fill vacant positions. These vacancies could
occur as coders leave the organization, or they may be entirely
new positions that are created to accommodate overflows due
to ICD-10.
According to a recent survey conducted by staffing and re-

cruitment firm HIM Connections, more than half of the coding


managers who responded indicated that their facility had implementedor has considered implementingan apprenticeship program for entry-level candidates (i.e., graduates of an accredited HIM program with no previous HIM work experience).
Most respondents indicated that they normally require at least
one to two years of experience for both inpatient and outpatient
coding positions.
In addition, the AHIMA Foundation has announced the
launch of a Registered HIM Apprenticeship Program in which
new graduates interested in coding, CDI specialist, business
analyst, or data analyst roles are matched with employers
looking for qualified workers. These apprenticeships, discussed in detail online at www.ahimafoundation.org/prodev/
Registered_Apprenticeship.aspx, are paid programs that typically offer positions lasting one or two years with the goal of
permanent placement.
The launch of this program comes in the wake of the Department of Labors certification of AHIMAs National Guidelines for
Apprenticeship Standards in June 2013. The certification award
was presented during a summit to address the shortage of HIM/
HIT professionals in rural and underserved communities and to
increase employment opportunities for US veterans.

Creating a Win-Win for Employers, Graduates


Apprenticeships are all about proactive planning. By training
these individuals nowand oftentimes before full-time positions become availableorganizations are ready when the
demand for coding increases. Not only do coding apprentices
forge a relationship with the institution, but they are also fully
trained on its specific systems and internal processes. This institution-specific knowledge is invaluable and often takes months
or even years to amass.
Organizations have found it helpful to establish a pool of individuals who are ready to go in the event that a position becomes available. As the industry moves into the final stretch of
ICD-10 implementation, organizations nationwide will be vying
for outsourced coding resources. Many vendors may find themselves stretched to the maximum and unable to accommodate
requests for staffing. Organizations need to have a back-up plan.
Not only is this a smart business move, it could also help save
money on outsourcing costs in the long run.
Apprentices also reap many benefits from these programs.
Most are extremely grateful for the opportunity to gain experience and put their newfound knowledge to good use. These individuals also tend to have incredible loyalty to the institution
for having given them the chance to progress in their career.
Typically these programs are a win-win for all involvedthe
hospital, the new graduate, and the entire HIM profession.
In an ideal world, coding managers would probably welcome
the opportunity to train new graduates. However, with limited
internal resources and ongoing staffing shortages, its often not
possible to mentor new professionals and guide them toward
becoming fully productive coders. Management resources and
coding experts time are in high demand and short supply. Time
and resources are the biggest barriers to creating a post-gradJournal of AHIMA January 15/39

A Foot in the Door

uate program. In this case, organizations could consider partnering with a vendor to help customize their training plan and
progress of the participants.

Starting an Apprenticeship Program at Baptist


Health System
Like many organizations, 2012 was a difficult year for Alabamabased Baptist Health System in terms of ICD-10 preparations
and staffing challenges. During 2012, three coders left the systems centralized coding department to work for large consulting companies and vendors where they could make more money. The four-hospital health system has lost one coder every
additional year since then. An apprenticeship program seemed
like a sensible solution to fill coding vacancies and help new
professionals gain valuable experience.
The program, which launched in late 2013, initially included
two post-graduate positionsone inpatient and one outpatient. These positions were offered to new graduates at a lower
pay grade than other coding positions. However, all other benefitssuch as incentives, retention bonuses, and paid time off
remained the same. Two post-graduates, who completed HIM
programs in Alabama, signed a two-year contract to undergo
comprehensive training and to ensure that Baptist Health System would eventually see a return on investment.
If either graduate left the organization prior to completion
of the program, he or she would be required to reimburse the
health system for any education-related expenses, such as their
ICD-10 training, and any retention incentives paid to them.
The health system reviewed more than 15 applications for its
apprenticeship program. Priority was given to individuals who
had obtained their RHIT or RHIA credential or who were eligible to receive it. Candidates also took a coding exam. The final
decision was based on test results as well as the individuals personality and work ethic.

Baptists 12-Phase Plan


Post-graduates had very little hands-on coding experience,
which meant Baptist Health System had to develop a comprehensive 12-phase coder development plan. As part of the plan,
each post-graduate was assigned a mentor within the coding
department who took them through each phase of the program. The inpatient and outpatient leads served in this mentor role, providing training regarding specialty coding, coding
guidelines, and how to review physician documentation for
important details such as medical necessity.
Training began with an orientation to the health systems
electronic health record (EHR) (i.e., coding flags, abstracting,
work queues). From there, post-graduates spent approximately four weeks learning outpatient diagnostics and emergency
room (ER) coding. Once both post-graduates had achieved a
96 percent or above coding accuracy rate for three consecutive weeks, they progressed to focus on inpatient or outpatient
coding.
Outpatient training included seven to eight weeks on simple
surgeries like cataracts and pain blocks, and eight to 13 weeks
on intermediate surgeries. The outpatient post-graduate also
40/Journal of AHIMA January 15

learned how to code complex surgeries, observation, and infusions and injections. Inpatient training included 12 to 15 weeks
on psychiatric coding, 10 to 13 weeks on OB/GYN coding, and
11 to 13 weeks on cardiac catheterizations. The inpatient postgraduate also learned inpatient cardiology, orthopedics, and
general surgery/medicine.
Throughout the program, post-graduates spent approximately
four hours per day training and four hours per day coding actual
cases based on the information they had just learned. Coding
mentors initially reviewed 100 percent of these cases (pre-bill)
until post-graduates had achieved a 96 percent accuracy rate. At
that point, the percentage of cases reviewed pre-bill decreased
over time.
The program included constant communication between the
post-graduate and coding mentor regarding weekly accuracy
rates. Post-graduates were also required to monitor account
and claim edit work queues for charts they previously coded.
This included a manual review of each edit in the EHR. Coding mentors, in turn, kept the coding manager and HIM director
informed of each post-graduates progress and accuracy rates.
Coding mentors were able to make time to teach the postgraduates because they had the support of other coders on the
HIM team. These other coders often absorbed some of the coding duties so the lead coders could assist the post-graduates.
Everyone had to support the program and believe in its efficacy in order for Baptist Health System to achieve its goals. Coders
were involved in every step of the planning, and collaboration
and open communication were paramount. It took significant
teamwork to be able to accommodate training and auditing
time.

Expanding the Program


One month after the program launched Baptist Health System
began to receive inquiries from other students interested in participating in the apprenticeship program. Given the uncertainty
of outsourced coding services vendors abilities to guarantee
a certain number of full-time employees (FTEs) heading into
ICD-10, the health system decided to expand its post-graduate
program to secure additional support.
In January 2014, Baptist Health System added five additional
positions to its apprenticeship program. The goal was to train
these individuals well in advance of what was then the October
1, 2014 ICD-10 deadline so that they would be available and already up to speed on Baptist Health Systems policies and procedures when productivity started to wane or if coders left prior
to go-live. As positions became available post-implementation,
these new graduates would also be among the first to be considered for the job.
All coders needed to be on board with the expanded program
in order to make it work. Coders participated in a coding roundtable to voice any concerns before the program grew into its
next iteration. After unanimous support of growing the program
to include five new positions, the HIM team got to work revising
its training methodology.
In the expanded program, post-graduates now rotate through
several mentors, each of whom trains them on a specific ser-

A Foot in the Door

vice line. These mentorsall current coders working for Baptist


Health Systemteach a subject that capitalizes on his or her
strengths. For example, the coder with the greatest ER coding
abilities provides the ER coding mentoring for each post-graduate. Providing training in this way ensures that post-graduates
receive the best possible information, and it also creates a sense
of pride among current coders because it recognizes them for
their abilities.
In addition to receiving ICD-9 training, post-graduates also receive ICD-10 training. This training includes pre-test, individual
online modules, and a post-test. Current coding staff members
also receive this same training, some of which is provided during designated downtime and some of which is completed on
coders own time.

Strategies for Success


Executive level buy-in is critical for a post-graduate apprenticeship program, but coder buy-in is just as important. An
organization must be able to manage this program without
increasing accounts receivable or causing a decrease in productivity. Adding additional staff members to manage the program is likely not an option, which means that careful planning and preparation is required. Those looking to replicate
the Baptist Health Systems apprenticeship program should
consider the following tips:
Talk openly with coding staff members. Explain your
specific plan for training and how this training will be
provided. Encourage questions and dissenting opinions
so that all coders feel valued and respected. What will be
expected? What would they like to get out of such a program? What are their biggest fears? A successful postgraduate program not only addresses the needs of new
professionals, but it also takes into consideration the
needs of existing staff members for career growth and
new experiences.
Monitor performance constantly. This includes daily
monitoring of accuracy, accounts receivable, and productivity. If productivity starts to decrease as a result of the
program, take steps to address this immediately. The CFO
must have confidence in the program and not worry about
it affecting performance.
Plan ahead. When mentors take time off (i.e., sick days or
vacation) ensure that post-graduates work with someone
else on those days. On Fridays, ask post-graduates to only
code service lines with which theyre familiar and have
achieved a 96 percent or greater accuracy rate so the rest
of the team can address all pending claims prior to the
weekend.
Stay committed to the program. Once post-graduates
complete the program, try to place them in a full-time
position within the organization. These graduates need
to know that the organization is doing everything it can
to help them start their career. If a coding position isnt
available, consider placing the new graduate in another
department, such as the billing office, compliance, or
revenue integrity. As RAC and other focused reviews con-

Advice for New Graduates to Break


into HIM
IF LOCAL ORGANIZATIONS dont offer an apprenticeship
program, there are many steps that new graduates can take
to better prepare themselves for the demands of todays
job market. They can consider other internship opportunities, volunteering, working part-time in an HIM department,
and professional networking.
Internships help students explore their options and
choose a specific healthcare setting in which they might
want to work after graduation. Schools should help match
students with internship placements based on students interests and strengths.
Even if students cant find formal internship opportunities, they should consider volunteering. Even volunteer positions can help candidates stand out in a competitive job
market by providing hands-on experience and demonstrating commitment when applying for their first post-graduate
position. Volunteering can also help students get to know
other HIM professionals for networking purposes. Finally,
prospective HIM professionals should attend local, state,
and national AHIMA meetings to network and learn about
job openings.
As HIM graduates seek employment, it is important to
stay positive, value their worth, and keep perspective.

tinue to expand, the need for talented HIM professionals


will only grow. Also consider helping the post-graduate
network to find positions in other organizations.
Have good communication and an openness to change.
Being open to making changes to workflow and processes, and talking to your team about how these changes will
help the organization achieve its goals and objectives, will
be important throughout the process.

Program Benefits for Baptist Health System


Though it may take time and dedication, a well-planned postgraduate apprenticeship can be extremely beneficial for any
organization. Baptist Health System experienced the following
benefits:
Projected savings of nearly $600,000 for 2014-2015 due to
the decreased demand for contract coders as well as a 50
percent decrease in overtime payments
A loyal and knowledgeable pool of applicants from which
to draw on when positions become available
Increased retention and morale for existing coders who
take pride in the administrative support for the apprenticeship program
Increased ICD-9 coding productivity
Kayce Dover (kdover@himconnections.com) is president and CEO at HIM
Connections. Chloe Phillips (chloe.phillips@bhsala.com) is the corporate
director of HIM and clinical revenue at Baptist Health System where she
is responsible for HIM, coding, charge master, and clinical revenue across
four hospitals.
Journal of AHIMA January 15/41

Working Smart a professional practice forum


Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / Quality Care

Industry Awaits
Phase 2 of HIPAA
Audit Program
By Don Asmonga

THE WAIT FOR the second round of mandated privacy and security audits from the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) continues. OCR is currently working through final details for the revised audit plan as
they await finalization of new technology that will enable those
being audited the ability to submit information electronically.
The HIPAA audit program began with the passage of regulations required in the Health Information Technology for Economic and Clinical Health Act (HITECH) that was included
in the $787 billion American Recovery and Reinvestment Act
(ARRA) in February 2009. The ARRA-HITECH language required
HHS to conduct periodic audits to ensure covered entities and
business associates are complying with the HIPAA Privacy and
Security Rules and Breach Notification Standards.
To do this, OCR looked to do the following:1
1. Seek a comprehensive, flexible process for analyzing entity efforts to provide regulatory protections and individual
rights
2. Identify best practices and uncover risks and vulnerabilities not identified through other enforcement tools
3. Encourage consistent attention to compliance activities

Results of Phase 1 Audits


The OCR audit program commenced with a pilot from 2011 to
2012 that included 115 performance auditsthe first 20 to test
the original protocol and the next 95 using a modified protocol.2
Health plans, clearinghouses, and providers were audited.
The primary focus areas for the audits included 11 modules:
Breach notification
Security: Administrative safeguards, physical safeguards,
and technical safeguards
42/Journal of AHIMA January 15

P
 rivacy: Notice of Privacy Practices, rights to request privacy protection of personal health information (PHI), access of individuals to PHI, administrative requirements,
uses and disclosures of PHI, amendment of PHI, and accounting of disclosures
According to OCR, initial overall audit findings and observations (or terms that indicate a violation was committed) using
the modules above revealed there were no findings or observations for 13 entities (11 percent). This included two providers,
nine health plans, and two clearinghouses. Security accounted
for 60 percent of the findings and observations, only 28 percent
of the total. Also, providers had a greater proportion of findings
and observations (65 percent) than reflected by their proportion of the total set (53 percent). Smaller entities were shown
to struggle with all three areas, having issues in breach notification, security, and privacy.
The results from the security portion of the audits showed that:
Of the 59 providers audited, 58 had at least one security
finding or observation
There were no complete and accurate risk assessments in
two-thirds of the entities audited, which included 47 of 59
providers, 20 out of 35 health plans, and two out of seven
clearinghouses

A s for security addressable implementation specifications, most entities without a finding or observation met
the standard by fully implementing the addressable specification
The most common overall finding of the audits was that the
entity was unaware of the security requirements.

Phase 2 Waiting on Technology Upgrades


As OCR continues to mull the results from Phase 1, they wait in
earnest to move forward with Phase 2, which will enable OCR to
audit any covered entity and any business associate.
During a September 2014 presentation at the Healthcare Information and Management Systems Society (HIMSS) Security
Forum, Linda Sanches, senior advisor for health information
privacy at OCR, stated that the agency will begin the audits by
sending pre-screening surveys to covered entities and then their
business associates. In the process, OCR will ask the covered entities to identify their business associates and provide the business associates contact information. OCR will randomly select
covered entity and business associate audit subjects for 2015
from the information received and a National Provider Index.
Those selected will be a mix of covered entities from across the
country. OCR will then proceed with desk audits and, as resources permit, comprehensive onsite audits.
A panel discussion during this years AHIMA convention titled
Health Information Privacy: Privacy, Security, Breach Notification Rules and Enforcement included three OCR staff members
who confirmed that the covered entities and business associates
for the Phase 2 audits had been selected but not yet notified.

entities and business associates. With an influx of some additional funding, OCR has reduced the number of desk audits to
approximately 200 to enable more live, onsite audits of covered
entities and business associates. Whether a desk audit or a live
audit is conducted, it will be important to ensure that an organizations documentation is stellar and includes formal policies
and procedures for risk mitigation, sanctions process, and the
documentation of sanctions and incidents.
Being prepared for an audit comes with completing a regular
internal risk analysis. As noted earlier in the security audit results from Phase 1, nearly two-thirds of those audited did not
complete a comprehensive risk assessment. This will certainly
be an area of focus in Phase 2. Regular risk analyses can assist
with identifying gaps that may have arisen through changes and
updates in processes, technology, or even staff. Without doing
this, a covered entity could put themselves in jeopardy for some
hefty fines that range into the millions of dollars.

Prepare Now for Next Audit Round


Sometimes waiting is the hardest part. As of press time in early December, OCR was expected to announce the details and
timeline for the Phase 2 audits in the coming weeks or months.

Being prepared for an audit comes with completing a regular


internal risk analysis. As noted earlier in the security audit results
from Phase 1, nearly two-thirds of those audited did not complete
a comprehensive risk assessment.
Once underway, Phase 2 of the audit process will first train
its focus on covered entities and look at their risk analysis and
risk management areas of security, the content and timeliness
of their breach notifications, and their Notice of Privacy Practices, mandated by the HIPAA Privacy and Security Rules. Following that effort, the focus will shift to business associates
and their risk analysis and risk management security protocols
and whether or not the business associates are complying with
breach reporting requirements they must make to their partnered covered entity.
Attention will then return to the covered entities, and auditors
will look at additional security requirements that include device and media controls and transmission security. In addition,
OCR will review the covered entitys ability to meet the privacy
requirements related to safeguard policies and procedures and
training. Finally, the focus will include encryption and decryption, facility access controls (physical), and other areas of high
risk as identified by the 2012 Phase 1 audits, breach reports, and
complaints.
As mentioned, one of the primary reasons for the delay in the
audit program was the development of technology to enable
the better collection and processing of audit data. The original
plan from OCR was to conduct 400 desk audits of both covered

If an organization hasnt started already, it is important to review available, excellent resources provided by AHIMA, read
information on the OCR website, and talk with in-house HIPAA
experts to not only ensure that privacy, security, and breach
procedures are up-to-date and air tight, but that the organization is also prepared for a potential audit.
More information on the documentation needed for the audit
can be found at www.hhs.gov/ocr/privacy/hipaa/enforcement/
audit/auditpilotprogram.html, and on the OCR Audit Program
Protocol website at www.hhs.gov/ocr/privacy/hipaa/enforcement/audit/protocol.html. There are also helpful resources in
AHIMAs Engage communities. Some HIM and HIPAA privacy
and security consulting companies also provide mock audit services to prepare organizations for OCR audits.

Notes
1. Sanches, Linda. OCR Audits of HIPAA Privacy, Security
and Breach Notification, Phase 2. Presented at the HCCA
Compliance Institute, March 31, 2014.
2. Ibid.
Don Asmonga (dasmonga@privacyanalytics.ca) is vice president, standards and government affairs, at Privacy Analytics.
Journal of AHIMA January 15/43

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HIM Engaging the New


Frontier of Patient Portals
By Lesley Kadlec, MA, RHIA; Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA; and Diana Warner, MS, RHIA, CHPS, FAHIMA

ADVANCEMENT IN THE practice of medicine has entered its


next generation through the launch of new medications, new
medical techniques, and most of all new technologies. While
many of the advancements impact the provider-patient relationship directly, such as the execution of treatment and diagnosis,
other advancements provide for a different type of impact. Such
is the case with online patient portals that enable patients to
communicate directly with their providers and instantly access
health information.
Patients continue to play an increasingly active role in their
own healthcare by taking responsibility for the decisions made
about them. They have become more informed and are more
likely to educate themselves on the things they dont fully understand in healthcare. One technology that has remarkably
helped with this change is the growing use of the patient portal. Portals enable communication between physicians and patients and save time and money for the patient, provider, and
facility.
Health information management (HIM) professionals have
already been at the table to help implement and manage the
health information maintained within electronic health record
(EHR) systems, so, the natural progression for implementing
and managing patient portals has also fallen to HIM in many
healthcare organizations.
HIM professionals are very much aware that implementing a patient portal benefits patient care and provider workflow when developed in conjunction with an EHR. However,
it is critical that HIM professionals have early involvement in
the selection, implementation, and ongoing use of the patient
portals, not just the management of its release of information
functions.
44/Journal of AHIMA January 15

Typical Portal Functionality Useful, But Limited


Incentive payments that are part of the meaningful use EHR
Incentive Program are a major driver for many healthcare organizations to purchase and implement patient portals. Patient
portals are one of several communication tools that can be used
to achieve the federal stage 2 meaningful use EHR Incentive
Program requirements.
Many patient portals in use today serve only a few core functions:
Provide patients with an electronic version of the postvisit summary
A llow access to lab results that have been reviewed and
approved for inclusion by a clinician or other staff
Give patients the ability to request a prescription refill
Serve as a platform for secure messaging with nurses,
physicians, and other office staff
Offer a list of upcoming appointments, or the ability to review and schedule an appointment online
There are opportunities for a number of additional functionalities to be incorporated into a patient portal. Some of these
might include electronic release of information capability,
the ability for patients to incorporate a personal health record
(PHR) into their provider based health record, or allowing patients to read and request amendments to their EHR.
Engaging patients through a patient portal in a way that will be
meaningful to the patient helps improve patient commitment
to the organization, provides an opportunity for more effective
management of the healthcare record, and assists in timely revenue capture, as well as potentially facilitates the quick removal
of erroneous health information. All of these areas of engage-

ment have a direct and positive impact on health information


practices in the organization. The portal can also reduce staff
time by facilitating a reduction in patient phone calls, reducing
the need for paper forms, and promoting a 24/7 operation without the need for onsite staff to assist patients during off hours.

HIM Must Lead Portal Implementation


Portals are often implemented as part of an organizational strategy to improve patient communication and facilitate the coordination of patient care across the healthcare organization. The
inclusion of HIM leadership is often an after-thought, and is not
considered until the module or product has been installed and
documentation or records management difficulties are encountered.
In preparing for implementation, HIM professionals must
take the lead through the use of a variety of management and
facilitation skills, including:
Establish a portal implementation team, including stakeholders from across the organization, such as clinical
staff, registration and business office staff, and IT staff to
design workflows
Define types of records/information/data to be transmitted through the portal, taking into consideration status,
timeframes, and other rules of documentation (i.e., When
will information be available in the portal? Will only
signed documentation be available?)

Develop and conduct training sessions for clinicians,
nurses, receptionists, HIM staff, and billing/customer
service staff
Identify and gain support from a physician champion that
can provide reinforcement and assist in gaining buy-in
from physicians, nurses, and other clinicians during and
after the conversion
Engage patients through the creation of brochures, poster
boards, and through verbal discussions with patients at
the point of registration; HIM professionals can be relocated to patient care areas to assist with portal sign-up
during the early post-implementation period

About More than Just Meaningful Use


Many physician practices and acute care facilities are anxious to
incorporate a patient portal in conjunction with the implementation of an EHR to work toward qualifying for meaningful use
incentives. But to ensure long-term success, HIM professionals must continue to provide oversight and management of key
portal functionality.
HIM professionals can not only facilitate the organizations
long-term strategy for increasing patient communication, but
also take the lead in ongoing success of the portal to make sure
that the goal of improved patient engagement and improvement in patient care is fulfilled.
AHIMA is currently working with subject matter experts on

Becoming the Patient Portal


Representative
FOLLOWING IMPLEMENTATION OF a patient portal, HIM
staff should be given the necessary tools and training to
provide ongoing maintenance of the portal and support its
growth. HIM leadership should consider hiring or appointing patient portal representatives to field calls from patients.
The role of the portal representative may include some or all
of the following tasks:
1. Answer any phone queries that come in through a
dedicated patient portal phone line
2. Ensure resolution of any questions regarding the patient portal functionality and troubleshoot problems
with personal identification numbers (PINs) or requests for PIN changes
3. Manage the process for proxy or guarantor access for
parents of minors or for caregivers that the patient appoints to oversee the portal on their behalf
4. Quickly respond to any reports of incorrect information and direct patients to the necessary paperwork
for changes
5. Review and respond to any requests directed through
secure messaging to the HIM department (requests
for release of information, restrictions, amendments,
updated demographic information, etc.)
6. 
Facilitate communication with caregivers when test
results or other information is not available for patient
viewing

a Practice Brief providing recommended practices for the implementation and management of patient portals, due to be
published in the April 2015 Journal of AHIMA. Discussing operational and managerial needs, identifying stakeholders and
system selection, issues and challenges such as the privacy and
security of the protected health informaton within patient portals, and managing proxies and promoting consumer education
and engagement will all be addressed within this upcoming
Practice Brief.

Notes
1. Dixon, Anne. HIM Best Practices for Managing Patient
Portals. Journal of AHIMA 83, no. 3 (March 2012): 44-46.
 2. Centers for Medicare and Medicaid Services. Stage 2.
www.cms.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/Stage_2.html?gclid=CNbq89HV
w7oCFewRMwodQ2EAZQ.
Lesley Kadlec (Lesley.Kadlec@ahima.org), Angela Dinh Rose (angela.rose@
ahima.org), and Diana Warner (diana.warner@ahima.org) are directors of
HIM practice excellence at AHIMA.
Journal of AHIMA January 15/45

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Are We There Yet?


How to Improve Meaningful Use and Gauge Industry Performance
By Beth Acker Moodhard, RHIA, and Reed Gelzer, MD, MPH

ONE OF THE many benefits of working in the information management field is being a part of healthcares transformation to
the use of electronic health records (EHRs). Everyone has a
stake in this transformation, and an opportunity to help determine how the transition is actually proceeding.
In May 2013, the United States passed a significant EHR milestone: Over half of eligible professionals and 80 percent of hospitals had implemented EHR systems certified as capable of
meeting the health information technology (HIT) functional
requirements stipulated by the meaningful use EHR Incentive
Programs first stage. Each of those providers received taxpayer
dollars as a reward for their achievement.
As a result of these incentives, patient visits to a provider will
most likely involve an EHR system. Health data standards are
available so that an EHRs electronic health information can
be exchanged between organizations. And health information
exchange organizations have started to make it easier to connect to other providers. So the question arises, why do patients
still get asked repeatedly to share the same information over
and over again, detailing medications, allergies, family and personal medical history, every single time they see a healthcare
provider? A lot of progress has been made, but sometimes it just
does not feel like healthcare has reached its full potential in EHR
design and use.

Still on the EHR Journey


Information often lives in a progress note in a text only format,
not in a standardized or structured format. When a system is
not designed to capture information in a standardized fashion,
and in the form of exchangeable data, then it becomes very difficult to exchange. Initiatives are in place to ease this burden.
46/Journal of AHIMA January 15

Examples include the Institute of Medicines initiative to ensure


social and behavioral domains are captured in every EHR, and
the work being done by the Standards & Interoperability Framework to facilitate the functional exchange of information.2
Another challenge involves the small steps taken by the meaningful use program. Thanks to meaningful use, clinical professionals and hospitals are receiving monetary incentives to make
sure workable EHRs are implemented. However, EHRs that
qualify for participation in this program are only tested in labs,
not out in the real world, to exchange information with other
providers or organizations.

Current State of EHR Exchange Capabilities


To start, it helps to understand what a certified EHR must actually do at this point. Achieving stage 1 meaningful use certification requires making only some, not all, clinical summary information available electronically. For example, any meaningful
use-certified EHR must be capable of rendering, transmitting,
and receiving a standardized electronic document called the
patient summary. The patient summary must be standardized
to one of two formats called the Continuity of Care Document
(CCD), developed by standards organization Health Level Seven, or Continuity of Care Record.
Note that there are differences between the specification for a
CCD and the Continuity of Care Record. But, for the purposes of
this article, they can be considered approximately the same and
will be refered to as the CCD. Both are noted as acceptable in the
meaningful use certification test protocols.
Both are standards-based health information summary tools
that enable data to be shared across healthcare providers in a
meaningful way while ensuring data integrity and consistency.

Table 1: Simple Survey: Electronic Patient


Summary Capability
Question

Yes No

Comments

1. Can you get your patient summary


electronically?
2. Can you get your patient summary in
print?
3. Can your clinician (or hospital) send
your patient summary to another one
of your clinicians?

The CCD is intended to represent an exchangeable and useful


clinical summary in a form that will have the same content no
matter where it originates. The patient summary must be something the provider can send to another clinician or hospital so
that they have the information before a patient arrives there
assuming both facilities are using a meaningful use-certified
EHR. This is great for the harried patient who is tired of repeating their health history. Additionally, each facility should be
able to give any patient a copy of their records in either a printed
or electronic form, or both.3
In the early stages of the program, a meaningful use-certified
EHR was not actually required to produce or exchange a fully
capable version of all the possible CCD content.4 While the use
of standards-based terminologies and data sharing are key to
ensuring the portability and integrity of this data, not all data
available are required in a meaningful use-required patient
summary. The data are not expected to create a longitudinal
health record with all the information available everywhere.
The CCD is designed to present a subset of key health data
from the most recent information available to that specific doctor or hospital. So, a given CCD may appear wrong because it
only represents the information that specific doctor or hospital
has provided. This is part of the purpose of simplifying information exchange. Updates using the CCD are supposed to become
simpler, faster, and cheaper due to the ease of electronic exchange. Eventually all providers should have the same updated
information when all these functions are fully operational.
First, providers should focus on whether a given clinic or
hospital can actually give another facility a patient summary,
keeping in mind that a given summary may only be up-to-date
according to the information available at that time in the EHR
system that produces it. Then consider other current limitations
for the patient summary. For instance, stage 1 meaningful use
has only a minimum content requirement for the patient summary, stating it must include diagnostic test results, a problem
list, a medication list, and a medication allergy list.5
In sum, it is a very reasonable expectation that if a provider
attested for EHR incentive funds they have a system that is capable of sending and receiving a patient summary electronically
and a system that can meet the four requirements above. Furthermore, its reasonable to expect that these same providers
are able to provide the same electronic patient summary since

their EHR is required to render that summary. If the industry


can show that this capability actually exists, we will know where
we are on our journey to the full adoption, implementation, and
utilization of the EHR. At that point patients can quit reportingand clinicians can quit writingthe same information
over and over again.

Take Action, Take the Survey


Any provider that has attested that they have met the meaningful use incentive criteria should be able to provide patient summaries with at least the four components listed above. The reality is its hard to know if the results seen in the certification test
lab are achievable in actual practice.
In order to work together to find out the answer to Where
are we? and to spur more meaningful meaningful use, the
authors of this article are asking readers to take the survey included in Table 1 to your workplace, your doctors office, and
your hospital. Fill it out based on the responses you receive to
your request for a patient summary from their certified EHR system. Provide the survey to your peers, friends, and family members. Then share your results on AHIMAs Engage website, via
the event Complete the Electronic Patient Survey in the Information Governance and Standards Community. Dont forget to
post a short narrative of your experience as well.
Be prepared for a request to give a provider a blank disk or
empty USB drive so you can get the information. Depending on
the responses you get, you may also want to provide your clinicians or your hospital with a copy of this article.
Working together, health information management professionals can help make meaningful use in the US meaningful.
It can start with a dialogue on the Engage site, spurred by your
posted comments, support, and survey results.

Notes
1. Department of Health and Human Services. Doctors and hospitals use of health IT more than doubles since 2012. May 22, 2013. www.hhs.gov/news/
press/2013pres/05/20130522a.html.
2. Standards & Interoperability Framework. What is the S&I
Framework? www.siframework.org/whatis.html.
3. National Institute of Standards and Technology. Test Procedure for 170.304 (i) Exchange Clinical Information and
Patient Summary Record. September 24, 2010. http://
healthcare.nist.gov/docs/170.304.i_ExchangeClinicalinfoPatientSummaryRecordAmb_v1.1.pdf.
4. Corepoint Health. Understanding the Continuity of Care
Record. 2011. www.corepointhealth.com/sites/default/
files/whitepapers/understanding-the-continuity-of-carerecord-ccr.pdf.
5. National Institute of Standards and Technology. Test Procedure for 170.304 (i) Exchange Clinical Information and
Patient Summary Record.
Beth Acker Moodhard (Beth.Acker@va.gov) is a HIM specialist at the US
Department of Veterans Affairs. Reed Gelzer (r.gelzer@myfairpoint.net) is
a consultant with Trustworthy EHR.
Journal of AHIMA January 15/47

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Obtaining Quality Healthcare


through Patient and Caregiver
Engagement
By Vera Rulon, MS, RHIT, FAHIMA

AT AHIMAS NATIONAL Convention Angela Kennedy, EdD,


MBA, RHIA, shared a story about her adopted daughters diagnosis of cystic fibrosis, and the difficulty Kennedy faced in
getting her daughters medical history. Kennedys story made
it clear: Without this essential health information, patient empowerment is nearly impossible. Its like asking someone to
build a house without the benefit of blueprints.

Public Good: Its Personal


The concept of health records as the foundation for patient
empowerment was made even more personal by Dave deBronkhart, author and co-founder of the Society for Participatory Medicine who is also known as ePatient Dave. In an article
in iHealthBeat, deBronkhart provided examples of how a lack
of access or access to incorrect information in medical records
could have dire consequences.
In the iHealthBeat article Patient Participation: Let Patients
Help with Medical Record Quality, Completeness, deBronkhart
wrote:1
When my mother was discharged to rehab two years ago,
her hypothyroid came across to the new system as hyper.
The best clinician in the world, reading that information,
would have correctly caused a disaster.
I talked earlier this year with a nurse who was involved
in the death of a patient because of a fact missing from the
chart, and just last week I heard about a case where rule
out was omitted when a chart was transcribedrule out
afib came across as afib.
These stories are personal, but not rare. Health information
management (HIM) professionals can help solve these issues
48/Journal of AHIMA January 15

starting with an understanding of how access to information


can empower patients.

Patient Journey: Engagement and Shared DecisionMaking


Information is power, and good communication is a prerequisite to truly sharing the power of decision-making. Shared decision-making is an integrative process between a patient and
clinician that:2
Engages the patient throughout the process of decisionmaking
Provides the patient with balanced information about
treatment options
Incorporates patient preferences and values into the medical/treatment plan
The following examines each step in the patient journey
through the lens of the patients contribution to health information.
Family and medical history: Knowledge of family medical
history by patients and caregivers can help patients and their
medical teams assess the risks of various diseases. Digital technologies can help keep personal and family health information
up-to-date and track it quickly and seamlessly.
Diagnosis: When patients do their own research online, they
come prepared to ask questions of their physicians. The power
of questions is most prominent in the diagnosis process and in
helping both the doctor and patient assess options.
Decisions on treatment: Providers can share options in real
time through digital technologies. More importantly, by understanding patient preferences, shared decision-making is im-

proved by providing access to medical information in real time.


Monitoring and maintenance: Deploying mobile technologies may help patients and caregivers monitor health status,
maintain adherence to medical treatments, and share their data
with their healthcare team. This part of the journey lends itself
to the support of patient communities.
Health information technology (HIT) can enable the healthcare journey and informs patients. The article Informing and
Involving Patients to Improve the Quality of Medical Decisions
published in Health Affairs describes how HIT can help patients
access the right information at the right time and assist them
in making medical decisions. An example in the article from
Massachusetts General Hospital is when providers enter a new
problem list item for a patient an icon is generated indicating
that a decision aid is available. The decision aids, which include
educational booklets, DVDs, or interactive tools, help make
treatment choices and can be prescribed by the physician and
sent directly to the patient.
According to the article, HIT also enables the collection and
storage of information regarding patient priorities and preferences. In context of the starkest example of a medical erroroperating on the wrong patientthe authors argue that it is equally bad to operate on an informed individual who was given a
voice in the decision to have surgery and would have chosen not
to have the surgery. The authors state that the right patients
for surgery are the ones who are clinically appropriate and who
made an informed choice that surgery is the best way to treat
their condition. Healthcare professionals must ensure that every patient is fully informed and involved in making every important decision about their healthcare.

The Evidence: Patient Engagement Improves


Quality of Care
Evidence demonstrates that patients can improve the quality
of their health records. An example is the Open Notes project

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launched in 2010. Patients at several hospitals were given access


to physician notes through secure patient portals. While physicians were initially concerned about misinterpretation and the
potential time expenditure of explaining health record entries,
at the end of the experimental period, 99 percent of patients
wanted Open Notes to continue and no doctor elected to stop.3
Another pilot at Geisinger Health System gauged patients
ability to improve the accuracy of their health records. Patients
were given access to their medication lists and were asked to
provide feedback. Pharmacists accepted 68 of 121 updates that
were submitted by patientsa 56 percent acceptance rate.
Also, access allowed patients to add information, such as their
use of over-the-counter medication and supplements. In some
instances this revealed potential adverse events or errors. For
example, one patient had started taking B-12 vitamins postsurgery and had reported this on the form during the study. A
provider noted that the patient was already receiving B-12 injections, preventing an overdose.

Taking Action: Implications on Information


Governance and Research
Patient and caregiver engagement also means that there is more
data being collected, including data gained through novel, intensely personal channels such as wearable electronic monitoring devices and sensors. This poses both challenges and
opportunities for HIM leadership in the areas of information
governance (IG) and research.
Personal information should be incorporated into the patients medical record for a complete picture. Standards on how
information is collected and classified will be critical to ensure
interoperability, access, and usability of health information by
providers, patients, and researchers.
The security of personal information is paramount. The Food
and Drug Administration (FDA) recently issued the formal
guidance for the management of cybersecurity in medical de-

adopted by thousands of users to achieve

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Journal of AHIMA January 15/49

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The Patient Journey


THIS TABLE DEMONSTRATES patient input along their healthcare journey.

CARE CONTINUUM, PT

PROVIDER COMMUNICATION, PERSONAL HEALTH INFORMATION


Symptoms, Personal
Preferences, Family
History

Presentation
& Evaluation

Communicate
Share Data

Monitoring
Therapy

Diagnosis

Patient/Caregiver
Research

Shared DecisionMaking

Treatment
Decision

vices. This guidance recommends that manufacturers consider


security risks in the development of their devices and include
these measures in their FDA submissions.
Research is a very important aspect of information governance and AHIMAs public good strategic efforts. Clinical
trials are moving towards more mobile solutions to collecting
data and including the patient voice in the design of protocols.
The Patient Centered Outcomes Research Institute (PCORI),
established as an element of the Affordable Care Act, has set
its mission to help inform healthcare decisions and improve
healthcare delivery and outcomes. PCORIs position comes
from research guided by patients, caregivers, and the broader
healthcare community.4
PCORIs three goals impacting IG are:
Substantially increase the quantity, quality, and timeliness of useful, trustworthy information in support of
health decisions
Speed the use of patient-centered outcomes research evidence
Influence clinical and healthcare research to be more
patient-centered
Patient-centered systems must be built on trust, especially in
this new age of information sharing. As AHIMAs Information
50/Journal of AHIMA January 15

Consideration
of Treatment
Options

Governance Principles for Healthcare state, organizations regardless of their roles in healthcare must earn the confidence
of patients and society through a firm commitment to ethical
and responsible handling of personal health information.5 HIM
professionals must ensure that trust is both earned and sustained with patients and caregivers.

Making a Difference: The HIM Connection


The aim of AHIMAs public good strategic pillar is to empower
consumers to optimize their health through management of
their personal health information. One patient who has taken
charge of her health is Tracy Okubo, who wrote about her experience with personal health records in a Health IT Buzz blog
post. Diagnosed with lupus at an early age, Okubos family discovered that her medical records had been lost up until age 15.
Given the difficulty managing a complex condition like lupus,
she took charge of her health via a personal health record and is
managing her condition through her personal health information.6 Tracy leverages her iPhone to track her personal health
record which allows her to record details from her doctors visits.
She also uses her health plans patient portal where she accesses personal health information such as lab results, medication
lists, and connects with her doctors.
HIM professionals must remember to put patients and care-

givers first. After all, HIM professionals also walk in these shoes
as parents, friends, individuals, and community members.
Remembering this can help keep the patient voice as an HIM
professionals North Star, even as the world of information management and communication undergoes its most profound
revolution in history.

Files/HIM-Trends/IG_Principles.ashx.
6. Okubo, Tracy. Managing My Personal Health Record: My
Story of Living with Lupus. Health IT Buzz. September
26, 2013. www.healthit.gov/buzz-blog/electronic-healthand-medical-records/managing-personal-health-recordstory-living-lupus/.

Notes

References

1. deBronkart, Dave. Patient Participation: Let Patients Help


with Medical Record Quality, Completeness iHealthBeat. September 26, 2013. www.ihealthbeat.org/perspectives/2013/patient-participation-in-the-medical-recordlet-patients-help-with-quality-completeness.
2. Charles, C., A. Gafni, and E. Whelan. Shared DecisionMaking in the Medical Encounter: What Does It Mean?
(Or, It Takes at Least Two to Tango). Social Science and
Medicine 44, no. 5 (March 1997): 681-692.
3. Delbanco, Tom et al. Inviting Patients to Read Their Doctors Notes. Annals of Internal Medicine 157, no. 7 (2012):
461-470. http://annals.org/article.aspx?articleid=1363511.
4. Patient Centered Outcomes Research Institute. Strategic
Plan. November 18, 2013. www.pcori.org/assets/2013/11/
PCORI-Board-Meeting-Strategic-Plan-111813.pdf.
5. AHIMA. Information Governance Principles for Healthcare (IGPHC). 2014. www.ahima.org/~/media/AHIMA/

Delblanco, Tom et al. Open Notes: Doctors and Patients


Signing On. Annals of Internal Medicine 153, no. 2 (2010):
121-125.
Dullabh, Prashila et al. How Patients Can Improve the
Accuracy of their Medical Records. eGEMs 2, no. 3 (2014).
http://repository.academyhealth.org/egems/vol2/iss3/10.
US Food and Drug Administration. Content of Premarket
Submissions for Management of Cybersecurity in Medical
Devices. October 2, 2014. www.fda.gov/downloads/
Me d ic a l D e v ic e s/ D e v ic eR e g u l at ion a ndGu id a nc e/
GuidanceDocuments/UCM356190.pdf.
Fowler, Floyd et al. Informing and Involving Patients to
Improve the Quality of Medical Decisions. Health Affairs
30, no. 4 (April 2011): 699-706.
Vera Rulon (vera.rulon@pfizer.com) is the director of external communications at Pfizer Medical.

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Journal of AHIMA January 15/51

PRACTICE BRIEF
practice guidelines for managing health information

Measuring the Value of the Clinical


Documentation Improvement Practitioner
(CDIP) Credential

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 exclusively on acute care
Medicare patients. Today, as external influences such as fraud
and abuse programs, changes in reimbursement, complexity of
care, and quality report cards increase the need to tell an accurate patient story across the continuum of care, CDI programs
are morphing at a rapid pace. Their goal is to accurately tell the
patients story.
As the healthcare industry continues to expand and become
more dependent on clinical information for real time outcomes
reporting, there is a need for an increased number of CDI professionals. The Commission on Certification for Health Informatics and Information Management (CCHIIM) explored this
CDI role in 2011. Through a job analysis methodology that included a random sample of 4,923 CDI-related professionals, a
thorough foundation for the clinical documentation improvement practitioner (CDIP) credential was established.1
This Practice Brief will outline the benefits of the CDIP credential so that organizations and providers can be assured that
their CDIP-credentialed staff are ensuring clinical information
supports clinical care, treatment, coding guidelines, and reimbursement methodologies.

Skills and Background


Emerging professions or job roles bring an exciting air of possibility. New specializations continue to emerge because of a
variety of regulatory and environmental factors. For CDI, the
need for specialization emerged to certify individuals working in clinical documentation roles to ensure the integrity and
quality of their work. In an effort to fill an industry need for
a validated professional standard of CDI excellence, CCHIIM
used job analysis data to develop the CDIP credential exam
blueprint in accordance with test development best practice
methodology.
As a result, six domains were developed to create knowledgebased content areas of expertise:
1. Clinical coding practice
2. Leadership
3. Record review and document clarification
4. CDI metrics and statistics
5. Research and education
6. Compliance
52/Journal of AHIMA January 15

These six domains are weighted based on subject matter experts rankings of task or knowledge criticality and frequency.
The exam is based on validated, job-specific content so that
those who achieve the CDIP credential have proven their competencies and expertise related to the codified CDI body of
knowledge. As a result, the healthcare industry is strengthened
by this defined, measurable proficiency related to the quality of
clinical documentation.

Importance of Credentials
The delivery of healthcare continues to change, creating a need
for changes in industry personnel. However, one thing that will
never change is the need for qualified leaders. Leadership will
always involve communication, education, and collaboration
all key skills for the CDI professional. Regardless of an individuals healthcare background, the acquisition of the CDIP credential signifies that he or she is a professional with key leadership
skills. The CDIP credential identifies individuals who place importance on acquiring and maintaining knowledge and skills.
Hiring managers will look for this credential as a sign of competence and professionalism. The credential also demonstrates to
other disciplines a certain level of clinical competence required
for documentation review.
Organizations and providers are fully aware of the need for
accurate and timely documentation. Employing a CDIP professional ensures that there is a qualified individual with a
thorough understanding of the latest documentation, code assignment, metrics, and compliance information. In addition,
credentialed professionals may be elevated to management positions at a faster rate than their non-credentialed counterparts.
As with any industry, the healthcare industry recognizes advanced skills. CDIP professionals are often in a position to negotiate a higher rate of pay because the credential indicates a
higher level of knowledge and a commitment to training and
continuing education. In an industry where associate and baccalaureate degrees are almost undeniably required, and many
management positions require a masters degree, a credential
can make a difference in salary range.
AHIMA requires CDIP professionals to follow high standards
of professional and ethical behavior. These standards are outlined in the AHIMA Code of Ethics and Ethical Standards for
Clinical Documentation Improvement Professionals, and require continuing education hours to maintain the credential.

Practice Brief

These higher standards associated with the CDIP credential can


automatically boost professional reputation within the organization and healthcare field.

CDI Specialist Poll: What is Your Level of


Education?

CDI and HIM Naturally Overlap


Health information management (HIM) professionals have
the core fundamental skills associated with documentation,
coding, compliance, and information management that lend
themselves to documentation improvement. According to
a report from the AHIMA Foundation, 79 percent of work on
clinical documentation improvement is conducted in the HIM
department. As industry initiatives push forward with programs such as ICD-10-CM/PCS implementation, accountable
care organizations reimbursement models, fraud and abuse
compliance programs, and implementation of electronic
health records (EHRs), the importance of these fundamental
skills cannot be overstated. CDI professionals can also assist
case managers with meeting the Two-Midnight Physician Certification requirements.
Organizations implementing CDI programs depend on HIM
professionals skill set. The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle
and, more importantly, to a healthy patient.
HIM professionals also impact CDI programs by providing
education on compliant documentation practices to all clinicians. Organizations must compensate for this lack of training
by instituting CDI programs that align with good documentation habits. HIM professionals, through their education, are
familiar with compliant documentation rules and regulations
as well as accreditation standards that affect timely documentation. In addition, HIM professionals are also familiar with important areas such as privacy, security, and confidentiality that
also impact the sharing of clinical information.
As technology changes the way documentation is captured
through the use of EHRs, the need to have highly trained and
qualified professionals in CDI roles becomes more evident. The
CDIP credential distinguishes the HIM professional as a subject
matter expert on documentation and demonstrates competency in capturing documentation necessary to fully communicate
a patients health status and condition.

CDI Important to ICD-10 Success


An AHIMA-credentialed CDI professional possesses the skill
and knowledge necessary to work collaboratively with patient
care providers to obtain the increased specificity needed in the
ICD-10-CM/PCS code sets. The CDI specialist educates the provider at the point of care to ensure the patient record contains
the most specific, accurate, and compliant documentation that
adequately reflects quality of patient care while increasing accuracy in coding and reporting.
Specificity of code assignment in ICD-10-CM/PCS impacts
various areas, including medical necessity, risk of mortality, severity of illness, value-based purchasing, denials and appeals,
quality core measure indicators, hospital and physician profil-

7%
17%
45%

n Associates degree
n Bachelors degree
n Masters degree
n PhD or MD

31%

Source: 2014 AHIMA CDI Summit Audience Poll

ing, and reimbursement. Studies have shown that some hospitals currently lacking a CDI program have experienced up to 25
percent of denied claims due to unspecified diagnoses in preliminary ICD-10 gap analyses.2

CDI Focuses on Quality Documentation


The focus of most CDI programs is on improving the quality of
clinical documentation regardless of its impact on revenue. Arguably, the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete
and accurate reporting of diagnoses and procedures.
A successful CDI program can have an impact on Centers for
Medicare and Medicaid Services (CMS) quality measures, present on admission, pay-for-performance, value-based purchasing, data used for decision-making in healthcare reform, and
other national reporting initiatives that require the specificity of
clinical documentation.
American Hospital Association Coding Clinic authors accurately predicted in 1989 that data will be used to judge both
the quality and value of care provided by individual institutions
and physicians.3 Physician documentation and coded data
now serve as the foundation for risk-adjustment methodologies, such as the CMS Hierarchical Condition Categories (HCC)
and 3M APR-DRGs. Risk adjustment is integral to provider
profiles used by the Agency for Healthcare Research and Quality (AHRQ), Premier, Healthgrades, US News and World Report
rankings, and others.
Healthcare policymakers and payers use coded data to make
important decisions. CMS outlined their intentions in the
Roadmap for Implementing Value Driven Healthcare in the
Traditional Medicare Fee-for-Service Program by saying they
were transforming the Medicare program from a passive payer
of services into an active purchaser of higher quality, affordJournal of AHIMA January 15/53

Practice Brief

able care.4 Expanded programs are revamping how services are


paid, moving increasingly toward rewarding better value, outcomes, and innovations. Commercial payers are also increasingly adopting strategies that focus on physician documentation
and coded data to support quality initiatives, payment methodologies, payer contracts, and preferred provider arrangements.
Quality metrics, based in large part on coded data supplied
through hospital claims, have proliferated in recent years and
are widely disseminated across the Internet. Hospital Compare
suggests such information encourages hospitals to improve the
quality of care they provide.5 Consider that coded data is used
by CMS for:
Payment on an individual case basis
Adjustment of individual payments because of hospitalacquired conditions
Adjustment of base payments across a broad scale, such
as Medicare base rates for an entire year due to special
quality initiatives
Value-based purchasing, with 50 percent to 65 percent of
the facility performance score dependent on coded and
risk-adjusted data for mortality rates, patient-safety indicators, and Medicare spending per beneficiary
Readmission reduction program, based on select principal diagnosis codes and risk-adjusted cases for a growing
number of diagnoses and procedures
Hospital-acquired condition reduction program, where a
portion of the score is based on patient safety indicators
determined by coded data
Case identification for inpatient quality measures, such
as heart failure measures which are only applicable to patients with a coded principal diagnosis of heart failure
A nnual coding and documentation adjustment
Improving the accuracy of clinical documentation can reduce
compliance risks, minimize a healthcare facilitys vulnerability
during external audits, and provide insight into legal quality of
care issues.

Ethical Standards and Credential Maintenance


Ethical standards are a core component of any profession. The
AHIMA Ethical Standards for Clinical Documentation Improvement Professionals serve as a foundation for decision-making
processes and actions. A key principle within these standards
is to Support the reporting of all healthcare data elements (i.e.,
diagnosis and procedure codes, present on admission indicator) required for external reporting purposes (i.e., reimbursement and other administrative uses, population health, quality
and patient safety measurement, and research) completely and
accurately, in accordance with regulatory and documentation
standards and requirements and applicable official coding conventions, rules, and guidelines.6
These standards also emphasize the need for maintenance of
certification, including the CDIP credential, to continually enhance professional competency. Professionals holding a cur54/Journal of AHIMA January 15

rent CDIP credential have demonstrated commitment to staying abreast of an ever-changing healthcare field.
Healthcare organizations can be assured that their CDI professionals have demonstrated excellence in clinical care, treatment, coding guidelines, and reimbursement methodologies.
In order to maintain certification through AHIMA, credentialed
individuals are required to comply with the continuing education standards as set forth by CCHIIM.
It is recommended that healthcare organizations cover the expense of continuing education credits for their employees. Employer reimbursement for continuing educational opportunities
allows the credentialed CDI professional to keep abreast of the
latest developments; continues awareness of changing codes,
practices, and regulations; and assures the employer, peers, and
providers that the CDI professional maintains the highest level
of competency in their respective healthcare field.

Notes
1. Ryan, Jessica et al. Validating Competence: A New Credential for Clinical Documentation Improvement Practitioners. Perspectives in Health Information Management
(Spring 2013): 1-38. http://perspectives.ahima.org/validating-competence-a-new-credential-for-clinical-documentation-improvement-practitioners/.
2. Hall, Denise. ICD-10 and Clinical Documentation Improvement Programs. PYALeadership Briefing. June 2012.
3. American Hospital Association. Coding Clinic (First Quarter 1989): 5-7.
4. Centers for Medicare and Medicaid Services. Roadmap
for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program. www.cms.gov/
Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/downloads/VBPRoadmap_OEA_1-16_508.pdf.
5. Medicare Hospital Compare Website. www.medicare.gov/
HospitalCompare/?AspxAutoDetectCookieSupport=1.
6. AHIMA. Ethical Standards for Clinical Documentation
Improvement (CDI) Professionals. 2010. http://library.
ahima.org/xpedio/groups/public/documents/ahima/
bok1_047842.hcsp?dDocName=bok1_047842.

References
AHIMA. Clinical Documentation Guidance for ICD-10-CM/
PCS. Journal of AHIMA 85, no. 7 (July 2014): 52-55. http://
librar y.ahima.org/xpedio/groups/public/documents/
ahima/bok1_050701.hcsp?dDocName=bok1_050701.
AHIMA. Clinical Documentation Improvement Toolkit.
January 2014. http://library.ahima.org/xpedio/groups/
secure/documents/ahima/bok1_050585.pdf.
AHIMA. Guidance for Clinical Documentation Improvement
Programs. Journal of AHIMA 81, no. 5 (May 2010). http://
librar y.ahima.org/xpedio/groups/public/documents/
ahima/bok1_047343.hcsp?dDocName=bok1_047343.
AHIMA. Recruitment, Selection, and Orientation

Practice Brief

for CDI Specialists. Journal of AHIMA 84, no. 7


(July 2013): 58-62. http://library.ahima.org/xpedio/
g r o u p s /p u b l i c /d o c u m e n t s /a h i m a / b o k 1 _ 0 5 0 2 3 4 .
hcsp?dDocName=bok1_050234.
AHIMA. Using CDI Programs to Improve Acute Care Clinical
Documentation in Preparation for ICD-10-CM/PCS.
Journal of AHIMA 84, no. 6 (June 2013): 56-61. http://library.
ahima.org/xpedio/groups/public/documents/ahima/
bok1_050207.hcsp?dDocName=bok1_050207.
Bresnick, Jennifer. Top ICD-10 clinical documentation
improvement pain points. EHR Intelligence. January 6,
2014.
http://ehrintelligence.com/2014/01/06/top-icd-10clinical-documentation-improvement-pain-points/.
Commission on Certification for Health Informatics and
Information Management. AHIMA Candidate Guide.
May
2014.
www.ahima.org/~/media/AHIMA/Files/
Certification/Candidate_Guide.ashx.
Hart-Hester, Susan. Clinical Documentation Improvement
(CDI) Job Description Summative Report. Prepared for
AHIMA Foundation. 2014. www.ahimafoundation.org/
downloads/pdfs/CDI_SummativeReportFinal_.pdf.

Prepared By
Sheila Burgess, RN, RHIA, CDIP, CHTS-CP
Sharon Cooper, RN-BC, CDIP, CCS, CCDS, CHTS-CP
Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P,
FAHIMA
Susan Wallace, MEd, RHIA, CDIP, CCS, CCDS
Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR,
FAHIMA

Acknowledgements
Cecilia Backman, MBA, RHIA, CPHQ, FHIMSS
Patricia Buttner, RHIA, CDIP, CCS
Susan Clark, BS, RHIT, CHTS-PW, CHTS-IM
Marlisa Coloso, RHIA, CCS
Angie Comfort, RHIA, CDIP, CCS
Katherine Downing, MA, RHIA, CHPS, PMP
Pat Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC
Laurine Johnson, MS, RHIA
Cathy Munn, MPH, RHIA, CPHQ
Cindy Parman, CPC, CPC-H, RCC
Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA
Donna Wilson, RHIA, CCS, CCDS, CPHM

Journal of AHIMA January 15/55

Coding Notes

CDI Tips Developed to Maximize


ICD-10-CM/PCS
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS; William E. Haik, MD, FCCP, CDIP; and Heidi Hillstrom, MS/HSA, MBA, RN, PHN, CCDS, CCS

CLINICAL DOCUMENTATION IMPROVEMENT (CDI) efforts


have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI
programs have a far-reaching impact on todays data-centric
healthcare system. When the appropriate level of detail is available in the documentation, the documentation is then able to
support codeswhether ICD-9-CM, soon-to-be-adopted ICD10-CM/PCS, or CPTthat paint the fullest picture possible of
the patient as well as the care and services provided.
The medical record is the source document and vehicle for
which the documentation is captured and housed. Understanding the medical record documentation components, meanings,
and uses are critical to any healthcare organization today, and
its translation to the coded data takes great expertise. Specific
and complete documentation enables coded data to tell the
true story of patient care.
With the implementation of ICD-10-CM/PCS, CDI has new
opportunities to bring together the specificity and details of the
patient encounter.

ICD-10 Calls for Increased CDI Efforts, Expertise


The implementation of ICD-10-CM/PCS, a code set that involves significantly greater detail than ICD-9-CM, will lead
to an increased need for the expertise of CDI specialists. Allotting a strong role for CDI in healthcare organizations will
ensure an accurate and complete medical record for data capture and reporting.
Clinical documentation improvement specialists must be able
to identify documentation deficiencies in order to assist physi56/Journal of AHIMA January 15

cians and medical providers in achieving documentation that


accurately reflects severity of illness, risk of mortality, quality,
core measures, and the physician quality reporting system.
One example of the expanded detail in ICD-10-CM involves
the diagnosis of respiratory failure. Providers will need to
specify whether the respiratory failure is acute or chronic and
document whether the condition is either hypoxemic or hypercapnic. Another example includes data reporting for drug
underdosing. Documentation should specify if the drug underdosing was intentional or done for other reasons, such as an inability to afford the medication or a potential lack of cognitive
ability to take the medication as prescribed.
As the healthcare industry ventures toward the implementation of ICD-10-CM, CDI professionals must be ready to identify
the level of documentation specificity that ICD-10-CM entails.
This documentation specificity will have an invaluable impact
on almost all entities in healthcare.

Workgroup Develops Library of CDI ICD-10 Tips


The AHIMA CDI Workgroupwhose members include clinicians, CDI professionals, and HIM coding professionalshas
created a large library of ICD-10-CM/PCS documentation tips
in response to the greater specificity needs of the new code set.
These tips, now available as the Clinical Documentation Improvement ICD-10-CM/PCS Documentation Tips paper posted in AHIMAs HIM Body of Knowledge at http://bok.ahima.
org/PdfView?oid=300621, focus on the language and/or wording that will garnish greater detail and specificity of the coded
data for a given diagnosis, condition, disease, and/or surgical

Coding Notes

Library of CDI ICD-10 Tips


THE CDI ICD-10-CM/PCS tips library, developed by AHIMAs CDI Workgroup, includes the following:
Systemic Infection/Inflammation
Meningitis
Herpes Simplex
Anemia
Nutritional Anemia
Coagulopathy
Purpura
Obesity
Alcohol, Tobacco & Substance
Use
Altered Mental Status
Glaucoma
Hearing Loss
CVA
Cardiac Arrest
Asthma
Crohns/Regional Enteritis
Hepatic Encephalopathy
Non-Pressure Ulcers
Pathologic Fractures
Scoliosis
Acute Renal Failure
Newborn
Cleft Palate

Fractures
Burns
External Cause
History (Personal and Family)
Retained Foreign Body
Reproduction Services
Body Mass Index
Surgical Complications
CABG*
Omentectomy*
Cleft Palate Repair*
Amputations*
Hepatitis
MRSA/MSSA
Neoplasms
Hemolytic Anemia
Aplastic Anemia
Pancytopenia
Diabetes
Malnutrition
Major Depressive Disorder
Cerebral Palsy
Otitis Media
Heart Failure

procedure. Going through each chapter of ICD-10-CM was the


initial focus of the workgroups efforts, with expansion into the
procedure coding system (PCS).
Utilizing a process of walking through the ICD-10-CM chapters, the workgroup divided up a series of documentation tips
that identify key and detailed language as well as terminology
in order to capture a specific ICD-10 diagnosis code or codes. In
addition, the workgroup developed documentation tips specific
to ICD-10-PCS.
The following are two examples from the more than 60 CDI
ICD-10 tips developed by the workgroup.

ICD-10-CM Example: Chronic Kidney Disease (CKD)

Myocardial Infarction
Respiratory Failure
Pneumonia
Appendicitis
Pressure Ulcers
Cellulitis
Gout
Chronic Kidney Disease
OB/Pregnancy
Congenital Foot Deformities
Coma
Gustilo Classification
Underdosing
Encounter For
Genetic Carrier
Contact With and Exposure To
Socioeconomic and Psychosocial
Circumstances
Mechanical Device Complications
Debridement*
Lymph Node Chains*
Lysis of Adhesions*
Spinal Fusion*
*Notes ICD-10-PCS topic.

ICD-10-PCS Example: Coronary Artery Bypass


Grafting (CABG)
Origination/Destination of graft(s)

-- E
 xamples: aorta to RCA, LIMA to LAD (indicate if
the LIMA was used as a pedicle graft)
Type of graft(s) used

-- Examples: autologous artery, autologous vein


Number of sites bypassed

-- Examples: one, two, three, or four or more


Excision of autologous graft

-- Identify the vessel


E xamples: greater/lesser saphenous vein
(left/right), radial artery (left/right)

Document the stage of CKD

-------

Chronic kidney disease, stage 1


Chronic kidney disease, stage 2 (mild)
Chronic kidney disease, stage 3 (moderate)
Chronic kidney disease, stage 4 (severe)
Chronic kidney disease, stage 5
End-stage renal disease (ESRD)

D
 ocument any underlying cause of CKD such as Diabetes
or Hypertension
Specify if the patient is dependent on Dialysis
Chronic renal failure without a documented stage will be
assigned to Chronic kidney disease, unspecified
Document any associated diagnoses/conditions

Clinical documentation improvement specialists can utilize


these ICD-10-CM tip sheets now, before ICD-10 is implemented
in October 2015, to identify documentation deficiencies in order
to provide documentation improvement education and feedback to medical providers. ICD-10-CM documentation requirements and guidelines can be incorporated into current documentation practices to facilitate the transition to ICD-10-CM.

A Clinicians Perspective
From a clinicians perspective, most of the current documentation requirements for ICD-9-CM will increase significantly following ICD-10-CM/PCS implementation. The documentation
Journal of AHIMA January 15/57

Coding Notes

of types of heart failure (systolic and/or diastolic), pneumonia


(etiologies/mechanism), or orthopedic fracture causes (pathological/traumatic), and other conditions will persist. With ICD10-CM, however, the expanded detail encompassed by the code
set will require additional documentation and specification in
such areas as asthma, respiratory failure, and the causes and the
types of fractures.
With inpatient procedure reporting, physicians are not responsible for knowing the specific definitions of the ICD-10-PCS
root operationsbut their documentation must be sufficiently
descriptive to allow for translation into ICD-10-PCS. Despite the
coders ability to translate detailed operative descriptions into
root operations, physician usage of eponyms such as Billroth I
or II, for example, are not indexed in ICD-10-PCS. Therefore, a
complete description of these procedures is critical.
There are a multitude of changes occurring simultaneously
within the current healthcare environment that demand physicians attention. Therefore, the CDI ICD-10-CM/PCS Documentation Tips paper offers a concise tool for physicians to
prepare themselves for the additional changes that await them
in the transition to ICD-10-PCS. This library of documentation
tips offers a straightforward overview of more specific and complete reporting requirements of the ICD-10-CM/PCS code sets.
Additionally, ICD-10-CM/PCS documentation requirements
and guidelines can be incorporated into current documentation practices to facilitate the transition to ICD-10. Collaboration between health information management represen-

Coding Compliance AuditsMS-DRG/APR-DRG/APC


HCC, LTAC, Pro-Fee, CVIR/IR
ICD-9/ICD-10 Dual Coding Reviews
Online ICD-9 and ICD-10 Tutorials
Denial Reviews and Appeals
HIM Interim Management
Remote Coding Support
Medical Necessity Reviews

tatives, CDI specialists, and clinicians will give healthcare


providers an advantage for a successful transition to the new
code sets.

References
Centers for Medicare and Medicaid Services. 2014 ICD-10PCS Code Tables and Index. www.cms.gov/Medicare/
Coding/ICD10/2014-ICD-10-PCS.html.
Centers for Medicare and Medicaid Services. ICD-10.
October 29, 2014. www.cms.gov/Medicare/Coding/ICD10/
index.html?redirect=/icd10.
National Center for Health Statistics. ICD-10-CM Index and
Tabular. 2014. www.cdc.gov/nchs/icd/icd10cm.htm.
Gloryanne Bryant (gloryanne.h.bryant@kp.org) is the national director,
coding quality, education, systems and support, national revenue cycle for
Kaiser Foundation Health Plan and Hospitals. William E. Haik (william.
haik@drgreview.com) is director at DRG Review. Heidi Hillstrom (heidi.
hillstrom@slhduluth.com) is a CDI specialist at St. Lukes Hospital based
in Duluth, MN.

Link
Materials Available Online

http://bok.ahima.org/PdfView?oid=300621

The Clinical Documentation Improvement ICD-10-CM/PCS Documentation Tips paper is available in AHIMAs HIM Body of Knowledge.

Focus On
Missed Revenue

Database Solutions For the Ever-Changing Audit Environment

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58/Journal of AHIMA January 15

For years AHIMA has been


committed to making the
transition to ICD-10 as smooth,
efficient, and easy as possible.
Leverage AHIMAs wellestablished ICD-10
expertise and knowledge
during your transition.

Meetings
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These workshops are designed for those who already have ICD-10-PCS
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2015 Dates
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For additional details, visit ahima.org/events.

Online Education
AHIMA Learning Opportunities with CEUs include:
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Special offer bundles and corporate programs help stretch budget dollars
for comprehensive training solutions. For more information, visit ahima.org/
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Webinars
For one low price you and any number of your peers can benefit from reliable
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Topics include:
Beyond the Root Operations: Taking a Deeper Dive into ICD-10-PCS
Coding | January 15
ICD-10 Readiness and TestingGet ReadyAgain | January 22
ICD-10-CM/PCS History and Guidelines A to Z | January 29
ICD-10-CM Coding for Inpatient Rehab Facilities | February 3
ICD-10-CM Coding: Symptoms, Signs, Abnormal Clinical and Laboratory
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Books
ICD-9-CM Code Book,
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ISBN: 9781584264385
AHIMA 2014
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ICD-10-CM Code Book ,
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ISBN: 9781584264392
AHIMA 2014
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Coding, 2015 Edition
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Coding Notes

GEMs: Buyers Beware


CROSSWALK AND TRANSLATION TOOLS
CAN BRING UNEXPECTED RISKS
By Diana Reed, RHIT, CCS-P

WHEN IT COMES to converting superbills and claims from


ICD-9-CM to ICD-10-CM, many healthcare providers believe
that general equivalence mappings (GEMs) offer a cost effective
and simple solution. The ability to purchase relatively cheap automated mappings of specialties top codes contributes to this
sense of security. The mappings are often marketed using terms
such as translation tools or crosswalks. Mappings are useful
tools, but it is important that healthcare providers are also advised of the tools limitations.
Mapping simply provides a linkage between a code in one set
and its closest equivalent in the other code set without consideration of context or specific patient encounter information,
whereas coding involves assigning the most appropriate code
based on health record documentation, knowledge of other
codes in the medical record, and applicable coding guidelines.1
GEMs are not a catch-all solution for physician practices, and
offer a limited scope of use, according to guidance issued by the
Centers for Medicare and Medicaid Services (CMS). Once ICD10 is implemented, GEMs will be of limited use to most physician practices and may not be appropriate since coding should
occur directly to ICD-10 based on actual clinical documentation, rather than mapping from existing ICD-9 codes. In some
instances, GEMs can be helpful in validating ones coding practices to help identify some codes in ICD-10 relative to existing
ICD-9 codes for the purpose of training and validation.2
Simply put, mappings, crosswalks, or translation tools require
human intervention for validationand they do not substitute
for learning the new code set.

60/Journal of AHIMA January 15

GEMs Alone Cannot Replace Validation, Education


The following is an example of how crosswalks or translation
guides can be problematic when purchased with no further
plans for validation or education.
A gastroenterology practices providers were convinced that a
purchased crosswalk was all they needed for ICD-10-CM implementation. Their business office assured the providers that they
had things under control. But one employee was not so convinced after attending an ICD-10 Basics presentation and sought
further options for the practice. An AHIMA credentialed coding
consultant was contacted for specialty specific coding education. The consultant requested a list of the practices 30 most
common codes. Instead, the practice provided the consultant
with a copy of their purchased crosswalk and the national top
gastroenterology codes. Problems associated with depending on
mass-produced specialty specific crosswalks without validation
and training were obvious.

ICD-9-CM Inclusion Term not Crosswalked to ICD-10-CM


Subcategory Code
Code 535.10, Atrophic gastritis, without mention of hemorrhage
in ICD-9-CM was crosswalked to code K29.40, Chronic atrophic gastritis without bleeding in ICD-10-CM. But experienced
coders know that code 535.1- is also used for Chronic gastritis,
not otherwise stated. That is because chronic gastritis is listed
as an inclusion term under code 535.1-. No consideration was
given to this inclusion term. There is a new subcategory for this
condition in ICD-10-CM: K29.50, Unspecified chronic gastritis
without bleeding. The table on page 61 demonstrates how ICD-

Coding Notes

Table 1: Crosswalking Chronic Gastritis from ICD-9-CM to ICD-10-CM


THIS TABLE DEMONSTRATES how ICD-10-CM has revised the coding for chronic gastritis. Terms in parentheses are nonessential modifiers.

Alphabetic Index
ICD-9-CM

ICD-10-CM

Gastritis

Gastritis

Atrophic

535.1-

Atrophic (chronic)

K29.4-

Chronic
(atrophic)

535.1-

Chronic (antral)
(fundal)

K29.5-

Atrophic

K29.4-

Tabular List
ICD-9-CM
535.10

ICD-10-CM
Atrophic gastritis without
mention of hemorrhage
Atrophic-hyperplastic
gastritis and Chronic
(atrophic) gastritis are
listed as inclusion terms
for 535.10 and 535.11.

K29.40

Chronic atrophic gastritis without bleeding


Gastric atrophy is listed as an inclusion term for K29.40 and K29.41

K29.50

Unspecified chronic gastritis without bleeding


Chronic antral gastritis and Chronic fundal gastritis are listed as inclusion terms for K29.50 and K29.51

10-CM has revised the coding for chronic gastritis.


Chronic gastritis can be either atrophic or non-atrophic.3
ICD-10-CM, with its increased data granularity, takes into account this difference with a separate code for Chronic gastritis,
not otherwise stated. Non-specific chronic gastritis should not
be confused with Chronic superficial gastritis (K29.3-) which
causes pathological changes limited to the upper one-third of
the mucosa, or Chronic atrophic gastritis (K29.4-) which involves the full thickness of the mucosa, producing atrophy of
gastric glands with loss of cells.
Education is essential in the course of validating a practices
ICD-9 to ICD-10 crosswalk. Definitions of chronic gastritis
should be discussed and providers advised to include the type
in the record documentation. And although the crosswalk does
not address it, providers should also be aware of the need to assign an additional code for Helicobacter pylori when gastritis is
caused by that organism.

Missed New Subcategory Code


As any experienced gastroenterology coder knows, patients frequently receive diagnostic colonoscopies for a complaint of a
change in bowel habits. In ICD-9-CM there is not a specific code
for this condition. Code 787.99, Other symptoms involving the
digestive system is assigned. Change in bowel habits is listed
as an inclusion term in the tabular list under code 787.99. The
purchased crosswalk showed 787.99 mapped to the ICD-10-CM
code R19.8, Other specified symptoms and signs involving the
digestive system and abdomen. Although this is a correct direct

translation, the inclusion term change in bowel habits was ignored. There is actually a new code in ICD-10-CM for this condition, R19.4.

Missed Documentation Improvement Training Opportunity


Code 455.0, Internal hemorrhoids without complication, was
appropriately crosswalked to six potential ICD-10-CM codes.
Four of the codes are structured clinically and providers are now
able to designate the grade/degree of severity of hemorrhoids.
The other two codes are for other and unspecified. Reviewing
these codes with providers presents an opportunity to discuss
new documentation requirements and the importance of capturing severity levels.

Potential for Coding Convention Violations


Code 558.9, Other and unspecified noninfectious gastroenteritis and colitis was crosswalked to two ICD-10 codes, one
for other specified condition and one for unspecified. Coding
conventions state that other or other specified codes are for
use when the information in the health record provides detail
for which a specific code does not exist. How would a provider
know that a code does not exist for a specific condition unless
they were aware of all options?
Specific codes not presented as options on the crosswalk include K52.1, Toxic gastroenteritis and colitis; K52.0, Gastroenteritis and colitis due to radiation; K52.2, Allergic and dietetic
gastroenteritis and colitis; K52.81, Eosinophilic gastritis or gastroenteritis; and K52.82, Eosinophilic colitis.
Journal of AHIMA January 15/61

Coding Notes

Examples Highlight Need for Crosswalk Validation


These are just a few examples of the problems that arise from
an overreliance on GEMs to carry a practice through the transition to ICD-10-CM. The importance of validation of purchased
crosswalks and related training cannot be over-emphasized.
The caveat for healthcare providers is that there is no simple
crosswalk from ICD-9 to ICD-10 in the GEM files. GEMs may
provide a good starting point, but more intelligence is needed
for review and clarification. Training is essential for the ICD-9
to ICD-10 conversion. According to CMS, the state Medicaid
program, and AHIMA, providers should code natively, which
requires learning the ICD-10-CM code set and coding guidelines. Crosswalks or translation tools derived from GEMs are
not a substitutefor this education and training nor are they an
efficient solution when used alone.

Notes
1. AHIMA. Putting the ICD-10-CM/PCS GEMs into
Practice. May 2013. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050190.
hcsp?dDocName=bok1_050190.

Journal of AHIMA Continuing Education Quiz


Quiz ID: Q1538601 | EXPIRATION DATE: JANUARY 1, 2016
HIM Domain Area: Clinical Data Management
ArticleGEMs: Buyers Beware

2. Centers for Medicare and Medicaid Services. ICD-10


Implementation Guide for Small and Medium Practices.
October 2011. www.cms.gov/Medicare/Coding/ICD10/
downloads/ICD10SmallandMediumPractices508.pdf.
3. Rugge, Massimo and Robert M. Genta. Staging and grading of chronic gastritis. Human Pathology 36 (2005):
228-233. http://pathinformatics.com/department/documents/ChronicGastritis.pdf.

References
Centers for Disease Control and Prevention. International
Classification of Diseases, Ninth Revision, Clinical
Modification,
(ICD-9-CM).
www.cdc.gov/nchs/icd/
icd9cm.htm.
Centers for Disease Control and Prevention. International
Classification of Diseases, Tenth Revision, Clinical
Modification
(ICD-10-CM).
www.cdc.gov/nchs/icd/
icd10cm.htm.
Diana Reed (him.consulting@cox.net) is a consultant with Health Information Strategies.

TAKE THE QUIZ AT WWW.AHIMASTORE.ORG


NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED

REFER TO THE ARTICLE for the one best answer to each question. Questions are based solely on the content of the article.
1. GEMs mapping can take the place of coding when ICD-10-CM/PCS
is implemented.

a. true

b. false
2. Mappings, crosswalks, or translation tools require
for validation.

a. no knowledge of the new code set

b. human intervention

c. an untrained user

d. none of the above
3. The correct code for unspecified chronic gastritis without bleeding
in ICD-10-CM is:

a. K29.40, Chronic atrophic gastritis without bleeding

b. K29.50, Unspecified chronic gastritis without bleeding

c. K29.70, Gastritis (simple)

d. K29.71, Gastritis with bleeding
4. Chronic superficial gastritis:

a. involves the full thickness of the mucosa producing atrophy of
gastric glands with loss of cells

b. leads to atresia of esophagus

c. causes molecular changes of the lining of the esophagus

d. causes pathological changes limited to the upper one-third of
the mucosa
5. There is an ICD-10-CM code for change in bowel habits (R19.4).

a. true

b. false

6. In the example of the gastroenterology crosswalk ICD-9-CM Code


558.9, Other and unspecified noninfectious gastroenteritis and
colitis was crosswalked to how many ICD-10-CM codes?

a. four codes

b. three codes

c. two codes

d. one code
7. Coding conventions state that other or other specified codes
are for use when:

a. the information in the medical record does not provide enough
detail for a specific code selection

b. the information in the medical record provides detail for which
a specific code does not exist

c. used in conjunction with an underlying condition code and
they must be listed following the underlying condition

d. there is not a coding convention that addresses this topic
8. Providers are NOT able to designate the grade/degree of severity
of hemorrhoids in ICD-10-CM.

a. true

b. false
9. Reviewing codes with providers:

a. presents an opportunity to discuss new documentation
requirements and the importance of capturing severity levels

b. will not impact code selection and will not impact severity
levels

c. is not a good idea

d. is best done after claim submission
10. According to CMS, the States Medicaid Program, and AHIMA,
providers should code natively, which requires learning the ICD10-CM code set and coding guidelines.

a. true

b. false

62/Journal of AHIMA January 15

Information Governance Is a Strategic


Imperative for the Future of Healthcare.
Information Governance (IG) in healthcare is critical to meeting the triple aim of quality care for the
individual, population health, and lowering the per capita cost of healthcare. IG is also critical to ensuring
healthcare information can be trusted.
As the leader in health information management (HIM) for over 85 years, IG for healthcare is well
aligned with AHIMAs strategic initiatives.

Prepare for the future of IG with materials and resources from AHIMA.
ayout
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Information Governance Benchmarking White Paper


The survey and resulting white paper is the first IG for healthcare white paper
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of your organizations IG program.

Information Governance Principles for Healthcare (IGPHC)

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PUBLICATIONS

Implementing Health Information


Governance: Lessons from the Field
Linda Kloss, MA, RHIA, FAHIMA
This book outlines lessons from healthcare organizations
that have already made progress in formalizing IG. It offers
tested practices for aligning governance to the organizations goals,
building on what is working and guiding incremental improvement.
PRICE: $59.95 | MEMBER PRICE: $49.95
Product Number: AB100213

A TIMELY, ALL-NEW GUIDE FOR AN ALL-NEW FIELD!

Order your copy at ahimastore.org.


MX10270

Calendar

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

11

12

13

14

THURSDAY

FRIDAY

SATURDAY

10

15

16

17

23

24

WEBINAR:

Beyond
the Root
Operations:
Taking a Deeper
Dive into ICD10-PCS Coding
Advanced ICD-10-PCS Skills Workshop,
El Segundo, CA

18

19

20

21

22

WEBINAR: ICD-

10 Readiness
and Testing
Get Ready
Again

25

26

27

28

29

WEBINAR:

WEBINAR:

The Electronic
Health Record
as Electronically
Stored
Information:
Preservation
of ESI for
Litigation
Purposes

ICD-10-CM/
PCS History and
Guidelines from
A to Z

30

Advanced ICD-10-PCS Skills Workshop,


Houston, TX

AHIMA Annual Convention


2016 Baltimore, MD
October 15-20

64/Journal of AHIMA January 15

A Look Ahead

Keep Informed

FEBRUARY

CSA Engage Contest Winners Honored for


Outstanding Participation

Upcoming AHIMA Institutes, Seminars, Workshops,


and Webinars

Webinar: ICD-10-CM Coding for Inpatient Rehab


Facilities

Webinar: ICD-10-CM Coding: Symptoms, Signs,


Abnormal Clinical and Laboratory Findings

10

Webinar: Deep Dive: Concepts, Root Operations


and Body Systems in ICD-10-PCS Sections 1-5

11-13

Advanced ICD-10-PCS Skills Workshop, Atlanta,


GA

12

Webinar: How a Mock Audit Can Identify Gaps in


Preparedness

25-27

Advanced ICD-10-PCS Skills Workshop, Miami, FL

UPCOMING INSTITUTES, SEMINARS,


WORKSHOPS, AND WEBINARS
March 4-6

Advanced ICD-10-PCS Skills Workshop, Morrisville


(Raleigh), NC

March 16-17 CDIP Exam Prep Workshop, Chicago, IL


March 19

Webinar: Using CDI Programs to Improve Quality


Reporting

March 23-24 Leadership Advocacy Symposium and Hill Day,


Washington, DC
May 14-15

Faculty Development Regional Meeting,


Tacoma, WA

June 4-5

Faculty Development Regional Meeting, Miami, FL

June 18-19

Faculty Development Regional Meeting,


Wilmington, DE

June 21-23

Long-Term and Post-Acute Care Health IT Summit,


Baltimore, MD

June 25-26

Faculty Development Regional Meeting,


Minneapolis, MN

July 10-11

Leadership Symposium, Chicago, IL

July 18-22

Faculty Development Institute/Assembly on


Education Symposium, Austin, TX

August 6-7

Clinical Documentation Improvement Summit,


Alexandria, VA

September
26-27

Annual Clinical Coding Meeting, New Orleans, LA

September
26-27

Privacy and Security Institute, New Orleans, LA

Check www.ahima.org/events for the latest schedule of


institutes, seminars, and workshops.

Resources and News from AHIMA

Two Engage contests for AHIMAs component state


associations (CSAs) took place from October 1
through November 15, 2014, designed to encourage CSA members to explore how to get the most
out of the AHIMA social media site. The AHIMA volunteer leadership development team would like to
thank all the CSAs who participated in this contest.
The winners of each contest receive a $150 AmEx
gift card and recognition in AHIMA publications.
Members can visit http://engage.ahima.org to
network and communicate with other HIM professionals and AHIMA members.

The Engage Joinboree


The Engage Joinboree contest challenged CSAs to
increase the percentage of members in their CSAs
Engage community. The CSA that increased the
number of members in their CSA Engage community by the greatest percentage was Hawaii. The
AHIMA volunteer leadership development team
would like to congratulate the Hawaii CSA on their
accomplishment.

The Engage Post-a-Thon


The Engage Post-A-Thon contest challenged CSA
members to increase their engagement, as measured by unique discussion posts and library items
in their CSAs Engage community. The CSA that
increased their engagement on their CSA Engage
community by the highest percentage was West
Virginia. The volunteer leadership development
team would like to congratulate the West Virginia
CSA on their accomplishment.

CE Quizzes Now Only Available Online


As of January 1, 2015, mailed-in paper CE quizzes taken out of the print Journal of AHIMA will no
longer be accepted. CE quizzes will only be administered online at www.ahimastore.org. Journal
of AHIMA will continue to publish the quiz questions with their corresponding article as a courtesy
through the March 2015 issue, but these will not be
accepted if mailed in. Starting with the April 2015
issue a box will be included at the end of select
articles that points readers to the online version of
the quiz, available in the AHIMA Store. The Table
of Contents will also note which articles include an
online quiz.

AHIMA Volunteer Leaders

AHIMA BOARD OF DIRECTORS


President/Chair
Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
Senior Vice President of Health Information
Management and Consulting,
Peak Health Solutions, Inc.
San Diego, CA
(858) 746-7298
cassi.birnbaum@ahima.org
President/Chair-elect
Melissa M. Martin, RHIA, CCS, CHTS-IM
Chief Privacy Officer and Director of Health
Information Management, West Virginia
University Hospitals
Morgantown, WV
(304) 598-4109 x73716
martinme@wvuhealthcare.com
Speaker of the House of Delegates
Laura W. Pait, RHIA, CDIP, CCS
Pfafftown, NC
lwpait@aol.com

TERM ENDS 2015DIRECTORS


Dana C. McWay, JD, RHIA
Court Executive/Clerk of Court, US Bankruptcy
Court for the Eastern District of Missouri
(314) 244-4600
danahimlaw@aol.com
Treasurer
Susan J. Carey, RHIT, PMP
System Director, HIM, Norton Healthcare
Louisville, KY
(502) 629-8913
susan.carey@nortonhealthcare.org
Cindy Zak, MS, RHIA, PMP, FAHIMA
Executive Director Corporate HIM,
Yale New Haven Health System
Woodbridge, CT
(203) 688-5466
cindy.zak@ynhh.org

TERM ENDS 2016DIRECTORS


Zinethia L. Clemmons, MBA, MHA, RHIA, PMP
Senior Health Information Privacy Specialist,
Department of Health and Human Services/OCR
Washington, DC
(202) 495-0533
zinethia.clemmons@hhs.gov
Secretary
Ginna E. Evans, MBA, RHIA, FAHIMA
Business Analyst, Revenue Cycle Development,
Emory Healthcare
Avondale Estates, GA
(404) 778-7960
ginna.evans@emoryhealthcare.org
Colleen A. Goethals, MS, RHIA, FAHIMA
HIM Consultant, Cardone Record Services, Inc.
Belvidere, IL
(815) 378-2632
cgoethals@mmrainc.com
TERM ENDS 2017DIRECTORS
Barbara J. Manor, MA, RHIA
Vice President of HIM, SCL Health
Aurora, CO
(303) 403-7511
barbara.manor@sclhs.net

CEO, AHIMA
Lynne Thomas Gordon, MBA, RHIA, CAE,
FACHE, FAHIMA
Chicago, IL
(312) 233-1165
lynne.thomasgordon@ahima.org

Laura W. Pait, RHIA, CDIP, CCS


Pfafftown, NC
lwpait@aol.com
Dwan A. Thomas-Flowers, MBA, RHIA, CCS
Temporary Projects, HIM Operations, First Class
Solutions, Inc.
Jacksonville, FL
(904) 220-2486
HIMprofexcel@bellsouth.net
Susan E. White, PhD, RHIA, CHDA
Associate Professor, Clinical HRS HIM and
Systems Division, School of Health and
Rehabilitation Sciences, Ohio State University
(614) 247-2495
Columbus, OH
white.2@osu.edu
Advisor to the Board
David S. Muntz, CHCIO, FCHIME, LCHIME,
FHIMSS
Senior Vice President/CIO, GetWellNetwork
Bethesda, MD
(240) 482-3192
david.muntz@getwellnetwork.com

2015 CHAIRS OF AHIMA VOLUNTEER GROUPS


AHIMA Grace Awards Committee
Ann F. Chenoweth, MBA, RHIA
(801) 712-4537
afchenoweth@mmm.com

Engage Advisory Committee


Thomas J. Hunt, MBA, RHIA
(989) 725-8279
thunt@davenport.edu

Nominating Committee
Jill A. Finkelstein, MBA, RHIA, CHTS-TR
(954) 418-0938
jfinkelstein@browardhealth.org

State Advocacy Council


Debra K. Primeau, MA, RHIA, FAHIMA
(310) 617-0042
dprimeau@primeauconsultinggroup.com

AHIMA Triumph Awards Committee


Judith A. Gizinski, RHIA, MPH
(321) 757-5226
judy.gizinski@health-first.org

Exhibit Advisory Committee


Julie W. Clark
(770) 205-6198
jclark@creativelyclark.com

Virtual Lab Strategic Advisory Committee


John Richey, MBA, RHIA
(419) 447-9352
richey@findlay.edu

Annual Convention Program Committee


Kimberly D. Theodos, JD, MS, RHIA
(318) 257-2854
ktheodos@latech.edu

Fellowship Review Committee


Mona Y. Calhoun, MEd, MS, RHIA, FAHIMA
(301) 352-0304
mcalhoun@coppin.edu

Professional Ethics Committee


Rose T. Dunn, MBA, CPA, RHIA, CHPS, FAHIMA,
FACHE
(314) 209-7800
Rose.Dunn@FirstClassSolutions.com

2015 CHAIRS OF AFFILIATE VOLUNTEER GROUPS


AHIMA Foundation
Warren A. Jones, MD, FAAFP
(312) 233-1131
drwajones@bellsouth.net

Commission on Accreditation for


Health Informatics and Information
Management Education
Mervat Abdelhak, PhD, RHIA, FAHIMA
(312) 233-1548
info@cahiim.org

Commission on Certification for Health


Informatics and Information Management
Kay Merriweather, RHIA, CHDA, CDIP, CCS,
CCS-P, CPC-H
(404) 849-0459
wdmerr@earthlink.net

Council for Excellence in Education


Ellen Karl, MBA, RHIA, CHDA, FAHIMA
(646) 344-7324
ellen.karl@cuny.edu

Envisioning Collaborative
Laura W. Pait, RHIA, CDIP, CCS
(336) 946-1750
lpait@novanthealth.org

House Leadership
Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
edelahoussaye@iodincorporated.com

Judi G. Hofman, CHPS, BCRT, CAP, CHSS,


H-CAP
(541) 706-7760
jhofman@stcharleshealthcare.org

Susie L. James, RHIT, CCS


(205) 941-1105
sjames@mmplusinc.com

20152016 HOUSE OF DELEGATES


Speaker of the House of Delegates
Laura W. Pait, RHIA, CDIP, CCS
(336) 946-1750
lpait@novanthealth.org

Speaker-elect of the House of Delegates


Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
edelahoussaye@iodincorporated.com

2015 PRACTICE COUNCIL VOLUNTEER CONTACTS


Clinical Terminology & Classification
Cheryl Gregg Fahrenholz, RHIA, CCS-P
(937) 848-6080
Cheryl@phs4you.com

Enterprise Information Management


Kathleen Addison
(403) 943-0940
kathleen.addison@albertahealthservices.ca

Health Information Exchange


Neysa I. Noreen, RHIA
(507) 645-0715
neysa.noreen@childrensmn.org

Gail Garrett, RHIT


(615) 344-6247
Gail.Garrett@HCAHealthcare.com

Sharon Slivochka, RHIA


(440) 937-5532
sks622@roadrunner.com

Katherine Lusk, MHSM, RHIA


(214) 456-8576
Katherine.Lusk@childrens.com

Privacy and Security


Sharon Lewis, MBA, RHIA, CHPS, CPHQ,
FAHIMA
(805) 542-0160
sharonlewisrhia@att.net
Deanna Peterson, MHA, RHIA, CHPS
(314) 209-7800
Deanna.Peterson@firstclasssolutions.com

AHIMA volunteers also make valuable contributions as facilitators for Engage Online Communities. To locate the facilitator(s), go to a particular community, click on the Members tab, then click on the
community administrator link.

66/Journal of AHIMA January 15

AHIMA Volunteer Leaders

COMPONENT STATE ASSOCIATION PRESIDENTS


Alabama
Sharon Horton-Woodruff, RHIT
Cullman, AL
(256) 352-8337
sharon.horton@wallacestate.edu

Indiana
Deborah Grider, CDIP, CCS-P
McCordsville, IN
(317) 908-5992
deborahgrider@mac.com

Nevada
Gregory Schultz, RHIA
North Las Vegas, NV
(702) 526-8361
gschultz00@aol.com

South Dakota
Sheila Hargens, MSHI, CMT
Parkston, SD
(605) 928-3741
sheila.hargens@avera.org

Alaska
Janie Batres, RHIA, CDIP
Anchorage, AK
(907) 252-7228
janieleigh44@hotmail.com

Iowa
Mari Beth Schneider Lane, MS, RHIA
Sheldon, IA
(712) 324-5061
mlane@nwicc.edu

New Hampshire
Jean Wolf, RHIT, CHP
Gorham, NH
(603) 466-5406
jean.wolf@avhnh.org

Tennessee
Lela McFerrin, RHIA
Chattanooga, TN
(423) 493-1637
lela.mcferrin@hcahealthcare.com

Arizona
Christine Steigerwald, RHIA
Gilbert, AZ
(480) 292-8293
Christine.Steigerwald@bannerhealth.com

Kansas
Julie Hatesohl, RHIA
Junction City, KS
(785) 210-3498
phoebehat@cox.net

New Jersey
Carolyn Magnotta, RHIA
New Egypt, NJ
(609) 758-8890
magnottac@deborah.org

Texas
Terri Frnka, RHIT
Bryan, TX
terrifrnka@yahoo.com

Arkansas
Marilynn Frazier, RHIA, CHPS
Ozark, AR
(479) 667-5153
mfrazier@ftsm.mercy.net

Kentucky
Diba Thakali, RHIA
Lexington, KY
(859) 979-3049
diba.thakali@bhsi.com

New Mexico
Vicki Delgado, RHIT
Albuquerque, NM
(505) 948-6711
vicki.delgado@kindredhealthcare.com

California
Shirley Lewis, RHIA, DPA, CCS, CPHQ
Upland, CA
(909) 608-7657
shirley.lewis5@verizon.net

Louisiana
Lisa Delhomme, MHA, RHIA
Rayne, LA
(337) 277-5544
delhomme@louisiana.edu

New York
Sandra Macica, RHIA
Saratoga Springs, NY
(518) 584-0389
s.macica@elsevier.com

Colorado
Melinda Patten, CDIP, CHPS
Aurora, CO
(720) 777-6657
melinda.patten@childrenscolorado.org

Maine
Nora Brennen, RHIT
Topsham, ME
(207) 751-1853
Nora.Brennen@va.gov

North Carolina
Jolene Jarrell, RHIA, CCS
Apex, NC
jolene@drgreview.com

Connecticut
Elizabeth A. Taylor, MS, RHIT
East Hartford, CT
(860) 364-4417
liz.taylor@sharonhospital.com

Maryland
Sarah Allinson, RHIA
Baltimore, MD
(410) 499-7281
sarahballinson@gmail.com

Delaware
Marion Gentul, RHIA, CCS
Lewes, DE
(302) 827-1098
mgs60mga@yahoo.com

Massachusetts
Walter Houlihan, MBA, RHIA, CCS
Springfield, MA
(413) 322-4309
Walter.Houlihan@bhs.org

District of Columbia
Jeanne Mansell, RHIT, CHTS-CP, CHTS-PW,
CHTS-IM, CHTS-IS, CHTS-TS, CHTS-TR
Washington, DC
(202) 421-5172
jeanne87@hotmail.com

Michigan
Thomas Hunt, RHIA
Owosso, MI
(989) 725-8279
thunt@davenport.edu

Florida
Anita Doupnik, RHIA
Tampa, FL
(813) 907-9380
anita.doupnik@nuance.com

Minnesota
Jean MacDonell, RHIA
Grand Rapids, MN
(612) 719-3697
jean.macdonell@granditasca.org

Georgia
Allyson Welsh, MHA/INF
Decatur, GA
Allysonwelsh@gmail.com

Mississippi
Phyllis Spiers, RHIT
Carriere, MS
(601) 347-6318
pspiers@forrestgeneral.com

Hawaii
Marlisa Coloso, RHIA, CCS
Wailuku, HI
(808) 442-5509
mcoloso@hhsc.org

Missouri
Angela Talton, RHIA, CCS
Florissant, MO
(314) 276-4180
afranks@swbell.net

Idaho
Mona P. Doan, RHIT, CCS-P
Boise, ID
(208) 484-7076
monadoan@hotmail.com

Montana
Vicki Willcut, RHIA
Kalispell, MT
(406) 756-4758
vwillcut@krmc.org

Illinois
Teresa Phillips, RHIA
Effingham, IL
(217) 347-2806
teri.phillips@hshs.org

Nebraska
Shirley Carmichael, RHIT
Fairbury, NE
(402) 729-6854
shirley.carmichael@jchc.us

Utah
Vickie Griffin, RHIT, CCS
Bountiful, UT
vickie.griffin@Parallon.com
Vermont
Charmaine S. Vinton, RHIT, CCS, CPC
West Chesterfield, NH
(603) 357-0170
cvinto@bmhvt.org
Virginia
Darcell Campbell, RHIA
Hampton, VA
(757) 788-0052
DACampbell@cox.net

North Dakota
Tracey Regimbal, RHIT
Grand Forks, ND
traceyregimbal@hotmail.com

Washington
Sheryl Rose, RHIT
Spokane, WA
(509) 624-4109
sherylrose622@hotmail.com

Ohio
Pamela Greenstone, MEd, RHIA
Mason, OH
(513) 403-9014
Pamela.Greenstone@uc.edu

West Virgnia
Kathy Johnson, RHIA
Sinks Grove, WV
(304) 772-5312
kjohnson@care-communications.com

Oklahoma
Christy Hileman, MBA, RHIA, CCS
Mustang, OK
(405) 954-2824
christy.hileman@faa.gov

Wisconsin
Susan Casperson, RHIT
Cecil, WI
(715) 853-1370
susan.casperson@thedacare.org

Oregon
William Watkins, RHIA
Oregon City, OR
(503) 867-5173
william.w.watkins@kp.org

Wyoming
Kimberle Johnson, RHIA
Gillette, WY
(307) 682-1251
kim.johnson@ccmh.net

Pennsylvania
Laurine Johnson, MS, RHIA, FAHIMA
Sarver, PA
(724) 295-9429
ljohnson@peakhs.com
Puerto Rico
Yanet Soto, RHIA
Arecibo, PR
(787) 879-2835
ysoto@wilmamed.com
Rhode Island
Patti Nenna, RHIT
Bristol, RI
(401) 253-1686
pnenna@cox.net
South Carolina
Karen B. Farmer, RHIT
Greenville, SC
(864) 277-1982
kfarmer@ghs.org

E-mail changes to your listing to journal@ahima.org


Journal of AHIMA January 15/67

13.QC.2371_1_13.QC.2371_1 7/8/13 12:14 PM Page 1

Delivering
quality-focused
people, responses
and results.

Advertising Index
AHIMA........................................................... 18, 59, 63, 69

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AHIMA Thanks Its Loyalty Program Members


EXECUTIVE LEVEL

Caban Resources, LLC................................................... 25

Channel Publishing.........................................................30

Elsevier Clinical Solutions...............................................36

HCPro.............................................................................. 51

Health Information Associates................inside front cover

Healthcare Cost Solutions.............................................. 58

HealthPort....................................................................... 11

In Record Time, Inc........................................................... 5

Just Associates, Inc........................................................ 29

MedData, Inc..................................................... back cover

DIRECTOR LEVEL

MRO.................................................................................. 1

Perry Johnson & Associates, Inc.................................... 35

MANAGER LEVEL
QualCode, Inc.................................................................68

Textware Solutions-Instant Text..................................... 49

68/Journal of AHIMA January 15

AHIMA Advantage
is Now Mobile!
Download the AHIMA Advantage mobile app
to your Apple or Android device and read the
newsletter on the go at your convenience.

MX9937A

AHIMA Career Center


For classified advertising information,
call Emily Leahy: 410-584-1961 | e-mail:
eleahy@networkmediapartners.com

Exclusively Specializing
in HIM for
almost 25 years!
We assist both
job seekers and employers
in the following specialties:
Executive Level | Consultants
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Directors | Managers | Vendors

Certified Coders
Join our team! Ivinson offers competitive
salaries, a generous benefits package and a
great team environment!
For more information or to apply, visit our
website at www.ivinsonhospital.org or
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Nestled in the foothills of the Snowy Range
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Contact us in confidence:
Doug Ellie or
Perry Ellie, MA, RHIA, Fellow AHIMA

While the ads in this section are deemed to


be from reputable sources, the publisher
accepts no responsibility for the offers made.
All copy must conform to equal employment
opportunity guidelines, and the publisher
reserves the right to reject, withdraw, or
modify copy. A current rate card is available
on request.

Advertise in
the AHIMA
Career Center!
Contact Emily Leahy at 410-584-1961

Careers@HIMjobs.com
800-248-6989

70/Journal
15
70
/ Journal of AHIMA January 1
5

or eleahy@networkmediapartners.com
255 N. 30TH ST. LARAMIE, WY 82072
(307) 742-2141 | www.ivinsonhospital.org
Ivinson Memorial Hospital is an equal opportunity employer.

The Future is Now Remote Coding


When youre a coder at NewYork-Presbyterian, cases are like jigsaw puzzles that take your best
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Lauren, CCS, Coder, NewYork-Presbyterian/Weill Cornell

As the world of hospital medical record coding changes with the implementation of ICD-10 and technology advances,
NewYork-Presbyterian is ahead of our peers in rewarding our HIM and Documentation Improvement professionals.
From remote coding, new and highly competitive compensation, to fexible scheduling, training and development as
well as employee health and well-being were implementing initiatives that inspire excellence each and every day.
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Journal
Journal of
of AHIMA
AHIMA January
January 15/71
15 / 71

This is Going on Your


Permanent Record
HIPAA and the Right To Be Forgotten

TO MANY AMERICAN TECHNOLOGY OBSERVERS, courts in Japan and the European Union could be setting a controversial precedent in a series of rulings regarding the the right to be forgotten.
Courts in these jurisdictions have ruled against Google and Yahoo and in favor of
individuals that want the ability to request that search engines remove search results
that link to unsavorytrue or allegedpast behaviors. In early October, a Japanese court
ruled that Google must remove search results that tied a man to perceived associations
with criminal organizations. The individual said Google results associated with his name
violated his privacy and his right to be forgotten, according to the Associated Press.
Similarly, CTV News recently reported that a European Union official has proposed to
codify the right to be forgotten for citizens who demand the removal of personal
data from the Internet if theres no legitimate reason for keeping the material online.
As quoted in the New Yorker, Jennifer Granick, the director of civil liberties at the
Stanford Center for Internet and Society, said Europeans think of the right
to privacy as a fundamental human right, in the way that we think of
freedom of expression or the right to counsel When it comes to
privacy, the United States approach has been to provide protection for certain categories of information that are deemed
sensitive and then impose some obligation not to disclose
unless certain conditions are met. One of those categories
is health information, though healthcare organizations
wont honor a patients request to be forgotten when it
comes to their medical records. As a general rule, HIM
departments will refuse a patients request to delete
their records. Doing so would put the organization at
risk should the records be requested by a court of law,
HIM experts say, or should a patient suffer injury at the
hands of a provider due to the missing records.
Indeed, HIPAA is intended to make it very difficult
for a patients health information to become available
without their consent. But there are instances when
health information can be released without patient
consent. Releases to health plans for payment or insurance investigations, for example, are out of patients
hands. Courts can order the release of records. Also,
law enforcement can access an individuals protected
health information (PHI) if its relevant to an investigation, though they must do so through the proper channels. For example, if there is a bioterrorism threat or an
emergency, covered entities can be compelled by law enforcement to release relevant portions of a health record.
While recent updates to HIPAA through the HITECHHIPAA Omnibus Final Rule allow individuals to request
that procedures paid for out-of-pocket remain undisclosed
to their health plan, the same update allowed healthcare
providers to freely release the records of patients 50 years
after they die without consent. While the right to be forgotten may further define the lines of an individuals privacy
around the world, US residents can (hopefully) rest assured that
their health information isnt released unless it has to be.
72/Journal of AHIMA January 15

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