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JUNE 2015




ICD-10 in Action

Visit AHIMAs Instagram account for short videos and photos

that depict instances where ICD-10 would be needed in everyday
and not so everyday life.


How to Use the Digital Journal

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Pat is one of the

many reasons that
HIA is 10-Ready.
Pat Maccariella-Hafey
Director of Education
AHIMA Approved ICD-10-CM/PCS
Trainer and Ambassador


Since 2010 Health Information Associates has been preparing with one goal in mind: to ensure
every member of our team will confidently say I can do 10. With the implementation of ICD-10
rapidly approaching, clients will realize the benefit of 100 hours of dedicated education and
practical experience. From our AHIMA ICD-10 CM/PCS approved review consultants and
educators, to our coding specialists and compliance professionals, HIA stands ready to serve your
needs through implementation and beyond. Together we can move forward with confidence.

Compliance Reviews Education Coding Services

C a l l 8 6 6 - H I A- C O D E o r v i s i t h i a c o d e . c o m t o d a y.

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Contents June 2015



Life After ICD-10

How the healthcare world will change after ICD-10s implementation

By Mary Butler

Vol. 86, no. 6



Presidents Message
The Final Push to ICD-10 Implementation


Bulletin Board

pg. 34
Coders will soon be expected to do some heavy lifting with ICD-10.



Answering the Tough ICD-10 Questions

Coding experts offer tips on how to make it
to October 1, 2015 and beyond

By Barbara Hinkle-Azzara, RHIA, and Kim Carr, RHIT, CCS, CDIP, CCDS


Remediating ICD-10 Knowledge Loss

After delays push back implementation, how
unprepared will your coders be to use the
new code set?
By Michelle A. Black, RHIA; Illustration by Valerio Fabbretti


Ten Skills that Make a Great Leader

By Desla Mancilla, DHA, RHIA; Carolyn Guyton-Ringbloom, MBA, RD,

CAE; and Michelle Dougherty, MA, RHIA


Privacy Holes in the Hidden Healthcare

Students PHI-laden education records that
are stored and shared electronically dont
have the same safeguards as most EHRs
By Daniel A. DuBravec,CHTS, CEHRS, and Matt Daigle


Word from Washington

Transparency is a Top Priority, Says
New CMS Chief Data Officer


Inside Look
Paving the Final Steps to ICD-10




Keep Informed


Volunteer Leaders


AHIMA Career Center


Voices from the ICD-10 Zeitgeist

Contents June 2015

Working Smart



By Rita K. Bowen, MA, RHIA, CHPS, SSGB

By Anna Orlova, PhD

Navigating Privacy and Security

The Evolving Role of the Privacy
and Security Officer


e-HIM Best Practices

Rules of the Road Differ for
Inpatient and Outpatient ICD-10
By Tara Quick, RHIT, CCS,
and Stephani Hickman, CCS

Standards Strategies
Achieving Health Information
Systems Interoperability


The Sound Record

Evaluating the Information
Governance Principles for
Healthcare: Compliance and

By Galina Datskovsky, PhD; Ron Hedges, JD; Sofia

Empel, PhD; and Lydia Washington, MS, RHIA

Coding Notes



AHIMA members may earn continuing

education credits by successfully completing
the following quizzes at

By Karen Kostick, RHIT, CCS, CCS-P, and Gina Sanvik, RHIA


How Deep Do You Dig into ICD-10-PCS Coding?


Answering the Tough ICD-10 Questions

Domain: Clinical Data Management

By Charles Flewelling, Jr., RHIT


Injection and Infusion Coding Offers High Stakes

Practice Brief


Electronic Documentation Templates Support

ICD-10-CM/PCS Implementation (Updated)

4/Journal of AHIMA June 15

Ten Skills that Make a Great Leader

Domain: Performance Improvement


Injection and Infusion Coding Offers High Stakes

Domain: Clinical Data Management

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Contents June 2015
Solving Unique ICD-10
Concerns for Physician
Practice and Outpatient
Coders How are physician
practice and outpatient coders
preparing for ICD-10? How
do their concerns and areas
of focus differ from those of
inpatient coders?

Slideshow: ICD-10 in Action

Visit AHIMAs Instagram account for short videos and

photos that depict instances where ICD-10 would be
needed in everydayand not so everyday life.

Data Revolution

This monthly web-only column highlights and discusses

emerging trends and challenges related to healthcare
data and its ever changing life cycle.

Share and Connect with AHIMA

Follow AHIMA and Journal of AHIMA on these social media outlets.

6/Journal of AHIMA June 15

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The Journal of AHIMA is an official publication of AHIMA




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

Anne Zender, MA
Chris Dimick



Mary Butler


Patricia Buttner, RHIA, CDIP, CCS

Angie Comfort, RHIA, CDIP, CCS

Crystal Clack, MS, RHIA, CCS

Julie Dooling, RHIA, CHDA

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


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



Donna Rugg, RHIT, CCS

Maria Ward, MEd, RHIT, CCS-P

Diana Warner, MS, RHIA, CHPS, FAHIMA

Lydia Washington, MS, RHIA

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


ART DIRECTOR Graham Simpson


Linda Belli, RHIA

Gerry Berenholz, MPH, RHIA

Carol A. Campbell, DBA, RHIA


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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8/Journal of AHIMA June 15

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Presidents Message

The Final Push to ICD-10 Implementation

By Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA

CHILLS RUN UP and down my spine as

I write this article, knowing how hard we
have worked as a profession, association, and industry to get to this red letter
date for ICD-10-CM/PCS.
Just before I wrote this column, I was
on the edge of my seat along with the
rest of industry, watching as ICD-10
passed through the second major advocacy hurdle this year on April 15th with
the passage of H.R. 2, the Medicare
Access and CHIP Reauthorization Act.
This bill repealed the sustainable growth
rate (SGR) formula that adjusts Medicare payments to physicians. As many
will remember, last year it was a patch
bill to temporarily fix the issues with the
SGR that included language that delayed ICD-10 implementation until October 1, 2015. Even with this major hurdle
overcome, its important for us as health
information management professionals to continue to step up and advocate
for ICD-10 while volunteering to assist
unaffiliated physician groups as we get
closer to the finish line.
Now the fun begins: planning for implementation, remediation, and addressing
anticipated opportunities post-ICD-10

ICD-10 Prep Reaches Final Stages

As I check in with AHIMA members,
physician groups, and other healthcare
industry leaders, I know that we are collectively in great shape with our comprehensive implementation roadmaps,
project plans identifying the impact and
gaps, preparing and deploying our educational plans, dual coding and implementing new technology, designing processes and systems to better support
the transition, and comprehensive testing and remediation strategies.
We are now at the point where we
need to be planning for the critical
10/Journal of AHIMA June 15

tasks associated with our cutover and

post-implementation planning. Many
organizations are staffing their ICD-10
command centers, have set up ICD10 coding hotlines, and are ensuring
they have proactive revenue and denial management strategies.
Its important for us to be aware of the
potential contingencies we need to address, from lining up additional coding
and clinical documentation improvement resources to addressing the postimplementation productivity gap and remediating unanticipated documentation
integrity issues and payer denials.

Implementation is the Beginning

It has been a long road to reach this
point, but the implementation of ICD10-CM/PCS is just the beginning. After
the dust begins to settle, it will be time to
plan for the ICD-10 code thaw on October 1, 2016. HIM professionals will also
need to gear up to take advantage of the
new opportunities ICD-10-CM/PCS will
There is a huge light at the end of the
proverbial ICD-10 tunnel, with improvements in clinical documentation and robust data to fuel the granularity needed
to support disease management programs, accountable care organizations,
medical research, public health efforts,
outbreak investigation, and population
health improvement.
As we move from volume-based to
value-based reimbursement, it is essential that we have the health intelligence
necessary to manage patients from the
acute care setting to the medical home.
Now is the time to make the final push
toward realizing our ICD-10 vision!
Cassi Birnbaum ( is
senior vice president of HIM and consulting at
Peak Health Solutions.

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Bulletin Board whats happening in healthcare

Information Blocking Poses Threat to Health Information Exchange

Throughout 2014, the Office of the National Coordinator for Health IT (ONC)
says that it received 60 unsolicited
reports that healthcare providers and
health IT developers engaged in actions
intended to block information sharing.
Information blocking, as ONC referred to it in a report to Congress, is a
practice in which persons or entities
knowingly and unreasonably interfere
with the exchange or use of electronic health information. According to
ONC, information blocking activities
undertaken by electronic health record (EHR) vendors included charging
high fees to establish connections and
share patient records, requiring customers to use proprietary platforms

only, and making the price of switching

EHR systems prohibitively expensive.
Hospitals also engaged in information blocking practices in order to
control referrals and enhance their
market dominance, according to
ONC. One method employed by hospitals has been to deny the transfer or
sharing of patient information due to
compliance with HIPAA.
But it has been reported to ONC
that privacy and security laws are cited
in circumstances in which they do not
in fact impose restrictions, the report
states. For example, providers may
cite the HIPAA Privacy Rule as a reason for denying the exchange of electronic protected health information for

ONC: Health Information Exchange

Increasing, But Serious Roadblocks Remain
While a recent survey released by the
Office of the National Coordinator for
Health IT (ONC) shows that hospital
health information exchange is on the
rise, ONC head Karen DeSalvo, MD,
MPH, MSc, says the healthcare industry still has a long journey ahead
before it reaches true interoperability.
The American Hospital Association
survey announced by ONC shows that
in 2014 nearly 75 percent of hospitals
said they electronically exchanged
health information with an outside
ambulatory physician or hospitala
23 percent increase over 2013 and an
85 percent increase over 2008, according to an article in Health Data
Management. Hospitals were more
likely to exchange health information
with an ambulatory provider outside
of their network than they were an
outside hospital, the report showed.
Our past analysis showed steady
growth among hospitals with both
trading partners, however, we found
substantial deficits with hospital-to12/Journal of AHIMA June 15

hospital exchange, stated a blog coauthored by Erica Galvez, ONCs interoperability and exchange portfolio
manager, and Matthew Swain, program analyst at ONCs office of planning, evaluation, and analysis. Prior
research studies suggested that this
was due to competition and a weak
business model.
While the increase in exchange is
encouraging, major issues still stand
in the way of industry-wide interoperability of health information, DeSalvo said during a speech at the
Healthcare Information and Management Systems Societys annual
conference in April. DeSalvo said
there are three areas that need to be
addressed as quickly as possible to
foster interoperability: Establishing
standards, including APIs; achieving
clarity on data privacy and security
to foster trust; and practically tying
incentives to the use of electronic
health records, according to an article in Health Data Management.

treatment purposes, when the Rule

specifically permits such disclosures.
An ONC blog post co-written by
ONC Director Karen DeSalvo, MD,
MPH, MSc, outlined actions ONC and
other federal agencies could take to
combat information blocking, such as:
Proposing new certification requirements that strengthen surveillance
of certified health IT capabilities
Proposing new transparency obligations for certified health IT developers that require disclosure of
restrictions, limitations, and additional types of costs associated
with certified health IT capabilities

Working with the Centers for
Medicare and Medicaid Services

Saudi Arabia
Launches National
HIM Association
The country of Saudi Arabia has established a national health information management (HIM) association that will work
to improve the clinical documentation
and quality of medical records used by
the countrys healthcare professionals.
The Saudi Health Information Management Association (SHIMA) was officially established in April, with Hussein
Albishi, an early advocate for an HIM
association, named SHIMAs first president. Albishi serves as the HIM and
clinical coding specialist and advisor to
the vice minister of health at the Saudi
Arabia Ministry of Health.
The International Federation of Health
Information Management Associations
(IFHIMA), the global organization representing national HIM associations
around the world, supported the establishment of SHIMA by writing a letter
of supports to the Saudi Arabian Ministry of Health. SHIMA is expected to
become an IFHIMA member soon.

to coordinate healthcare payment

incentives and leverage other
market drivers to reward interoperability and exchange and discourage information blocking
Helping federal and state law enforcement agencies identify and
effectively investigate information blocking in cases where such
conduct may violate existing federal or state laws
Working with the Office for Civil
Rights to improve stakeholder understanding of the HIPAA privacy
and security standards related to
information sharing
Despite the reports of information
blocking by vendors and providers,

several recent reports suggest that

EHRs, health information exchange
initiatives, and vendor-based data
sharing groups are improving rates of
data exchange.
More documents using the Consolidated Clinical Document Architecture (C-CDA) standard are being
exchanged than ever before. Epic Systems told Modern Healthcare that Epic
went from exchanging 4.6 million
documents in July 2014, with 480,000
documents outside the Epic ecosystem, to roughly 10.2 million in March,
including 1.36 million outside. The outside data exchange includes non-Epic
EHRs, health information exchanges,
and the Defense and Veterans Affairs
departments health systems.

Basic EHR System Adoption On the Rise in

Acute Care Hospitals
Three out of four non-federal acute care hospitals had adopted at least a basic
electronic health record (EHR) system in 2014, according to a new Data Brief from
the Office of the National Coordinator for Health IT (ONC). According to the brief,
these numbers represent an increase of 27 percent from 2013 and an eight-fold
increase from 2008. Basic EHR adoption represents a minimum use of core
functionality determined to be essential to an EHR system, according to ONC. In
addition, the brief notes that 97 percent of acute care hospitals possessed EHR
technology certified to meet federal requirements in 2014, which means these
hospitals should have the technology needed to meet the meaningful use EHR
Incentive Program requirements, including security and interoperability.

Percent of Hospitals

A report from the Ponemon Institute finds

that about nine out of 10 healthcare
firms have been the victim of a data
breach over the past two years, with
an average cost of over $2 million per
incident in damages.
Virginia Commonwealth University and
Qualcomm Institute data scientists at
the University of California-San Diego are
working together to determine how Big
Data gleaned from EHRs and health
information exchanges could boost
population health.
The Centers for Medicare and Medicaid
Services (CMS) has updated the clinical
quality measures for the 2016 EHR Incentive Programs, the Physician Quality Reporting System, and the Inpatient
Quality Reporting Program.
Cleveland Clinic has announced that
it will publish its health analytics
algorithm portfolio, which will cover
surgery, oncology, cardiology, and
other areas, in the Apervita Market.
Palo Alto Medical Foundation and UnitedHealthcare will be launching an accountable care organization in 2015 that will
service over 63,000 patients.
CMS Office of Information Services
Deputy Director Henry Chao has retired from his post, where he served as
the technology lead for the launch of

EHR System Adoption in Acute Care Hospitals


Imprivata has acquired HT Systems as

part of efforts to enter the patient identification market.


Quest Diagnostics, Inc. and the French

National Institute of Health and Medical
Research are working together to build
a database of cancer-causing gene
mutations to better predict breast and
ovarian cancers.















Nurses at Boston Childrens Hospital have

designed a mobile tool that will allow a
second nurse to remotely verify bedside
medications and doses, as well as allow the second nurse to send an instant
message to the bedside nurse.

Source: Charles, Dustin et al. Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care
Hospitals: 2008-2014. ONC Data Brief, no. 23, April 2015.

Journal of AHIMA June 15/13

Bulletin Board whats happening in healthcare

Use of Data Analytics to Boom in the Next

Three Years
A study in the IEEE Journal of Biomedical and Health Informatics combines
Twitter posts and air quality and hospital data to create a model for predicting emergency room trends for asthma
patients. The team of researchers says
that their model can currently anticipate emergency room visits with 70
percent precision.
A survey from HIMSS Analytics finds
that 71 percent of nurses would not
want to go back to paper records
from electronic health records (EHRs).
Seventy percent of the 626 registered
nurses that were surveyed said that
EHRs offer more comprehensive patient information, and 72 percent noted
the reduction of medication mistakes
thanks to EHRs.
A study published by researchers at
Johns Hopkins University School of
Medicine in the Journal for Healthcare
Quality finds that most US clinical
registries lack critical features necessary to render the information they
collect useful. Our results highlight
the acute need to improve the way
clinical outcomes data are collected
and reported, said Marty Makary, MD,
MPH, senior investigator and professor
of surgery at Johns Hopkins University
School of Medicine.

14/Journal of AHIMA June 15

The use of data analytics to improve

care quality and monitor population
health is gaining popularity now, but
within three years its use will nearly
double, a new survey reveals.
Currently, according to the results of
a HealthLeaders Media survey, 95 percent of health systems use data analytics to improve clinical quality, and 47
percent said they use data analytics to
assess population health needs. But
within three years, of those same organizations, 78 percent say they expect to
use data analytics to respond to population health needs.
Even though an advisor cautions that
we dont know the degree of utilization,
the survey analysis reports, the results
indicate there is broad recognition that
IT will need to operate with a higher level
of sophistication as their organizations
approach value-based care.

Data from electronic health records

(EHRs) are increasingly going to be part
of the equation as healthcare organizations use data and predictive analytics
to make decisions going forward.
A new paper from the healthcare
analytics vendor Optum advocated for
healthcare organizations to employ a
Moneyball approach to analytics. Moneyball refers to a statistics and analytics
techniquecalled sabermetricsused
by the managers of the Oakland Athletics to predict which under-budget players gave them the best shot at scoring
the most runs in a season, Optum noted.
In the same way, analyzing EMRs
can help healthcare providers predict which patients will need care and
when. With that knowledge, providers
can deliver better, timelier care without
the added costs of unexpected hospitalizations, the report said.

New Maturity Model Aims to Build

Telemedicine Industry Standard
Co-developed by the healthcare advisory practice of Ernst and Young and a
panel of national telemedicine experts,
the Telemedicine Adoption Model is a
telemedicine maturity adoption model
that provides a standard for assessing
and describing the maturity of various
telemedicine programs, according to
a news release from Ernst and Young.
An eight-level model that describes a
full range of telemedicine capabilities,
the maturity model is the first of its kind
for the telemedicine industry and took
a year of research, development, and
validation by experts to complete. The
hope is a standardized national system
will make it easier for healthcare providers to compare, analyze, and implement
telemedicine programs and speed telemedicine adoption.
The model ranges from 0 to 7:

7Full interoperability, with all
data transmitted to and analyzed in

an internal electronic health record.

Telemedicine services offered
for patients across the care continuum for multiple specialties.
5Remote monitoring of patients
at home, with equipment dispensed by the provider.
4Use of complex technology to
support care for patients at various
levels and across various specialties. Use of specialized cameras
and monitoring instruments.

3Use of simple exam cameras
and viewing monitors to perform
virtual consults. Transmission of
images and data.
2Transmission of data and education to patients through dedicated portal.

1Use of technologies such as
video conferencing.

0Emerging telemedicine programs.

Proposed Meaningful Use Changes Draw Fire

The recently issued proposed rule relaxing some of the meaningful use
EHR Incentive Programs more stringent requirements has drawn both
sighs of relief and shouts of criticism in
the health IT industry.
The proposed rule, released April
10 by the Centers for Medicare and
Medicaid Services (CMS), called for
realigning the reporting period beginning in 2015 so hospitals would participate on the calendar year instead
of the fiscal year; and allowing a 90day reporting period in 2015, instead
of the previous year long reporting period, to accommodate the implementation of these proposed changes.
Additionally, the rule loosened a
meaningful use measure that required
eligible providers to demonstrate that
five percent of EHR users have viewed,
downloaded, or transmitted information contained in their patient portal.
Under the new proposed rule, eligible providers only need to prove that
equal to or greater than 1 patient has

interacted with their record.

The weakened patient engagement
measurement upset patient rights
activists, including former ONC director Farzad Mostashari, MD, who
expressed the sentiment that the
modification watered down important benchmarks meant to connect
patients with their own health data.
In a series of social media posts and
in his presentation at the Healthcare
Information and Management Systems Society (HIMSS) annual conference, Mostashari pitched the idea
of a day of action in which patients
would be encouraged to ask their
providers for copies of their records.
To spread awareness for this day of
action, Mostashari and others are
employing the social media hashtag
Patients are not an advocacy
group. They are not a special interest. Theyre why we do this, Mostashari said at the HIMSS conference,
according to Med City News.


Basic ICD-10-CM/PCS and ICD-9CM Coding, 2015 Edition, provides
students and professionals with a
balanced approach to coding. In-depth
instruction and practical exercises build
a foundation from which to apply ICD10-CM/PCS and ICD-9-CM conventions and rules to everyday examples
using actual case documentation.
I.C.E. Medical Cards allow individuals
to create a personal electronic health
record that only they control, which can
be shared via the access info provided
on the card in the event of emergency.
The system is designed to get pertinent
health and emergency contact information to emergency healthcare providers
as soon as its needed.

Health IT Could Address Childhood Obesity,

Study Suggests
As the issue of childhood obesity continues to confront US pediatric healthcare providers, a study published in
JAMA Pediatrics suggests that computerized health records might hold
the key to achieving more positive outcomes. The issue of childhood obesity
is on the rise; this health issue affects
three times as many children and adolescents as were affected one generation ago, according to an article in
Medical News Today.
The study compared the results of pediatric practices that provided standard
care, those that employed an electronic
health record (EHR) to alert clinicians to
children with a high body mass index
(BMI) and provide links to obesity screening and weight management tools, and
those that employed these tools as well

as a health coach to work with families

of children identified by the EHR. The researchers found that the children in the
practices that provided EHR- and health
coaching-supported interventions experienced the greatest reductions in BMI.
Based on these results, the studys
authors concluded that interventions
leveraging efficient health information
technology for the provision of reliable clinical decision support systems
for pediatric clinicians and self-guided
behavior change for families resulted
in BMI improvements for children. The
use of electronic health records offers
the potential for improving the quality of
care for obese children and for accelerating the use of evidence on obesity
screening and management by primary
care clinicians, the authors wrote.

The AHIMA ICD-10 Academy: Building Expertise in Coding is a dynamic

program for coder training in both ICD10-CM and ICD-10-PCS. Designed
for coding professionals who seek to
achieve proficiency in both systems,
the program provides a well-rounded
base of knowledge and exposure to
advanced cases in ICD-10-CM/PCS.
Students and professionals interested
in learning ICD-10 diagnosis and procedure coding are welcome to register
for this program.
NextGen Healthcare, a health information systems provider, has launched a
tool designed to support population
health and care management. Called
NextGen Care, the solution is built onto
NextGens ambulatory solution suite.

Journal of AHIMA June 15/15

Word from Washington

Transparency is a Top Priority, Says New

CMS Chief Data Officer
By AHIMAs Advocacy and Policy Team


Office of Enterprise Data and Analytics and the first chief data officer at the
Centers for Medicare and Medicaid Services (CMS), recognizes the pivotal role
that data and information should play in
transforming healthcare.
Before Brennan took on the role of
leading the office this past November, he
served as acting director of CMS Offices
of Enterprise Management. In the following interview, Brennan outlines his plans
for the newly created Office of Enterprise
Data and Analytics (OEDA).
JAHIMA: Please describe the role of
the OEDA.
Brennan: Our primary role is overseeing improvements in data collection, use,
and dissemination as CMS strives to be
more transparent and to use that in the
drive toward higher quality patient-centered care at a lower cost.
It has become increasingly apparent
that with our aggressive moves toward
value-based purchasing and industry reform, data and analytics have become
core business functions of the agency.
The role of the office is to maximize and
leverage data in as many ways as possible, both internally and externally.
JAHIMA: Would you elaborate on how
this new office represents a change in
the role that data plays in healthcare
payment and delivery?
Brennan: Now that we hold providers
significantly more accountable for not
only the volume of care but also the quality of that care, we have to aggressively
mine our data, not only to help us understand the care that they are providing,
but to help them better understand the
care that they are providing.
Some examples are the provision of
monthly claims data feeds to ACOs [accountable care organizations], the gradual rollout of the value-based payment
16/Journal of AHIMA June 15

modifier, and the Quality and Resource

Use Reports (QRURs) that most Medicare physicians in the United States will
receive over the next couple of years.
JAHIMA: Would you describe some of
the ways that you are working to make
data more transparent and meaningful
to users?
Brennan: We have been very active
over the past few years in leveraging and
releasing as much data as possible for
completely open and public consumption to both spur a vibrant health data
ecosystem and make more information
available on how our vast and complex
health system operates. The new office
was created to take those data releases
to the next level.
We are committed to getting as much
data out there as possible in a responsible way that in no way compromises
beneficiary privacy. CMS is routinely
looked to by other agencies as a leader in
the open data and transparency field. We
are releasing data that would have been
unimaginable just two or three years ago.
The clearest example of that is the
provider-specific data that we have released, including the release of physician
utilization data last April that contained
more than nine million lines of information on over 800,000 Medicare providers.
We continue to look closely at other data
resources that we could aggregate and
make available in a similar manner.
We also are working hard to make data
releases appeal to multiple users. Although making the data available in a
machine-readable format is important,
we have taken additional steps to make
the data available in a more user-friendly
manner for folks who may not necessarily
be as sophisticated at manipulating data
using statistical software programs or Excel. We have built a number of consumerfacing easy-to-use dashboards covering

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Word from Washington

our physician utilization data, as well as our county-level geographic variation data and chronic condition data. All three of
those releases include Medicare-specific data.
JAHIMA: What other initiatives do you plan to work on
in 2015?
Brennan: We have a lot of new data sources that we are trying
to integrate and understand. Marketplace data is an excellent
example. We are into the second year of the health insurance
marketplaces, so there is a lot more data to analyze, and we
can begin to look at year-on-year differences and trends.
We also plan to get involved in greater analysis of Medicare
Advantage plan encounter data, which was recently submitted to the agency for the first time.
JAHIMA: What do you see as some of the major challenges in your new role?
Brennan: They are exciting and fun challenges. Changing
the culture around data at the agency is very important. I
often say that data transparency begins at home, and we are
working hard to ensure that all folks at the agency that need
data can get it in as seamless a manner as possible.
The other big challenge is continuing to push the envelope
on the development of internal analytics or advanced external
information products. We have had a lot of success in this area
with predictive modeling to identify fraud as well as real-time
analysis of claims data to track readmissions in near-real time.
But, obviously, there is much more that we can do in that area.
Finally, one of the big challenges that we are excited to confront is better integrating and coordinating of data from multiple sources into a single more cohesive framework where
we can use the best components of different datasets to develop insights. Just to clarifyI am not necessarily calling for
all of the data to be held in one giant database, but rather for
us to be able to combine or use data from multiple different
sources in a cohesive and collaborative way.
The best example is better linking the vast quantities of
quality data that we have with the payment and claims utilization data. We also should begin to link the data we have
from the HITECH [Health Information Technology for Economic and Clinical Health Act] payment incentive program to
traditional administrative claims.
In the longer term, the challenge that everybody faces is
better integrating clinical and administrative data for analytical purposes.

In Other News: CSAs Head to the Hill

In late March, 193 AHIMA members representing 45 states converged on the US Capitol in Washington, DC for AHIMAs 13th
Annual Leadership and Advocacy Symposium and Hill Day.
The Leadership and Advocacy Symposium on March 23
included several panel discussions designed to help the
component state associations (CSAs) hone their home-state
advocacy strategies, including using social media to engage
policymakers and the public. Christopher Boone, PhD, executive director at Health Data Consortium, presented a
keynote address on how recently proposed federal initiatives, coupled with marketplace changes, could advance
18/Journal of AHIMA June 15

the use of health data to improve patient outcomes.

During Hill Day on March
24, participants urged their
representatives in Congress
to oppose any legislative efforts to delay the transition
to ICD-10. AHIMA members
educated legislative aides on
the Hill about other key health
information topics, including
the need to address the frequent mismatch between paNiall Brennan, director of the Office
tients and their clinical data,
of Enterprise Data and Analytics,
which is a serious and growchief data officer at CMS
ing patient safety issue. They
also discussed how enhanced information management can
deliver measurable cost and quality improvements.
Hill Day attendees also had the opportunity to hear from
Denesecia Green, deputy director of the National Standards
Group, Office of Enterprise Information at CMS. Green discussed CMS ICD-10 preparation activities, testing, and outreach and education efforts aimed at ensuring even small
providers are ready for the transition.
The AHIMA Advocacy and Policy Team (
is based in Washington, DC.

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Inside Look

Paving the Final Steps to ICD-10

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

WHAT A DIFFERENCE a year makes.

A year ago, the HIM industry was reeling from an unexpected delay to the
implementation of ICD-10. The change
was brought on at the last minute,
slipped into legislation and passed
within a couple of days. The result was
a one-year delay of ICD-10 implementation until October 1, 2015.
The event generated waves of shock and
dismay. Healthcare organizations that had
invested time and money into preparation
had to put things on hold. Students who
were preparing to graduate and move into
new jobs had to sharpen their ICD-9 skills.
An industry that had been preparing diligently was now on hold.
Even worse, as a result of the delay,
there was the potential for cynicism and
apathy. Some might be convinced that
ICD-10 is never going to happen. It was
frustrating to be so closeyet so far
from what we as a profession believed to
be a positive, transformative change.
AHIMA and its members got busy. We
launched a multifaceted advocacy, outreach, and awareness campaign to advocate for a successful transition to ICD10 in 2015.
We reached out to national and local physician and physician practice
management groups to address their
concerns regarding ICD-10 and offer
implementation resources. We reached
out to national and local media outlets
to dispel myths and misinformation surrounding ICD-10 and to increase recognition of the importance of transitioning
in 2015. And we made our voices heard
on Capitol Hill, reaching out to legislators with thousands of Tweets, letters,
calls, and visits advocating for no further delay of ICD-10.
The articles in this months Journal focus on questions readers may have as
we prepare, once again, for the transi-

tion. In Life After ICD-10, Mary Butler

talks to experts who imagine what the
HIM/healthcare world will be like with
ICD-10-CM finally in place in the United
States. Barbara Hinkle-Azzara and Kim
Carr take on the skeptics in Answering
the Tough ICD-10 Questions. Managers
worried about retraining coders will find
useful data in Michelle Blacks Remediating ICD-10 Knowledge Loss, which
discusses the results of a survey to determine what ICD-10 data and knowledge was lost by coders during the delay and how that lost knowledge could
be regained.
Outside the ICD-10 realm, the results
of a focus group hone in on why people
need to develop leadership skills in order to get the HIM jobs of the future in
Ten Skills that Make a Great Leader.
And Daniel DuBravec and Matt Daigle
discuss the lack of administrative, physical, and technical safeguards in place
in K-12 schools to protect student health
information in Privacy Holes in the Hidden Healthcare System.
As of press time we are still on track for
ICD-10 implementation in October. But
were not out of the woods yet. Those
who seek to delay ICD-10 temporarily or
permanently may try again. But if they
do, well be ready, with an army of wellinformed, savvy advocates.
It is time to stop delaying the transition. The final rule adopting ICD-10 as
a replacement for ICD-9-CM was published more than six years ago. ICD-10
is a long-overdue improvement over the
current coding system.
As a country, we simply must move to
a more modern, precise code set to be
able to effectively use healthcare data
to improve quality of care, safety, and
outcomes, and to reform our payment
system so that it rewards value rather
than volume.
Journal of AHIMA June 15/21


22/Journal of AHIMA June 15

Life After ICD-10


By Mary Butler

ANYONE WHO HAS bought a home has inevitably heard at

some point along the way that real estate is always a gamble.
Thats cold comfort for anyone whos plunked down earnest
money on a fixer upper. But smart buyers know that if theyve
done their research and invested in the right places, their dream
home is well within reach if they can just look past the spackle
smears, dried wallpaper paste, and leaky pipes.
The transition from renting to owning is enough to send anyone into a panic, but putting the process off comes with risks as
well. What happens when your family suddenly gets bigger and
youre stuck with a leased home where nobody fits? Tempers
flare and pretty soon paying those inspection and lawyer fees
starts to feel like a bargain in exchange for your sanity.
The transition from ICD-9-CM to ICD-10-CM/PCS has been
fraught with similar frustrations. Medical researchers, coders,
billers, and payers have been struggling to make do with an outmoded classification system for decades, and at a great cost to
the healthcare system. Theyve been sidelined by politics, bureaucracy, and providers intimidated by the costs and investments required to make the transition.
On October 1, 2015 it should quickly become clear to coders and health information management (HIM) departments
whether or not their investments paid off. Like the new homeowners about to take a sledge hammer to drywall for the first
time, things might get messy at first, but theres no turning back
in pursuit of a better way.
To make the switch to ICD-10 successful, the healthcare industry will be looking to HIM leaders to help them look through
the implementation dust and debris of change and outward into
the near futurewhen the healthcare industry will finally be living the benefits of ICD-10. Its up to HIM leaders to let their facilities know what to expect when the coding switches flip on
October 1, six months after that, a year after that, and beyond.
Like real estate agents selling buyers on their dreams, HIM has
to be able to communicate the reality of the ICD-10 world.

Life After ICD-10: Implementation Date to Six Months

With ink on the contract and house keys in hand, new homeowners can finally see what theyre dealing with. Once they start
putting primer and color on the walls, its much easier to imagine what life will look like in the coming months.
Similarly, speculating about what life might be like for coders,
physicians, and hospitals immediately after the ICD-10 go-live
date is as hypothetical now as it will be in Octoberand ones
viewpoint is likely to have a lot to do with their level of preparedness. Facilities that have practiced dual coding or engaged in
end-to-end testing with their payers and with the Centers for
Medicare and Medicaid Services (CMS) will be much better off
than providers who have not, though a drop in coder productivity is expected across the board.
Pat Maccariella-Hafey, RHIA, CCS, CCS-P, CIRCC, director

of education at Health Information Associates, says the biggest

slowdowns in productivity are likely to be a result of the complexity of procedure codes.
A big area that will be challenging for coders is understanding
the procedures that the physicians are actually doingunderstanding what the physicians objectives are in order for them
to appropriately assign root operations and other characters of
the PCS code, Maccariella-Hafey says. That seems to be where
most coders struggle [and] will be an issue after implementation. That in turn will likely impact more than productivity.
She says theres a big difference between learning a coding or
classification system and being able to understand clinical factors of a diagnosis. This is especially true in coding surgical procedures. Making sure coders have a strong understanding of the
guidelines of ICD root operations should be a focus in preparation. This will be less of a problem for hospitals that have invested in dual coding and payer testing, but Maccariella-Hafey
says there are still hospitals out there that believe another delay
is in the offing and have put off this type of practice.
Hospitals and physician practices need to continue ICD-10
training for coding staff well after October 1, says Maggie Foley,
PhD, RHIA, CCS, associate professor in the HIM department at
Temple University.
We provide lengthy clarifications in [in-house] coding clinics,
and that information will need to be discussed with coding staff.
[We will also need to] address issues identified in audits when
training the coders, Foley says. I think the clinical documentation improvement (CDI) efforts will continue to focus more on
procedural information than diagnostic information compared
to ICD-9 because of the greater specificity in codes.
Providers need to remain mindful that ICD-10 is also being
used to drive quality initiatives, and continue training efforts as
such. CMS and other insurers are moving towards reimbursement systems with greater emphasis on quality of care and outcome measures. ICD-10s greater detail related to these topics
will enhance the use of codes for assessing quality and reporting
outcomes, Foley says. An example of this is the greater detail in
complication coding in ICD-10-CM. When coding a procedural
complication, such as a hemorrhage or stroke, ICD-10-CM requires further specificity to indicate whether the event occurred
intraoperatively or postoperatively, Foley says.
Some HIM professionals anticipate that a degree of chaos will ensue after the go-live date, and many have found in audits that their
current ICD-9 coding is far from perfectwhich complicates matters. This was evident with the recent success of Recovery Audit Contractors (RAC), who found plenty of issues to scrutinize in ICD-9.
Wendy Coplan-Gould, RHIA, president of HRS, says she is
concerned that competing health IT initiatives, in combination
with the ICD-10 transition, could force some hospitals to close
in the long-term, particularly those hospitals that didnt get a
line of credit in advance of claim denials or hospitals that didnt
Journal of AHIMA June 15/23

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put extra cash in the payroll coffers. She fears that the loss of
coder productivity could hurt providers bottom line. But she
emphasizes that practice makes perfect.
I think that anybody and everybody should be chomping
at the bit to do end-to-end testing. The end-to-end testing can
bring up many more problems than just coding problems. It
can help identify IT questions and demographics and claim
edits. The more you practice, the better off you are when you
go-live, Coplan-Gould says.
Come October 1, coders and HIM departments will need to
be prepared to defend their code assignments for accurate and
timely reimbursement. Danielle Reno, MHA, CHC, CCS, CCSP, ICD-10 director at Sutter Health, says the business validation
of report remediation is absolutely critical to ensure providers
have a seamless transition after ICD-10 go-live.
At Sutter, Reno says her team has taken reports to quality review
specialists, nurses, and HIM departments for review and asked,
Are these reports what you think you need to see in an ICD-10
world? and Can you help us understand if these are correct?
If you dont get that business validation, the meaning behind the
initial reporting might be changed, Reno says. There are so many
new codes in ICD-10 that when you map the ICD-9 codes to the
ICD-10 codes, it could be a one-too-many situation where you have
to have someone that really knows the code set or an HIM resource
that can validate a code set to be included in that new reporting.
Even among facilities that have been diligent in their preparations for ICD-10, close auditing of ICD-9 coding has revealed
weaknesses that could show up in ICD-10 coding as well. Unless
these weaknesses are addressed in training, they could persist
and cause problems after the transition. Foley says that conditions such as sepsis and procedures like spinal fusions are commonly coded improperly. Those topics are difficult in ICD-9,
they continue to be difficult in ICD-10. But you start to recognize some of the weaknesses in the coding staff regardless of the
coding system, Foley explains. Whether its understanding the
clinical process of sepsis, or whether its understanding whats
actually done during a fusion procedure and all the different
ways they can be done, you need an understanding.

Life After ICD-10: One to Five Years

One year after closing, our plucky homeowners barely recognize the home they had when they first got the keys. Hammers
have been put away, sconces have been hung, and their furniture is finally starting to look like it belongs there, though longterm projects remain. At least nobody is arguing about sharing
the bathroom. A year after October 1, 2015, coders will still likely
face some uncertainty, but real change should be apparent.
Sandra Kersten, MPH, RHIA, a senior consultant for eCatalyst
Healthcare Solutions currently assigned as an ICD-10 project
manager at a Chicago-area hospital, says that based on the results of dual coding efforts shes seen, theres reason to believe
there will be a permanent reduction in coder productivity. This
means that investing in extra coders before and after the transition is a smart move for facilities that can afford it. Clearly, this
is an opportunity for student coders.

Life After ICD-10

ICD-10s Long, Dramatic Timeline

April 2014
The Protecting
Access to Medicare
Act of 2014 is
which contains a
provision prohibiting the HHS
Secretary from
adopting the
ICD-10 code prior
to October 1, 2015.

January 2015
CMS begins end to
end testing of ICD-10.

Facing backlash from
physicians groups, HHS
publishes a final rule that
delays the compliance
date for ICD-10-CM/PCS
from October 1, 2013 to
October 1, 2014.

HHS publishes a notice of
proposed rulemaking for the
replacement of ICD-9-CM
by ICD-10-CM and ICD-10PCS on October 1, 2011.

CMS institutes a code freeze
in preparation for ICD-10.

The National Committee
on Vital and Health
Statistics (NCVHS) sends
the Secretary of the US
Department of Health and
Human Services (HHS) a
letter saying ICD-9-CM
could stress the quality
of the healthcare system
to the point where quality
care could become

October 1, 2015
implementation deadline.

HHS publishes a final rule
for adoption of ICD-10CM/PCS, pushing the
implementation deadline
to October 1, 2013.

ICD-10 is released by the
World Health Organization.

The Healthcare Financing
Administration contracts with
3M to develop the procedure
classification system to
replace Volume 3 of ICD9-CM (hospital inpatient
procedures), known as ICD10-PCS. The new procedure
classification adheres to the
criteria established by NCVHS
for a procedure classification
system in 1993.

Subcommittee on Health of
House Ways and Means Committee holds hearing on the adoption
of ICD-10-CM and ICD-10-PCS.

ICD-10 is implemented in the
US for mortality reporting.

The Centers for Medicare and
Medicaid Services (CMS) posts the
ICD-10-PCS coding system, training
material, and crosswalk to ICD-9-CM
procedure codes on its website.

ICD-9-CM is implemented
in the United States.
Journal of AHIMA June 15/25

Life After ICD-10

I think another piece in the short term [is] that it might actually level the playing field for newer coders because you just
think about it, Kersten says. If no one has much experience on
ICD-10 coding then maybe, if we need new coders, hospitals
will be a little more open to hiring coders with less experience.
Results of preliminary provider end-to-end testing with the
Centers for Medicare and Medicaid Services (CMS) is one encouraging spot for those concerned about denial rates. According to the results from one week of testing with CMS that ran
January 26, 2015 to February 3, 2015, 81 percent of test claims
submitted by providers were accepted. Whats more, the leading
reason for rejected claims was non-ICD-10-related errors, such
as use of an incorrect National Provider Identifier, an incorrect
health insurance claim number, or dates of service outside the
range valid for testing. Nearly 660 providers participated, submitting about 15,000 test claims.
By its very nature, coding in ICD-10 requires an elevated clinical understanding of disease processes, the clinical factors behind a diagnosis, and an ability to read and understand lab values and diagnostic reports. Maccariella-Hafey says the benefits
of a more sophisticated coding workforce will be evident well
before the five years post-implementation mark.
I can see that coders will be even more educated in the clinical aspects of medicine and surgery. So coders are going to
become more knowledgeable and the coding will be more accurate because there wont be problem areas that need to be addressed through Coding Clinics, she says.
Sutter Healths Reno strongly believes that the availability of
more precise, accurate data from ICD-10 will benefit the healthcare system within the first five years after implementation.
I absolutely believe were going to have better patient care. I
also believe that our payment and reimbursement systems are
going to change. The data that government and commercial
payers have right now doesnt really indicate how good or bad
patients are at taking care of themselvesor the quality of care
theyre receiving from practitioners, Reno says. I believe that
in five years from nowand I think its going to be even faster
than thatwere probably going to be able to monitor patients
investments in their own health and monitor the quality of care
from individuals to providers.
Rhonda Butler, CCS, CCS-P, senior clinical research analyst
at 3M Health Information Systems, has an optimistic shortterm outlook with regard to ICD-10 implementation. Many
have speculated that some hospitals wont make the transition
at all, and it is true that some hospitals and physician offices
have put off ICD-10 training and other transition planning until the last minute. But that doesnt mean October 1 is going to
spell disaster, Butler says.
I dont subscribe to the gloom and doom predictions of dire
impact on small hospitals, at least as far as coding goes, she
says. By definition, small hospitals have less complex cases to
code, and their coding tends to be the common scenarios for
which there is plenty of accessible coding advice and resources.
I believe that coders everywhere are rising to the challenge.
HIM departments need to be proactive in making sure their
vendors are ready before the transition, but tweaking will con26/Journal of AHIMA June 15

tinue after implementation, too, particularly with electronic

health record (EHR) systems. Reno says she is working with her
vendor to make sure the EHR is able to capture the documentation specificity necessary to code charts in ICD-10. However,
some other providers are taking a wait-and-see approach.
Weve had to work with them [the EHR vendor] pretty tightly
on what we call smart tools where the physicians can actually
select within the smart text the specificity they want, Reno says.
[For example,] if they type congestive heart failure they can select whether its acute or chronic right in the smart text too.

Life After ICD-10: Five to 10 Years

Post-Implementation (and Beyond)
Within five or 10 years of purchasing a home, lucky homeowners have a hard time remembering the angst of the early days.
A garden is blooming out back, granite counter tops look like
theyve been there forever, and entertaining in the space is a
breeze. A mortgage still looms, but paying it is routine.
A common refrain from the government and other industry
advocates pushing for the transition to ICD-10 is that its time
for the US to catch up with the rest of the world. And within 10
years of implementing ICD-10 those advocates should see that
vision become a reality. A major expectation about ICD-10 is
that it will help stimulate programs like patient-centered medical homes, value-based purchasing, and accountable care organizations by giving the government and care management
organizations better data to work with. Everyone stands to benefit from improved data quality, says Maccariella-Hafey. From
a reimbursement standpoint, I could seewhether its CMS or
insurance companiesmaking more specific coverage determinations based on more accurate and precise data, she notes.
From a quality perspective a lot of entities will use this data.
The more specific the data, the more accurate decisions can be
made, and accurate assumptions based on that data. I know
CMS uses it for a lot of different core measures.
Researchers and public health monitoring organizations want
to be able to compare data apples to apples for global disease
monitoring. And the US government needs more accurate data
to advance reimbursement reforms. Butler believes that when
ICD-10 is in full swing10 years from now and beyondthe US
will be well on its way to achieving those goals.
Both ICD-10-CM and ICD-10-PCS are database friendly, in the
sense that the same level and type of detail is applied consistently
across the code set. That means they are much easier to incorporate into smart and cool apps that take advantage of that consistency, Butler says. My hope is that for the long term we will be
able to significantly enlarge the sweet spot where machines can
efficiently and accurately take on as much of the coding burden
that it can, and leave the fun stuff for the next generation of codersa bunch of smart multi-taskers who are perfectly at home in
the world of information delivered electronically.
She is quick to note that more accurate data doesnt magically translate into increased healthcare quality and value. It will
take lots of good people working together, and using great tools,
to realize the potential of ICD-10, she notes.
But thats not to minimize the power of ICD-10 to help fix

Life After ICD-10

some of healthcares biggest challenges. John Hughes, MD, professor of medicine at Yale School of Medicine, has been using
ICD-9 data for 15 years for his research. Dr. Hughes research
focuses on patient classification systems with a specific interest
in readmission complications and predicting resource use.
Dr. Hughes says he started to become frustrated with the lack of
precision in ICD-9 about 10 years ago when he and his colleagues
were investigating causes of hospital readmissions but had to
create workarounds to identify various causes of complications.
We had to come up with combinations of diagnosis codes,
which might be vague, and then procedure codes to find what
the complication was or the severity of the complication. Very
often the procedure codes werent that precise either, Dr.
Hughes says. So that was just the way of the world and we dealt
with it. But, there was always that lack of precision.
A common cause of hospital readmissions is post-surgical complications. But for researchers like Dr. Hughes, its difficult to find
patterns in surgical complications when the codes arent specific
enough to capture an error with a technique or instrument.
To demonstrate the inadequacy, Dr. Hughes uses the hypothetical scenario in which a patient sustains a puncture wound
that severed the left femoral artery. The patient undergoes surgery where the damaged portion of the artery was replaced with
a synthetic graft, which is coded in ICD-9 as resection with replacement without any mention of the type of replacement or
which side of the body the procedure was done. This lack of detail is problematic when a complication such as bleeding at the
graft site occurs, and the ensuing surgical fix is coded in ICD-9
as mechanical complication of other vascular device or graft
with a procedure code of revision of vascular procedure.
When this event is coded in ICD-10 a researcher can learn
that the complication was a hemorrhage, know exactly where
it happened, and that the revision involved a procedure to resuture the graft using an open approach.
When we have new procedures, inevitably there are going to be
complications. Its very useful to be able to look to see what types
of complications are happening in relation to procedures and
to focus on possible problems with the procedures. A lot of that
stuff you cant do prospectively. Its only after people have been
performing the surgeries in the real world that you see these patterns emerge where there seems to be complications, Dr. Hughes
says.If theres patterns, you may be able to say This is a problem
with this particular technique or this particular procedure and we
need to examine why thats happening and try to fix it.
He notes that using ICD-10 for his and others research wont
start a revolution, just a much more sensible and effective way
to perform the task already being done.
Like a homeowner, the repairs and renovations (updates and
corrections) will never fully be done in ICD-10-CM/PCS. But
with the bulk of the implementation heavy lifting done in the first
couple years, healthcare professionals will be set up for years and
years of use of a new code set that provides more specificity, accuracy, and data that leads to a better quality of life for patients.

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Journal of AHIMA June 15/27

Answering the TOUGH

ICD-10 Questions
By Barbara Hinkle-Azzara, RHIA, and Kim Carr, RHIT, CCS, CDIP, CCDS

AT A US HOUSE of Representatives subcommittee hearing on

February 11, lawmakers and stakeholders agreed that the implementation of the ICD-10-CM/PCS code sets should not be further
delayed. Moreover, in March the House passed legislation that
provides a permanent replacement to the Sustainable Growth
Rate (SGR) with no delay of ICD-10 added to the bill. The Senate
confirmed its passage on April 14, 2015, further clearing the way
for ICD-10 to become the US code set on October 1, 2015.
Now with only four months to go, it is imperative that providers prepare. This is the optimal time for health information
management (HIM) directors to make their final push to secure
resources and funds necessary to ensure a successful conversion to ICD-10. The healthcare industry must now move full
speed toward October 1, 2015. This includes balancing the ICD10 practice needs of tomorrow with the ICD-9 discharged not
final billed (DNFB) demands of today.
It is now time to answer the tough ICD-10 questions lingering
on the doorstep of the new code sets implementation. Below,
HIM experts answer these questions and offer advice on how
best to hit the implementation deadline running.

28/Journal of AHIMA June 15

How to Overcome Organizational Skepticism After

Years of Crying Wolf
After all the setbacks and delays, many hospital executives remain
reluctant to dedicate additional resources toward the ICD-10 conversion. Few providers have sufficient resources to keep preparing
year after year without benefit of progress or return on investment.
But while caution is understandable, time has run out.
When the 2014 delay was announced, some organizations
dropped their ICD-10 readiness programs altogether. Others maintained their progress, but at diminished rates. For example, hospitals on the progressive end of ICD-10 readiness continued to dual
code, but decreased their volume. Hospitals on the conservative
end stopped dual coding altogether and are just now reinstating
their programs. And the perspective from IT departments is that
some health information technology (HIT) software vendors also
postponed ICD-10 software updates and transition testing.
Size makes a difference when it comes to ICD-10 preparation.
Larger organizations are more likely than their smaller counterparts to have funding for multiple projects. Therefore, theyve
had more resources available to continue preparing for ICD-10.

Answering the Tough

ICD-10 Questions

Smaller facilities typically lack funding for more than one project
at a time, and thus focused on immediate concerns during the past
year. Resources went first to electronic health record (EHR) systems,
and then to ICD-10. Each ICD-10 delay made it harder for HIM directors to convince team members that ICD-10 remained a priority.
But some remained vigilant in their ICD-10 preparations. Rochester Regional Health System, based in Rochester, NY, demonstrates
how strong HIM leadership helps to sustain ICD-10 momentum. By
maintaining their dual coding program and tightening collaboration
with their ICD-10 planning team, the HIM team at Rochester Regional has successfully progressed toward ICD-10 despite the delay.
For this organization, HIM is the epicenter of the ICD-10 change.

Regaining Lost ICD-10 Momentum Hard, But Possible

Serving New Yorks greater Rochester and Finger Lakes regions,
Rochester Regional Health System combines the resources
of legacy Rochester General Health System and legacy Unity
Health System with a team of 14,000 caregivers providing services for more than 150 locations across four counties. The organizations HIM leadership team for ICD-10 includes: Karen M.
Linder, BS, RHIT, CCS, CCS-P, AHIMA-approved ICD-10-CM/
PCS trainer, coding manager; Julieanne Arcuri, MS, RHIT, CCS,
AHIMA-approved ICD-10-CM/PCS trainer, coding manager;
Kimberly Miller, RHIT, CCDS, AHIMA-approved ICD-10-CM/
PCS trainer, manager of clinical documentation improvement;
and Judy Kelly, MS, RHIA, CCS, CCS-P, AHIMA-approved ICD10-CM/PCS trainer and senior director of HIM.
Linder, Arcuri, Miller, and Kelly kept implementation efforts
steady during the delays, especially in the areas of dual coding
and clinical documentation improvement (CDI). Also, the organizations ICD-10 project team remained intact and active,
meeting every two weeks with representation from HIM, CDI,
denial coordination, and information technology (IT) departments. Other attendees to the committee included the coding
integrity coordinator and a physician advisor. The organizations testing and IT systems took a break from ICD-10 during
the delay to address stage 2 of the meaningful use EHR Incentive Program, but as of January 2015 their focus was back on
ICD-10 and system readiness.
We maintained and kept our dual coding program going during the delays, while continuing to audit our dual coded cases,
Arcuri says. It took a lot of hard work and planning to get the
program up and running initially, including contracting with
an outside coding company for back-up inpatient (IP) coding
support. The organization didnt want to waste the progress
they had made. Furthermore, the ICD-10 executive sponsor remained supportive of funding the dual coding investment.
To help subsidize our dual coding program, we split the
costs between operations and the ICD-10 budget, Kelly says.
Data gathered through dual coding now helps steer final preparedness efforts and support continued executive investments in the program.
However, continuing funding for the CDI program was difficult. CDI team attrition occurred during the delay, which required additional funding for training. Were now rejuvenating
the CDI team with new staff, but recruiting and training CDI
specialists is challenging, Kelly says.

Top Obstacle to ICD-10 Implementation:

Compliance Date Uncertainty
SINCE 2009, WEDI has conducted surveys to assess readiness for ICD-10 implementation. Findings from the latest
WEDI survey, conducted in February 2015 and released
April 3, show some progress since the 2014 survey.1
However, compliance date uncertainty has led to new
readiness concerns, with more than 50 percent of all respondentsproviders, vendors, health plansciting uncertainty over future delays as the primary obstacle to
implementation progress. About two-thirds of the 1,174
survey participants had slowed or entirely stopped preparation as a result of the delay. The 2015 survey included 796
providers, 205 health plans, and 173 vendors.
Four key areas were impacted by the 2014 delay, according to the WEDI survey:

1. Provider Impact Assessments

About 33 percent of providers had completed impact assessments, down from more than 50 percent in August
2014. Further analysis revealed:
More than 60 percent of hospitals/health systems had
completed assessments.

Fewer than 20 percent of physician practices had
completed assessments.

2. Provider Testing
Only 25 percent of respondents had begun external testing
and only a few others had completed this step, down from
about 35 percent in August 2014. Further analysis showed:
More than 50 percent of hospitals/health systems had
begun external testing.
Approximately 10 percent of physician practices had
begun external testing.

3. Health Plan Testing

More than 50 percent of health plans had begun external
testing, and few had completed testing.

4. Vendor Product Availability

About 60 percent said their vendor products were available
or they had started customer testing, a slight decrease from
about two-thirds in August 2014.
Read the results of the full survey at

How to Find Coding Gaps, Analyze for Efficiency

During the delay, Rochester Regional used claims analysis
software to review all dual coded claims and identify shifts in
diagnosis-related groups (DRGs). The results of this analysis
have helped the coding team understand ICD-9 versus ICD10 coding as well as claims and reimbursement differences.
The inpatient coding integrity coordinator/educator (CIC/E)
continues to analyze the root causes of these differences and
reports back to the ICD-10 team.
Journal of AHIMA June 15/29

Answering the Tough

ICD-10 Questions


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30/Journal of AHIMA June 15

The DRG differences between ICD-9 and ICD-10 as identified

through dual coded claims analysis fall into three categories:
1. Coder knowledge/learning/dealing with the new complexities of ICD-10
2. Documentation gaps/CDI opportunities
Changes to severity of illness classificationcomplication/comorbidity (CC) or major complication/comorbidity
(MCC) cases
A pyramid of the coding team, CIC/Es, and CDI specialists focus on high-impact cases and areas to address the three reasons
for DRG shift. By far, the most common reason for DRG shift is
coding knowledge, particularly in the procedure coding system
(PCS). Root operations, additional knowledge of anatomy and
physiology, and device detail are key concepts for coders. The
common themes found through auditing are shared with coders as broader educational efforts, including team huddles.

ICD-10 Has a Huge Learning CurveUse Backups

if Necessary
There is a huge learning curve for ICD-10. The goal at Rochester Regional is to make sure everyone responsible for any type
of code assignment completes the curve prior to the October 1,
2015 deadline. Meeting this goal will help minimize the impact
to accounts receivable (AR). However, it will always be a fine
balance between ensuring thorough preparation for ICD-10
and maintaining a healthy AR.
To gain ICD-10 knowledge while simultaneously meeting
ICD-9 deadlines, the organization partnered with an outside
coding company early in the process and has continued to use
their support. Our back-up contract coders from HRS manage
the day-to-day inpatient coding workload so that our internal
coding team can dual code cases, keep practicing, and maintain
their knowledge, Arcuri says.
HRS also worked with Rochester Regionals HIM team to create a set of practice cases for dual coding. These dual coded cases
give the contract coding service provider an opportunity to establish Rochester Regional-specific coding guidelines for ICD10 ahead of the curve. HRS will also support Kellys team during
implementation to help cover expected productivity drops.
Organizations with minimal ICD-10 funding can take advantage of free coding seminars. Vendors, the Centers for Medicare
and Medicaid Services (CMS), and the American Hospital Association (AHA) offer ICD-10 outreach and training webinars for
all stakeholders. While many of these resources dont provide
complete coder training, they are a step in the right direction
offering comprehensive overviews of ICD-10 for general users
and administrative audiences.

Most Physicians Dont Like ICD-10Convince Them

When youre in the coding trenches, you understand the need
for ICD-10. But beyond HIM, it is difficult for stakeholdersespecially physiciansto swallow the short-term cash outlay to
realize a long-term, global benefit. Likewise, its hard to convince those not in the coding trenches that ICD-10 has longterm value. In fact, some physicians refer to ICD-10 as the
unpopular mandate. In terms of dollars, making the case for a

Answering the Tough

ICD-10 Questions

huge short-term hit to achieve a long-term gain is not easy.

According to an article in AHIMAs Perspectives in Health Information Management, it will take inpatient coders 69 percent
longer to code in ICD-10.2 That is because the codes are much
more specific, requiring additional documentation from providers. Education for physicians, mid-level providers, and other
clinicians is critical for ICD-10s success.
In a recent study by Nachimson Advisors, it is estimated that
the move to ICD-10 will increase documentation activities about
15 to 20 percent.3 This translates into a permanent increase of
three to four percent of a physicians time spent on documentation for ICD-10-CM. Nachimson suggests that this will be a permanent increase, not just an implementation or learning curve
during the initial phase of ICD-10. It is a physician workload increase with no expected boost in payment, due to the increased
requirements for providing specific information for coding.
Physicians must be educated on documentation requirements
to allow assignment of the most specific and accurate codes when
they are charting encounters. Even if they begin with a limited volume of cases, physician practices should ensure registration, coding, and billing staff are practicing with ICD-10. If they dont start
soon, getting up to speed after the October 1, 2015 deadline will be
difficult. Our physician educational efforts were significantly impacted by the delay, Kelly says. The organization re-evaluated its
timeline and is now restarting physician training for ICD-10.
For physician offices, Linders focus is to audit and educate directly with clinicians. Her goal is to raise the urgency and focus on
learning ICD-10 as it relates to their specific cases and patients.


There is a great need for outpatient (OP) CDI, Linder adds. This
need is not greater than inpatient, but its just as important. The
clinics have been very receptive to our reviews and help.
Physician offices are generally places where people are coding, but they arent necessarily trained coders. Its just a part of
the job, not their designated role, Kelly says. Examples include
front desk staff, nurse assistants, and physicians handling coding assignments themselves. Because these are non-traditional
HIM areas, there is a strong possibility for pushback on more
education. We just want them to learn the basics at this point
and by doing so begin looking ahead to how much more ICD-10
information theyll need in the year ahead, Linder says.
Best practice is to begin with the top 10 DRGs for each specialty. HIM teams should conduct documentation reviews for their
affiliated practices and staff. Starting with notes for the physician visits, Rochester Regional has two resources dedicated to
conducting office documentation reviews.
Some doctors are going to hit a wall, Linder suggests.
Searching for ICD-10 narratives will take longer, and physicians may also experience a productivity setback on the number
of relative value units they generate. Linder expects that HIM
will be asked to do a lot more remedial work, education, and
support for medical practices once ICD-10 is implemented.
Kelly and her team suggested other HIM departments work
with their physicians to identify keywords that they can use
within EHR systems to limit searches and find ICD-10 codes
quickly. Physician practices are also advised to allow extra time
for patient visits during the upcoming conversion.


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Journal of AHIMA June 15/31

Answering the Tough

ICD-10 Questions

At an executive level, Kelly and her team communicated the

risk of poor physician practice readiness for ICD-10. Theres still
a significant amount of risk to hospital organizations with regard to physician practices and ICD-10, including:
Physician practices dont have extra staff to allow for dual
Codes in everyones head will changeyou can no longer
rely on memory.
ICD-9 cheat sheets are no longer valid, and ICD-10 cheat
sheets may be too onerous.
Staff in offices may need to clarify more codes with the
Doctors are familiar with frequently-used ICD-9 codes; this
will not be the case in ICD-10.

retary Sylvia Mathews Burwell, former Workgroup for Electronic Data Interchange (WEDI) Chair Jim Daley expressed concern
about industry preparedness, stating that many organizations
failed to take full advantage of the additional time afforded by
the most recent one-year delay.4 Unless all industry segments
take the initiative to make a dedicated effort and move forward
with their implementation work, there will be significant disruption on Oct. 1, 2015, Daley says.
HIM professionals must lead the charge to regain ICD-10 momentum and keep that momentum going during the next few
months and beyond. This includes reaching out to affiliated
physician practices to provide support. Collaboration is the key
to success. The sooner organizations realize this, the better off
theyll be in this new world of ICD-10.

No One is Likely Responsible, So Take Responsibility

for Updating the EHR


Finally, using tools already available is another good way to reignite

ICD-10 education with physicians and begin improving clinical
documentation for ICD-10. Building prompts into EHR documentation templates is one simple, yet effective, way to make physicians aware of additional documentation requirements for ICD-10.
While HIM is not directly responsible for building ICD-10
prompts into the EHR, they should work closely with CDI and
IT teams to get the job done. Many organizations struggle to
identify an official owner for this task, creating gaps in ICD10 preparation.
At Rochester Regional, the CDI team prompts physicians for
more specific documentation for ICD-10, especially around laterality. Some prompts have been implemented with the organizations order entry and problem list modules.

Stop Stalling and Get on Board the ICD-10 Wagon

At this point, the industry cant afford to postpone preparations any
further. Though healthcare leaders are dealing with many priorities right now, they must get on board with ICD-10. The short-term
costs will be forgotten once the long-term benefits are achieved.
In a letter to Department of Health and Human Services Sec-

Journal of AHIMA Continuing Education Quiz

Quiz ID: Q1518606 | EXPIRATION DATE: JUNE 1, 2016
HIM Domain Area: Clinical Data Management
ArticleAnswering the Tough ICD-10 Questions


32/Journal of AHIMA June 15

1. WEDI. WEDI Survey Suggests Mixed Industry ICD-10

Readiness. WEDI press release. April 6, 2015. www.wedi.
2. Stanfill, Mary et al. Preparing for ICD-10-CM/PCS Implementation: Impact on Productivity and Quality. Perspectives in Health Information Management. June 2014. http://
3. Nachimson Advisors. The Cost of Implementing ICD-10
for Physician Practices Updating the 2008 Nachimson
Advisors Study. February 12, 2014.
4. WEDI. Letter to HHS Secretary Burwell on Workgroup
for Electronic Data Interchange ICD-10 Survey Results.
March 31, 2015.
Barbara Hinkle-Azzara ( is vice president of
HIM operations and Kim Carr ( is director of clinical
documentation at HRS.



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34/Journal of AHIMA June 15

Remediating ICD-10
Knowledge Loss


By Michelle A. Black, RHIA Illustration by Valerio Fabbretti

IF YOU DONT use it, you lose it. This is true for much of what
we learn in life, and its particularly true when it comes to ICD10-CM/PCS. Although most organizations initiated ICD-10
coder training in 2013, many decided to cease training and dual
coding practice after the second ICD-10 implementation delay
was announced last year.
Now with the ICD-10 implementation deadline quickly
coming up, HIM directors and ICD-10 trainers must measure
coder knowledge loss, identify specific areas of concern, and
implement effective strategies to get coder know-how back
in shape by the October 1, 2015 compliance date. This article
explains how to restrengthen those coding muscles and go
from flab to fab.

Impact of the Delay on Training

Whether the decision was based on budgetary constraints
or the drive to meet daily discharged not final billed (DNFB)
goals, the impact of ceasing training and dual coding efforts
during the ICD-10 delay is the same. Coders lost the ICD-10
knowledge they had amassed. Just how much knowledge
might have been lost, what is the impact, and what can be
done about it now as the deadline approaches are the three
important questions HIM professionals must ask.
The first step is to acknowledge two primary knowledge loss
concerns: coding accuracy and coder productivity. When coders arent given sufficient practice time, accuracy suffers. For
example, a deluge of claims rejections and denials are expected
during the fourth quarter of 2015 if codes are inaccurate or improperly assigned. An organizations ability to quickly review
rejections, resubmit claims, and remediate underlying code accuracy issues will be paramount to ensuring steady cash flow
and accounts receivables. Productivity also will be impacted as
coders can no longer rely on memorized codes or cheat sheets.
Knowledge loss, accuracy, and productivity are intertwined.
October 1, 2015 is not the point at which managers should discover that coders have knowledge deficiencies. Now is the time
to identify these gaps.

Assess Knowledge Gaps

Knowledge loss will vary from institution to institution and
from coder to coder. Some organizations may have required
coders to practice ICD-10 regularly despite the delays, while
others may have halted all efforts awaiting a final decision
on the new implementation deadline. Some coders may have
taken the initiative to practice on their own. Newer graduates may have retained more information than those who
have worked with ICD-9-CM throughout careers that span
multiple decades.

Cost Justify Your Efforts

THERE ARE MANY areas of knowledge loss expected in
ICD-10 that must be remediated through additional education and dual coding practice. Combination codes provide
an important example.
While coders may understand the concept of a combination code, they may not be able to identify all instances in
which a combination code is required.
Consider this example: A physician documents diabetes with diabetic neuropathy. A coder assigns ICD-10
code E11.9 (type 2 diabetes without complications) and
ICD-10 G62.9 (polyneuropathy, unspecified) instead of
ICD-10 combination code E11.40 (type 2 diabetes with
diabetic neuropathy, unspecified). Reporting the diabetes and neuropathy separately significantly reduces the
reimbursement that the organization will receive and to
which it is entitled.
These types of specific examples must be used by ICD10 trainers and HIM directors to justify the costs of training,
education, and coder assessment.

HIM directors, ICD-10 trainers, and coding managers should

assess each coder individually to fully understand and address any gaps. According to data compiled by coding vendor
H.I.M. On Call, knowledge loss regarding PCS coding may be
most significant.
At H.I.M. On Call, 150 coders were trained and tested on ICD10 during late 2013 and early 2014. Post delay, these coders were
shifted back to ICD-9 production coding. In early 2015, their
ICD-10 knowledge was reassessed using actual cases and a live
testing environment. The data from the vendors online coder
assessments revealed the greatest knowledge loss was related
to PCS coding. In particular, significant drops in ICD-10 knowledge and expertise were revealed in the following five procedure areas:
Upper veins
Lower veins
Lymphatic and hemic systems
Cardiovascular system
Urinary system
These results are probably not uncommon industry-wide.
There are fundamental differences between the PCS coding
structure in ICD-9 versus ICD-10 tables and root operations.
Additional areas of PCS knowledge deficiency based on data
analysis include:
Journal of AHIMA June 15/35

Remediating ICD-10
Knowledge Loss

Five Readiness Questions to Ask Vendors

ALTHOUGH MANY CODING vendors have stated that they
will be ready for the ICD-10 transition, keep in mind that just
like hospitals theyve had to pull coders away from ICD-10
to accommodate current-day ICD-9 coding. Dont assume
that your vendor has provided sufficient practice time for
their coders during the delay. Organizations need the reassurance of knowing that when the time comes for ICD-10
go-live, their contract coders will be ready.
Here are five important questions to ask your outsourced
coding partners:
Have your coders continued to practice with ICD-10
by dual coding actual cases?
Do you have a central learning program that includes
ICD-10 modules and, if so, have coders maintained
their knowledge?
How many hours of practice time do these coders
have each week?
What other types of training materials have you provided your coders for ICD-10?
How do you assess your coders in ICD-10 and what
accuracy levels have they achieved?

Laparoscopic procedures
Spinal and ankle fusions
Epidural injections
Certain root proceduresespecially dilation, excision,

resection, and extirpation

One coder shared anecdotally that shes also concerned about

PCS primarily because of a lack of timely and complete physician documentation that will be necessary to build a code. The
lack of timely access to operative reports will compound the
difficulty of coding nuances within ICD-10-PCS. Timeliness of
surgical documentation must be addressed in conjunction with
coder retraining.
In assessing the same group of coders, accuracy rates for ICD10-CM remained fairly consistent with pre-delay findings except for the following six diagnosis areas:
Labor and OB/GYN codes (including pre-term births and
Contusions and sprains
Underdosing (a new concept in ICD-10-CM)
Although coders may have forgotten some of what they
learned, there is time to repair this knowledge loss between now
and October 1, 2015.
36/Journal of AHIMA June 15

Take These Steps Now to Reduce Coder Brain Drain

Especially for ICD-10-PCS, HIM directors and managers should
repeat a full round of basic PCS refresher training. This should
include basic training regarding the fundamental differences
between PCS and ICD-9 code structure, and training on how to
navigate the PCS tables and root operations.
Once this training is complete, the following six strategies
should be implemented as soon as possible to help coders remediate knowledge lost during the delay and successfully cross
the ICD-10 learning chasm.

1. Identify a dedicated ICD-10 resource who can train and audit.

This individual is critical to the overall success of an organizations retraining efforts. If the organization doesnt intend to
hire a new employee to serve in this role, consider appointing
an existing coder or auditor who has demonstrated a strong
proficiency and interest in ICD-10. This individual can then perform the following tasks:
Select a comprehensive sample of records for dual coding
purposes based on high volume and common services.
Review records that have been dual coded to ensure accuracy.
Provide immediate feedback to coders based on dual coding results.
Track and trend accuracy rates for each individual coder.
Redirect refresher training efforts based on knowledge
deficits, including one-on-one training, if necessary.
Lead group discussions/meetings during which coders
can discuss one or more scenarios in ICD-10.
Compile ICD-10-related questions as they arise.

Develop internal ICD-10 coding guidelines to ensure
Monitor compliance after ICD-10 go-live to perform additional training as necessary.
Appointing someone in charge of ICD-10 retraining ensures that organizations make the most of the time that remains before the deadline, spend resources wisely, and direct efforts toward areas of ICD-10 with which coders need
the most assistance.

2. Build in time for dual coding and practice.

Each coder should be able to practice ICD-10 for at least a few
hours each week. This time may be spread over several days, or
it could occur on one day of the week. Directors and managers should be flexible with the practice schedule. The number
of hours each week could fluctuate depending on how coders
progress. Likewise, if the organizations census fluctuates in
terms of volume or severity, seize these opportunities for training and practice purposes.
HIM directors and managers shouldnt underestimate the time
it will take for coders to relearn some of this information. Erring on
the side of caution is advised. Also keep in mind that coders may be
tempted to practice what they know, but its important to break out
of ones comfort zone, particularly with more complex procedures.

Remediating ICD-10
Knowledge Loss

3. Set your budget and advocate for more funding.

Coders will be successful when they have the full support of executive leadership. Training and dual coding practice take coders away from the current DNFB. CFOs need to understand the
importance of refresher training and practice time.
Reiterate that outsource coding may be necessary to ensure
internal coders have sufficient time to learn and relearn this
new system. Even after go-live, training is inevitableits a continual learning process. ICD-10 training time and back-up coding resources should be included in every organizations longterm operational budget.

4. Encourage coders to take advantage of PCS tools.

When it comes to PCS, memorization is key. The more root operations coders can memorize, the better off theyll be. There are
plenty of flashcards and even mobile apps that can help coders
accomplish this. Coders can use these tools when its convenient for them without having to block off significant periods of
time during their personal lives.

5. Survey your staff.

Directors and managers should meet with each coder individually to better understand areas for improvement. Ask
staff members:
With what aspects of ICD-10 do you feel most comfortable?
What areas need improvement? For example, do you struggle with certain diagnoses, body systems, or procedures?
W hen dual coding, do you spend more time on certain
cases than others? Why?
Is there any information (i.e., guidelines, root operations,
anatomy) that you know youve forgotten?
Do you spend time outside of work practicing ICD-10?
Why or why not?
Do you feel that the organization has provided the training that you need? If not, what suggestions can you make?
W hat else can the organization do to make this transition
easier for you?
Coders will appreciate the fact that managers take time out of
their busy days to truly understand how coders feel about the
transition. Nobody wants to admit they have forgotten information, but its best to be open and honest so knowledge gaps can
be addressed.

6. Perform ongoing assessments.

Dont assume that coders are competent in ICD-10 simply because theyve completed certain training modules or read certain materials. ICD-10 includes many nuances. Trainers and
coding managers must be certain that coders grasp its concepts.
Ongoing assessments fill this need.
Coders should receive immediate feedback regarding the
accuracy of their work. In a practice environment, immediate
feedback ensures coders have time to practice correct methods. In a real environment, immediate feedback ensures that

mistakes dont snowball into hundreds of thousands of dollars

worthor moreof denials.
The greatest challenge for any teacher is finding the time to
grade papers. The same will be true of ICD-10 trainers and mentors. Coder assessments must be conducted either manually or
using an automated tool. A strong answer key is essential and
should be used to review codes during training, practice, and
dual coding. Automation greatly enhances the assessment process and reduces the amount of time trainers and managers
must dedicate to this critical step.
Following initial implementation and go-live, continually assess accuracy and productivity. Develop ongoing training and
assessment efforts accordingly. For example, perform spot
checks on certain procedures or service lines. Reiterate to coders that these audits are not punitive, but rather are designed to
improve the department as a whole.

7. Target education going forward.

Competencies may vary widely in a single department. Dont
waste valuable group time on training certain aspects of
ICD-10 needed only by one or two individuals. Use information gleaned during coder assessments and ongoing audits
to drive educational efforts. Focus efforts and resources by
providing targeted education where it is needed and has the
most impact. For example, individual coders may require
remedial education on a particular root operation. Include
only those who need that education. Dont assume it will be
beneficial for everyone. Coders dont necessarily need to relearn what they already know well.

Address Knowledge Loss, Dont Ignore It

Everyone acknowledges that some ICD-10 knowledge was lost
due to the delay. Knowledge loss is just one of many costs associated with multiple delays of ICD-10. Rather than bury their
heads in the sand, organizations must address the knowledge
loss issue and pursue remedial actions nowduring the last
four months of ICD-10 preparation.
Finally, dont make coders feel discouraged about knowledge
lossempower them to improve on deficiencies and become a
more effective professional.
Cassie Milligan, RHIT, CCS, manager of coding quality improvement at H.I.M. On Call, offered sage advice to others
working through the transition. If you are a hospital-based
coder, I suggest you take advantage of any training the hospital has to offer. If you are an independent contract coder, I
suggest you invest in seminars or boot camps to refresh your
knowledge on ICD-10, Milligan says. If this is your career,
then the money will be well spent. Also read any trade magazines you can find on ICD-10 coding scenarios, and visit the
AHIMA website. There is a lot of free information out there if
you just take the time to seek it out.
Michelle A. Black ( is director of coding
quality and education at H.I.M. ON CALL.
Journal of AHIMA June 15/37

By Desla Mancilla, DHA, RHIA; Carolyn Guyton-Ringbloom, MBA, RD, CAE; and Michelle Dougherty, MA, RHIA

JOBS IN THE health information management (HIM) profession are becoming increasingly advanced in the need for both
technical expertise and leadership skills. This shift is particularly important to recognize as HIM professionals navigate new career opportunities and changes ahead. Strong leaders are needed in the profession to help guide and shape the future of HIM.
But what leadership skills have helped HIM leaders succeed
in the past? How does education and volunteerism support
leadership development? These questions were asked of several
HIM executive and director leaders at the 2014 AHIMA Annual
Convention and Exhibit in San Diego, CA. The insights gained
from that discussion provide the following picture of what skills
are critically important in these changing times.

Ten Important Leadership Skills

At the convention, 18 HIM leaders shared their perspectives on
the leadership characteristics and skills that most strongly contributed to their success and led to professional recognition in
38/Journal of AHIMA June 15

their organization. Two focus groups were heldone with HIM

executives and one with HIM directorsand their responses
analyzed to identify themes in their advancement.
Leadership is strongly represented in the HIM professional
body of knowledge. The concept of leadership encompasses a
broad swath of opportunities open to HIM professionals. Not
unlike other fields of practice, the HIM skill set is undergirded
by a foundation of necessary skills that can propel qualified individuals to the highest level of recognition within a variety of
The focus group participants believed that the following 10
leadership skills are critical to their success:
Confidence and Courage: Believe in yourself and your
convictions; have the strength to assert yourself and push
forward when you believe in something. Leaders need to
have executive presence.
Desire to Achieve: The drive to succeed, meet goals, get
things done, and achieve results.

Ten Skills that Make a

Great Leader

Figure 1: Common Employability Skills

THESE EMPLOYABILITY SKILLS are interconnected to allow employers to look at the full scope of what skills are necessary
in all major economic sectors. Together, attainment of these business-defined skills prepares individuals for careers and for
further education and training.

Source: National Network of Business and Industry Associations. Common Employability Skills. July 22, 2014.

 ision: The ability to see the whole picture, including
what the future will look like. From that big picture, the
ability to set future direction and strategy, understand
what is happening in the current environment, determine
how to get to a future state, and motivate others to follow.
Innovation: Become an intuitive thinker who looks for better
ways and is not constrained by the past (or current) practice.
Flexibility: Creativity and the ability to adapt and accept
change. Not only has a plan B, but also a plan C.
Integrity: Being a trusted leader, someone people want to
follow and believe in their direction. Loyalty and honesty
are important.
Collaborative Skills: Diplomatic and able to form relationships. Considers self a facilitator and part of the team.

Ability to put self in others shoes. Ability to delegate and

develop a team.
Communication Skills: Although already a common
employability skill (see Figure 1 above), strong communication ability is critical for a leader. This is the ability to
provide clear direction and effectively write, speak, and
K nowledge: Has recognized expertise and technical
skills, and surrounds self with knowledgeable people.
L ife-long Learner: Never stops learninghas an interest and desire to continually gain new skills, knowledge,
and education.
There are multiple avenues a person can take to develop their
Journal of AHIMA June 15/39

Ten Skills that Make a

Great Leader

One Members Path to Leadership

JANNIFER OWENS, MSA, BSHA, CCS, CPC, CIRCC, senior HIMS coding director at Banner
Health and a leadership roundtable participant, began working in HIM 18 years ago, with the
majority of that time working in coding. She began seeking leadership roles around 2006
and has worked in a variety of positions since then. In November of 2010, she began working
for Banner Health and, during that time, moved from a senior coding manager to acute care
coding director and, finally, to senior coding director.
Owens practices lifelong learning by pursuing higher education and obtaining relevant
credentials, including a bachelors degree in healthcare administration, a masters degree in
accounting, and several coding certifications.
The leadership skills that Owens uses most successfully have been building relationships
and executive presence. Building relationships is important to ensure that others realize
your value, Owens says. Accountability, trust, and respect are imperative in building strong
relationships between a leader and their peers or a leader and their staff. From an executive
presence perspective a suitable level of confidence and intelligence should be expressed, one should communicate clearly
and appropriately, and composure must be mantained during difficult situations. Through the application of these and a
few other techniques, I have been able to successfully obtain increasingly higher job levels, Owens says.
Additionally, a key leadership skill of Owens is effective collaboration with her staff of around 200 people. We work in a
team environment and use each others skills to create and finalize decisions, Owens says. In addition, she fosters trust
between team members, which has led to the ability to maintain goals and provide increased job satisfaction.
Owens has also volunteered nationally and on the state level in appointed and elected positions. This year she was elected
as the treasurer-elect of her state HIM association. She also volunteers within her organizationfor example, with other groups
on system initiatives. Owens is displaying her leadership skills across the system. I really feel like a great leader is one who
is easily approachable, sincere, and humble, while still demonstrating confidence, knowledge, and composure, she says.

leadership skills. One of them is to conduct a self-assessment

of the 10 previously discussed leadership skills and determine
personal areas of growth and development. Another is to identify good role models in your organization. They can help identify
the characteristics that are valued. Seek a mentor that can guide
and offer advice in your leadership growth. Also, take advantage
of leadership development programs offered in the work place.
In addition to these steps, one can also seek ongoing formal
education and volunteer roles to build skills.

Leadership and Education Intertwined

The HIM leaders in the focus groups recognized the importance
of continuing their formal education to advance their career not
only to gain knowledge and technical skills, but to understand
how to act like a professional, work as a team, think strategically,
and improve communication skills.
A strong academic foundation provides a core set of competencies for HIM leaders. As noted in the 10 leadership skills,
many are considered soft skills (integrity, collaboration,
problem solving, work ethic). The National Network of Business and Industry Associations identified a core set of fundamental skills and competencies for leadership. Figure 1 on
page 39 illustrates these common employability skills categorized in four areas: personal skills, people skills, workplace
skills, and applied knowledge. Attainment of these businessdefined skills can prepare an individual for both career and
educational goals.
40/Journal of AHIMA June 15

Relationship Between Volunteerism and Leadership

Volunteerism and leadership go hand in handeither by supporting the development of leadership skills or providing an opportunity to give back for the benefit of others.
Networking is key for professionals, as many times it is who
you know that opens doors. The HIM leader focus groups
agreed that volunteering provides an opportunity to network.
Volunteering surrounds you with other dedicated professionals with advanced skill sets. This can also help you develop your
own skills. Also, volunteer activities usually are a group effort,
so participants learn how to work with people who likely have
differing work styles, opinions, and skill levels. Jannifer Owens,
MSA, BSHA, CCS, CPC, CIRCC, the senior HIMS coding director at Banner Health, says in order to work with others one must
develop an environment of appropriate, respectful communication where all can be open, honest, and not afraid to state
their opinion.
Networking allows you to identify with the best and the brightest, and also allows others to find you as one of the stars. Additionally, networking provides a group of colleagues with whom
to ask questions or look for best practices.
Volunteer positions provide the opportunity to learn new
skills, expand current skills, or try out different skills. Within
a work environment, many times you are using one set of skills
and dont have the opportunity to expand those skills. Volunteering allows this opportunity. You can choose a volunteer
position that expands familiar skill sets or learn something

Ten Skills that Make a

Great Leader

completely new. The leadership panelists discussed how they

refined current skills, such as directing a team, or expanded
those skills by trying a position different from what they did
in their current practice.

Earning an advanced degree

opens doors. But networking,
volunteering, and being willing
to step out of your comfort
zone gives you even greater
leadership opportunities.
Nancy Glaubke, MBA, RHIA,
corporate HIM director, Adventist
HIM professionals can assess their volunteer leadership
skills by completing the Volunteer Leadership Competencies Self Assessment at This assessment can help identify what volunteer positions might fit
your skills or which ones you would like to strengthen in a
volunteer role. After the assessment, look for volunteer opportunities at both the local component state association
and the national AHIMA.
Continued learning should be an objective for all professionals, and is key for leaders. The focus group participants identified a number of ways that they, as leaders, continue to learn.
This included listening to other people and also taking ideas
and morphing them into their own. They agreed that leaders
dont have to reinvent the wheel. Additionally, listen to other

Journal of AHIMA Continuing Education Quiz

Quiz ID: Q1528606 | EXPIRATION DATE: JUNE 1, 2016
HIM Domain Area: Performance Improvement
ArticleTen Skills that Make a Great Leader

peoples stories, since these are invaluable learning opportunities. They may have handled a situation similar to one you are
dealing with currently. Lastly, develop strategic planning skills.
A leader in any capacity must have this ability.
Getting to know someone through a volunteer opportunity
can lead to a job opportunity. Many within the focus group
shared how volunteering opened doors to promising career opportunities. An employer could see you as a leader in a volunteer role and then think of you for a position when it becomes
available. For the volunteer, it allows you to get to know others
and show off your strengths.
Resilience, grit, and confidence are three core leadership characteristics that author Lareina Yee identifies as necessary for
women to be successfully viewed as leaders in her recent article
Fostering Women Leaders: A fitness test for your top team.
In a female-dominated profession, these findings are important and also consistent with the focus groups insights. While
not necessarily referred to with the same words, the HIM leaders identified these characteristics as confidence, courage, and
the desire to achieve. To sum up their advice to future leaders of
the profession: Preparation begets opportunity, so prepare academically, volunteer, and network. Do this and you will be ready
to make your mark when opportunity arises.

Yee, Lareina. Fostering women leaders: A fitness test for
your top team. McKinsey Quarterly. January 2015. www.
Desla Mancilla ( is senior director of academic
affairs and Carolyn Guyton-Ringbloom (carolyn.guyton-ringbloom@ahima.
org) is senior director of volunteer leadership development at AHIMA. Michelle
Dougherty ( is a senior health informatics research scientist with RTI Internationals Center for the Advancement of Health IT.




Journal of AHIMA June 15/41

Privacy HOLES
in the Hidden
By Daniel A. DuBravec,CHTS, CEHRS, and Matt Daigle

42/Journal of AHIMA June 15

Privacy Holes in the Hidden

Healthcare System

WITH STUDENT SAFETY and privacy an increasing parental

concern, school administrators nationwide are sitting on a powder keg of potential backlash because of a gray area of student
privacy protections that Julia Lear, senior advisor for the Center of Health and Health Care in Schools at George Washington
University, calls the hidden healthcare system.1
Lears hidden healthcare system exists in every town, every
county, and every state. Its a mottled system, attending to the
needs of nearly 50 million students in approximately 100,000 public schools.2 Another 40,480 private and religious K12 schools require health services.3 Within the schools themselves, the healthcare system is varied, with some having a large staff of full-time
school nurses while others share a single nurse amongst multiple
schools and can rely on unlicensed assistive personnel as needed.4
Equally varied is how school districts document care and
treatment. When a student is treated by a school nurse, the
medical encounter is often entered into a system using the districts software of choice. Sometimes this software is maintained
by the school on the local network; other times it is hosted by
a vendor as a cloud-based application. A vast majority of survey respondents (59 percent) told the National Association of
School Nurses that they use electronic health records (EHRs)
to document student health data containing treatment notes,
screenings, and sometimes medical charts.
The privacy and security of this medical information can vary,
and some are concerned that not enough is being done to protect this hidden healthcare systems medical records.

Students Left Behind

At a federal level, health record privacy concerns have given
birth to a number of laws and regulations. The best known of
these is the Health Insurance Portability and Accountability Act
(HIPAA). HIPAA was enacted in 1996 to establish transaction,
security, privacy, and other safeguards to protect health information when stored and shared electronically. It is specifically
created for healthcare providers (or covered entities) who conduct electronic transactions that contain patient information.
K12 schools would only be considered covered entities if they
were electronically billing Medicaid-covered services from the
school location.5 Since medical data recorded by the schools is
stored and classified as an education record, it does not fall under
HIPAA. Instead, education records are covered by a different federal law, the Family Educational Rights and Privacy Act (FERPA).
FERPA was created specifically for the privacy of student records as a whole, allowing parents the right to access and review
student records, make modifications if they are incorrect, and to
grant disclosure of the records. This law ensures student record
confidentiality to the extent that it sets some limitations for how
the information is shared.6 In fact, FERPA only provides protections to schools that receive federal funds. Therefore, students of
private and religious schools often find themselves without any
federal protection by either HIPAA or FERPA.
Parents in many cases carry a common, false assumption that
this medical data captured by nurses at local schools and local
clinics are equally protected by HIPAA, and, if not, FERPA.
HIPAA security rules, and the security risk assessment tools
based thereon (such as those recently released by the US De-

partment of Health and Human Services (HHS)) were designed

to protect patient data, but the same focus on electronic protected health information (e-PHI) does not appear to extend to
students attending K12 schools.
In the US, schools compile detailed and robust education
records directly related to each student, and these records are
maintained by an educational agency, institution, or party acting
on behalf of the institution.7 There are many components of this
record, including: the cumulative file; the clinic file; the disciplinary file; the special services file; and the English for Speakers
of Other Languages (ESOL) file.
For students attending a K12 school, health information recorded by a school nurse is not classified as a medical record,
but rather is combined with all the students education and demographic information. The clinic file can also contain many
medical record file types, such as annual health data, cumulative health records, emergency care information, general health
information, and medical flag information. Heres where things
start to become graywhen this type of data is collected by K12
schools electronically, the only distinction between it and the
data stored at a clinic or hospital in an EHR are the laws which
govern it and any established legal safeguards.

Where are the Safeguards?

A review of current guidelines and laws found that there are many
concerning areas related to electronic student medical information security within K12 schools. It raises a critical question: Do
public, private, and parochial K12 schools have administrative,
physical, and technical safeguards in place for their electronic
datawhich includes medical and other privacy information
when it is being shared with K12 administrative staff, faculty,
school volunteers, and sometimes even software vendors?
The authors found that there are a number of developing
trends that should be worrisome to school administrators:
In general, the majority of K12 schools do not fall under
HIPAA protection and guidance. If those same records
were stored by local clinics or hospitals, federal mandates
would call for HIPAA protection and the issuance of fines if
those laws were violated.
Public K12 schools do fall under FERPA federal privacy
regulations, but not for medical records, and private institutions have even fewer protections. Similar HIPAA-like
privacy guidelines for administrative, physical, and technical
safeguards are minimal to non-existent. Private or religious
schools are not subject to HIPAA or FERPA guidelines.
Data is at risk whether from negligent behavior or from
malicious attacks. New reports and studies indicate a
growing awareness and concern that sensitive student data
is poorly protected and improperly shared, or being intentionally hacked due to weak security safeguards.8 For example, in early 2014, Loudoun County Public Schools discovered that personal information about students and staff
members was publicly availablenot because of the efforts
of a clever or disgruntled hacker, but rather by a third-party
vendor contracted by Loudoun County who failed to implement password protections within their software. This allowed more than 1,300 links to the schools confidential inJournal of AHIMA June 15/43

Privacy Holes in the Hidden

Healthcare System

formation to be accessible by any Internet user with access

to Google.9 This is an example of only one school system
out of thousands who find themselves in similar situations.
FERPA does not contain specific breach notification requirements when sensitive data is hacked or released through
employee negligence. A breach of this type does require the
school to record the incident, but its the schools prerogative
whether to notify parents or guardians about a breach.

Student Health Data Faces Many Risks

A recent survey revealed that more than 40 percent of schools
use cloud applications to store their data.10 If you read the privacy policy of these vendors, youll notice that nearly all have a
clause that some of the data might be shared and their privacy
policy may change at any time. A 2013 report by Fordham Universitys Center on Law and Information Privacy revealed none
of the schools surveyed by the authors had a contract in place
requiring the hosting cloud service provider to notify the school
if the service provider becomes a target of a data breach.11
There are other concerns with the cloud. The recent bankruptcy of software vendor ConnectEDU forced the intervention
of the Federal Trade Commission to prevent 20 million student
records from being sold to a venture capital company.12 Another
complication is where the cloud emanates fromespecially
when the servers that hold the data arent located in the United
States. Very few K12 schools are aware of the student data privacy risks presented by foreign storage of US student data.13
The varied nature of school personnel also presents its own
challenges. Student medical data may be viewed by more than
just the school nurse or the current classroom instructor due to
lax school policies or limited access control from poorly designed
software. This opens the door to legal access by anyone who may
be on the schools staff under the auspices of legitimate educational interest, which can include parents and community volunteers, since it is highly unlikely that the school administration
requires volunteers to sign non-disclosure agreements to prevent
them from revealing what they might see in a students record.
Thats not to discourage the use or downplay the benefits of storing student data electronically in K12 school systems, especially
in a fiscally challenging environment. School budget savings can
be expected to reach 27 percent by 2016 by shifting paper-based
or local network applications to cloud computing servers.14
Also, the resulting increase in the usefulness of these records
has allowed K12 school systems to more effectively use student
EHRs to track immunizations, concussions, and the prevalence
of flu viruses. Just like with traditional hospital EHRs, student
electronic records also allow school nurses to more effectively
track medication doses they have administered.15 These rewards
further reinforce the urgency of the matterthat immediate attention and local, state, and federal legislation needs to be the
priority of school administrators.
If action isnt taken soon, school systems will ultimately be
mired in litigation as student data is exposed in large scale breaches because proper security protections were ignored or deemed
too costly to implement. One solution would be the broader application of HHS HIPAA guidelines, which can be used just as effectively within the K12 school environment. Also, since student
44/Journal of AHIMA June 15

records contain medical information, relevant software should

be required to go through an EHR certification process similar to
what the Office of the National Coordinator for Health IT requires
of EHRs that are to be used by hospitals and clinics.

More Legislation Needed to Protect Data

The strange dichotomy of how student medical data is treated differently by K12 schools versus medical data stored by EHRs in
hospitals has not gone unnoticed. In 2012, the Electronic Privacy
Information Center (EPIC) brought legal action against the US Department of Education to challenge FERPAs current guidelines.
Unfortunately, the court dismissed the lawsuit stating that EPIC did
not have standing to bring the claims asserted in the complaint.16
The issue seems to be reaching a crossroads in 2015. An April
17, 2015 Washington Post article on Virginias legislative efforts
to ensure parents are notified of school data breaches states that
in the first three months of 2015 more than 160 bills were introduced in 41 state legislatures to address education data privacy.17 Of these states, California implemented the Student Online Personal Information Protection Act, which since January 1,
2015 prohibits operators of Internet websites or online services
from disclosing, compiling, or selling student data.
At a federal level, President Barack Obama urged Congress to
impose similar restrictions.18 Google, Apple, Microsoft, and 73
education technology providers have pledged to follow the Future of Privacy Forum (FPF) and the Software and Information
Industry Association (SIIA) Student Privacy Pledge to protect
students from the collection, maintenance, and use of student
personal information by software vendors.19
In reality, these efforts only go so far. Granted, they will offer
some cursory protections against the sharing of student data
with external vendors. But how this data is shared internally
within the individual schools and school systems remains a
massive concern. Only by requiring mandatory national guidelines of administrative, physical, and technical safeguards specified by HIPAA will student data then have the same privacy protections as all other electronic medical records.

1. Lear, Julia. Health At School: A Hidden Health Care System Emerges From The Shadows. Health Affairs 26, no. 2
(March 2007): 409-419.
2. Robert Wood Johnson Foundation. School Nurse Shortage May Imperil Some Children, RWJF Scholars Warn.
December 12, 2013.
3. Center for Education Reform. K-12 Facts. September
4. Johnson, H. K. and M.D. Bergren. Meaningful Use of School
Health Data. The Journal of School Nursing 27, no. 2 (April
2011): 102-110.
5. Dinsmore & Shohl LLP. Understanding the Privacy Rights
of HIPAA & FERPA in Schools. The National Law Review.
January 7, 2011.

Privacy Holes in the Hidden

Healthcare System

6. US Department of Education. Family Educational Rights

and Privacy Act Regulations (FERPA). January 2012.
7. Association of State and Territorial Health Officials. Comparison of FERPA and HIPAA Privacy Rule for Accessing
Student Health Data. June 6, 2014.
8. Herold, Benjamin. Danger Posed by Student-Data Breaches
Prompts Action. Education Week. January 22, 2014.
9. Nadler, Danielle. Loudoun Schools Repair Online Data
Breach. Leesburg Today. January 7, 2014. www.leesburgtoday.
10. Lynch, Matthew. Cloud Computing and K-12 Classrooms. Education Week. October 11, 2013. http://blogs.
11. Reidenberg, Joel et al. Privacy and Cloud Computing in
Public Schools. Fordham University Center on Law and Information Policy. December 13, 2013. http://law.fordham.
12. Haimson, Leonie. 20 million student records put at risk by
ConnectEDUs bankruptcy. NYC Public School Parents
Blog. May 29, 2014. http://nycpublicschoolparents.blogspot.

13. Reidenberg, Joel et al. Privacy and Cloud Computing in
Public Schools.
14. Lynch, Matthew. Cloud Computing and K-12 Classrooms.
15. Atwal, Parmeeth. Improving Health Care in Schools: School
Nurse Leader Gives Districts EHR System an A+. HealthITBuzz. May 9, 2012.
16. Electronic Privacy Information Center. EPIC v. The U.S.
Department of Education. September 24, 2014. http://
17. Amundson, Kristen. Avoiding a Privacy Headache. Washington Post. April 17, 2015.
18. Simon, Stephanie. Barack Obama to seek limits on student data mining. Politico. January 11, 2015.
19. Ghosh, D. Privacy Pledge. Student Privacy Pledge. 2014.
Daniel A. DuBravec ( is a senior consultant at LMI, a nonprofit government consulting firm. DuBravec holds multiple EHR certifications
and is a consultant for the government on EHR patient privacy and security
standards. Matt Daigle ( is senior public affairs specialist for
LMI and holds a masters degree in journalism from Northwestern University.


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Journal of AHIMA June 15/45

Working Smart a professional practice forum

Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / The Sound Record

The Evolving Role

of the Privacy and
Security Officer
By Rita K. Bowen, MA, RHIA, CHPS, SSGB

FIFTEEN YEARS AGO, many individuals accepted the role of

the privacy officer with a perception that it would be a role involving the education and training of individuals on HIPAA rules
and regulations, developing policy, and responding to reported
incidents. The security officer was focused on system integrity
and may or may not have been actively involved in systems access approval. Their role and focus was most likely centered on
information controlled in the data center, and primarily focused
on detection and protection of that domain.
Today these roles require a constant awareness of the everchanging landscape that determines how health information is
used and shared. As organizations prepare their information governance plans, privacy and security officers must be included to
map out what data elements are transferred among systems and
validate the appropriateness and security of the processes.
The focus of privacy and security is how to meet information access demands while still maintaining the sensitivity of the information being shared. Along with existing federal regulations for health
information protection, 47 states have versions of their own rules
and regulations for breach notification. States may also have their
own definition of when an incident is a reportable breach.

High-Profile Breaches Alter Security Mindsets

A lesson learned from the breaches of 2014 is that an organization
cannot be over-prepared. High profile breach incidents involving
Anthem, Target, and Home Depot proved that traditional security solutions are not effective. Every reported incident should be
evaluated and used as an opportunity to identify where privacy
and security gaps might exist and how they should be resolved.
Privacy and security officers need to think like a thief and determine what data elements are vulnerable and how that infor46/Journal of AHIMA June 15

mation can be used for personal gainthen figure out a way to

protect against those threats. Organizations must identify the
continuing advanced techniques for intrusion that defy detection by traditional security solutions. Privacy and security officers must stay constantly aware of regulations and penalties
that may result in reputational harm as the result of an incident.
Privacy and security compliance officers should report directly
to the organizations CEO and board of directors as these positions must be vigilant about the organizations environment and
create a strategic approach for that environment to be managed.
This can be accomplished by conducting frequent environmental scans, which can help organizations be continually prepared
to respond to security threats or breaches. Examples such as the
breach reported by insurer Anthem in 2014 that impacted millions of people has shown the industry that timelines are important, as is recording each item reviewed, how a decision was
made, and the resulting outcome. How an organization manages
its response to incidents is also paramount.

Managing Incident Response

It is vital that privacy and security officers have a thorough and
complete plan in place for when an incident is reported. It must
be timely and consistent in the analysis and reporting of mitigation efforts. Whether there is a single response plan of action,
ad-hoc committee response type action, or a fully active privacy
and security incident response team, the response timeline is
essential. The timeline is reduced if an organization has a privacy and security incident response team that has predefined
roles and action requirements. Every event should result in a
post-mortem review to determine if improvements in the review and response timeline can be realized.

A clear definition of all roles involved in that process is necessary to help ensure an organizations success following the unwelcome attention that comes from a breach. The breach incidents reported in the media last year led to some top executives
losing their jobs because the incidents were handled poorly
within their organizations.
Privacy and security officers should be focused on organizational objectives that are audited for effectiveness, and reported
to executive leadership and the board of directors. The processes must be consistent, repeatable, and manageable. Incident
response should include:
Discovery of the incident
Timely reporting of said incident
Containment of the incident
Documentation assessment
For each incident it is important to break down the human
factor. According to a recent Ponemon Institute report, human errors and system problems caused two-thirds of data
breaches in 2012.1 An Ernst and Young analysis found similar
results.2 Thirty-eight percent of respondents said employee
carelessness or lack of awareness was the primary threat that
increased their exposure risk.

Both the nature and sheer volume of data have evolved and
grown at a rapid pace over the last two decades, and that trend
will likely continue. According to Cisco, global IP traffic has increased fivefold over the past five years, and will increase threefold over the next five years.3
So yes, the jobs have changed, but the continued focus must
be on education of the individuals working within the organization and those handling the information that privacy and security officers have been entrusted to protect.

1. Ponemon Institute. Cost of a Data Breach: Global Analysis. June 1, 2014.
2. Prince, Brian. Cybersecurity Requires Proactive Approach: Ernst & Young. Security Week. November 3, 2014.
3. Cisco. Cisco Visual Networking Index: Forecast and Methodology, 2013-2018. June 10, 2014.
Rita Bowen ( is senior vice president of HIM,
privacy officer, at HealthPort.

Journal of AHIMA June 15/47

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Rules of the Road Differ for Inpatient

and Outpatient ICD-10 Coding
By Tara Quick, RHIT, CCS, and Stephani Hickman, CCS

AS FACILITIES APPROACH the final laps in the race towards implementation of the International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM), they should heed
the yellow caution flag warning of basic challenges with the vast
differences between inpatient and outpatient coding. It is important to use caution during our current race and to stay in the correct lane with code assignment of inpatient stays and outpatient
encounters. This article will provide some rules of the road as facilities stay focused on the implementation of ICD-10-CM.

First Warning Lap: Resources

Coders should be well equipped with the proper resources they
need for assigning inpatient diagnoses and procedures codes.
For inpatient coding, an understanding of the Uniform Hospital
Discharge Data Set (UHDDS) definitions, anatomy and physiology, the International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM) instructional notations and
conventions, and ICD-9-CM Official Guidelines for Coding and
Reporting is needed. This will help in the assignment of correct
ICD-9-CM diagnoses and procedures to hospital inpatient medical records. ICD-9-CM contains three volumes to aid in choosing the correct diagnoses and proceduresVolume 1 Tabular
List: Diagnosis Classification; Volume 2 Alphabetic Index: Diagnosis Classification; and Volume 3 Tabular List and Alphabetic
Index: Procedure Classification. A supplemental resource to use
when coding is the American Hospital Associations (AHAs)
Coding Clinic for ICD-9-CM, which provides coding advice.

Changing Lanes: Outpatient Coding

Coders need to know how to switch gears when it comes to acquiring resources for outpatient coding. The terms encounter
48/Journal of AHIMA June 15

and visit are often used interchangeably in describing outpatient services, but the term encounter will be used for this article. For diagnosis coding of outpatient encounters, one needs
a full understanding of the UHDDS definitions, anatomy and
physiology, Volumes 1 and 2 of ICD-9-CM, along with ICD-9CM instructional notations and conventions, and the current
version of ICD-9-CM Official Guidelines for Coding and Reporting. Diagnoses are assigned using the first two volumes of
the ICD-9-CM coding book, supplemented with AHAs Coding
Clinic for ICD-9-CM. Outpatient procedures are assigned from
the American Medical Associations (AMAs) Current Procedural Terminology (CPT) Manual which includes Level I modifiers
approved for hospital outpatient use and the Centers for Medicare and Medicaid Services (CMS) Level II Healthcare Common
Procedure Coding System (HCPCS), including Level II National
Modifiers. Procedure coding is supplemented with the AMAs
CPT Assistant and AHAs Coding Clinic for HCPCS. Although
outpatient encounters are not required by CMS or third-party
payers to report ICD-9-CM Volume III procedure codes, and do
not base reimbursement on the use of these codes, some facilities continue to utilize them for internal data capture.

Ground Rules for the Road

Now that everyone is in the correct lane, what are the rules of the
road? The principal diagnosis for inpatient coding is defined in
the UHDDS as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the
hospital for care. Once the principal diagnosis is established, the
coder should continue to read through the entire medical record
and assign any and all applicable secondary diagnoses. In the
inpatient hospital stay, if a diagnosis documented at the time of

discharge is qualified as probable, suspected, likely, questionable, possible, or rule out, and has not been ruled out at
the time of discharge, the condition should be coded as an existing or established diagnosis. In addition to assigning ICD-9-CM
diagnoses, hospitals are required to report present on admission
information for all diagnoses when submitting inpatient claims.
Although both inpatient and outpatient coding utilizes Volumes 1 and 2 of the ICD-9-CM manuals in the assignment of
diagnoses, there are vast differences. The UHDDS definition of
principal diagnosis applies to non-outpatient settings: acute
care short-term hospitals, long-term care hospitals, psychiatric
hospitals, home health agencies, rehabilitation facilities, nursing homes, and other settings.
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and
do not apply to outpatient coding. Do not code diagnoses documented as probable, suspected, questionable, rule out,
working diagnosis, or other similar terms indicating uncertainty
for outpatient encounters. Instead, code the condition(s) to the
highest degree of certainty for that encounter, such as symptoms,
signs, abnormal test results, or other reason for the encounter.
Instead of using the term principal diagnosis as with inpatient
stays, the term first-listed diagnosis is appropriate in the outpatient setting. The conventions of ICD-9-CM, along with the general
and disease-specific guidelines, take precedence over the outpatient guidelines of first-listed diagnosis. List first the ICD-9-CM
code for the diagnosis, condition, problem, or other reason for the
encounter shown in the medical record to be chiefly responsible for
the services provided. In some cases, the first-listed diagnosis may
be a symptom when a diagnosis has not been established or confirmed by the physician. Outpatient encounters for circumstances
other than a disease or injury are assigned ICD-9-CM codes under
The Supplementary Classification of Factors Influencing Health
Status and Contact with Health Services (V01.0-V91.99).
Furthermore, clarification on assignment of the first-listed diagnosis is based on the outpatient encounter service type. The
first-listed code for an outpatient surgical encounter should be
the reason for the surgery. Even if the patient is scheduled for
outpatient surgery and develops a complication requiring admission to observation, the first-listed code remains the reason
for surgery, followed by secondary diagnosis codes for all applicable documented complications.
However, if the postoperative diagnosis is known to be different from the preoperative diagnosis, select the postoperative
diagnosis because it is the most definitive diagnosis. An example of this is when a patient presents for outpatient surgery for
evaluation of rectal bleeding and after colonoscopy it is determined that the patient has bleeding from internal hemorrhoids.
The preoperative diagnosis is 569.3-rectal bleeding and the
more definitive postoperative diagnosis is 455.2-internal hemorrhoids with other complication. The first-listed diagnosis for
outpatient diagnostic and therapeutic services is the diagnosis,
condition, problem, or other reason shown in the medical record to be chiefly responsible for the outpatient services.
Codes for diagnoses (i.e., chronic conditions) may be se-

quenced as additional diagnoses. For outpatient encounters with

diagnostic tests that have been interpreted by a physician and the
final report is available at the time of coding, code any confirmed
or definitive diagnosis documented in the interpretation.
Do not code related signs and symptoms as additional diagnoses.
An example of this is when a patient presents for an MRI for evaluation of shoulder pain and the interpretation portion on the radiology report lists a tear of the biceps tendon. In this case the first-listed diagnosis would be 840.8, Sprains and strains of other specified
sites of shoulder and upper arm. A code for shoulder pain would
not be assigned since a definitive diagnosis has been established.
The first-listed diagnosis for outpatient therapeutic services
for chemotherapy, radiation therapy, or rehabilitation is the appropriate V code for the therapy followed by secondary codes
for the diagnosis or problem for which the service is being performed. The first-listed diagnosis for preoperative evaluation
services should be from category V72.8, Other specified examinations, to describe the preoperative consultations. Code also
any findings related to the preoperative evaluation. For routine
outpatient prenatal encounters without complications, the firstlisted code should be either V22.0, Supervision of normal first
pregnancy, or V22.1, Supervision of other normal pregnancy.
Tara Quick ( and Stephani Hickman
( are senior consultants, facility audit services, at Altegra Health.

Ov er 30 ye ars ex perien ce in rev enu e c yc le

Highest Quality &

Internal QA Checks &
Lowest rates on the
Flexibility & Excellent

Other revenue
cycle services

Offering full time, part-time, and as needed support.

All coders are certified and in the U.S.
Journal of AHIMA June 15/49

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Achieving Health Information

Systems Interoperability
By Anna Orlova, PhD

WITH THE GROWING adoption of health information technology (HIT), interoperabilityor the sharing of data between
systemshas become a topic that everybody in healthcare is
talking about. Interoperability impacts every stakeholder in
healthcare with each individual party involved in a complex
multi-dimensional, multi-domain, multi-stakeholder activity.
The ultimate aim of interoperability is to improve the safety,
quality, effectiveness, and efficiency of healthcare delivery, and
to improve individual and population health.
Healthcare is rather new to interoperability. Other industries
have been on the interoperability journey for several decades.
They include banking, transportation, and retail, and their successes are realized every day while managing personal and
business finances, traveling, and shopping. This success shows
that healthcare has a shot at achieving interoperability, though
the challenges it faces are unique to the industry.

Defining Interoperability, Understanding Each Other

Since its still a new term for the healthcare industry, defining
interoperability is necessary so that all stakeholders can be
on the same page.
Several definitions of interoperability have been introduced.
The draft Roadmap for Interoperability, published in January
2015 by the Office of the National Coordinator for Health Information Technology (ONC),1 used the Institute of Electrical and
Electronics Engineers (IEEE) definition:
Interoperability is defined as the ability of a system to exchange electronic health information with and use electronic
health information from their systems without special effort
on the part of the user. Interoperability is made possible by the
implementation of standards.2
50/Journal of AHIMA June 15

However, the IEEE definition of interoperability does

not define all necessary aspects of data, information, and
knowledge sharing needed in healthcare because it addresses only electronic information exchange and use. To
have accurate data, interoperability has to begin at the point
of data capture.
In addition, the IEEE definition does not adequately take
into consideration the central role of human intervention with
electronic information generation, exchange, and utilization in
healthcare. These human interventions include defining:
Information needs and priorities for a medical problem
and its solution
Information gathering and access
Information processing
Information utilization
In the context of aligning user needs with technical HIT capabilities, the definition of interoperability provided in 2007
by Health Level Seven (HL7) is more comprehensivewith
one change added by the authors, capture:
Interoperability means the ability to [capture,] communicate,
and exchange data accurately, effectively, securely, and consistently with different information technology systems, software
applications, and networks in various settings, and exchange
data such that clinical or operational purpose and meaning of
the data are preserved and unaltered.3

The word capture was added to the original HL7 definition

to reflect the need for capturing quality data before it is communicated and exchanged. Broader discussion with all affected stakeholders is needed to comprehensively define and

agree upon the definition of interoperability.

HL7s approach to interoperability is based on three interoperability pillars:4
1. Semantic interoperabilityshared content
2. Technical interoperabilityshared information exchange
Functional interoperabilityshared rules of information
exchanges (i.e., business rules and information governance)
These interoperability pillars could serve as a basis for the
Nationwide Interoperability Framework and supporting infrastructure needed to enable data, information, and knowledge
generation, sharing, and utilization in healthcare.
Standards are central to enable interoperability. Individual
standards that various standards-development organizations have been developing over the past 30 years now have
to work together. The new type of standardinteroperability
standarddefines how the individual standards have to work
together for a specific healthcare scenario (use case). The interoperability standard is a product of standards harmonization (i.e., analysis of addressing gaps and overlaps of individual standards).
Thus, interoperability standards are defined as special
products of standards harmonization activitiesa meta-standard (standard about standards), an assembly of standards,
interoperability specifications, interoperability guidelines,
reference standards portfolio, etc.that define how individual
standards have to work together to enable interoperability for
a specific healthcare domain (use case) (i.e., care coordination, radiology, laboratory, pharmacy, data reporting, population health, etc.).
The term interoperability standards was introduced in
2005 by the Health Information Technology Standards Panel
(HITSP).5 Between 2005 and 2010, the American Health Information Community (AHIC) developed various interoperability specifications for the national use cases.
The International Organization for Standardization (ISO)
Technical Committee (TC) 215 Health Informatics, with leadership from the US Technical Advisory Group (TAG) for ISO/
TC 215, and the active engagement and support of many TC215
member nations, is defining an interoperability standards
portfolio for a specific domain (use case) as a grouping of individual standards.6

AHIMA Approach for Interoperability: Working

Together Towards Interoperability
The draft ONC Interoperability Roadmap, now seeking public
comments, initiated a collaboration of various stakeholders
to define a nationwide approach for achieving interoperability. In the comments submitted in April 2015 on the roadmap,
AHIMA outlined its approach for achieving interoperability in
AHIMAs approach for health information systems is based

on the following three overarching constituents:

1. Leadership
2. Accountability
3. Methodology

Leadership to establish public-private partnerships to define,
develop, and execute the interoperability agenda on the policy
and technical levels should be based on federal regulation and
the role of the federal government in standardization.

Accountability ensures fiscal responsibility of participating
stakeholders in delivering standards-based interoperable solutions in healthcare for data, information, and knowledge
generation, sharing, and use. Accountability should be based
on federal regulation with checks and balances policies.

Methodology is needed to enable the development, implementation, and operation of standards-based interoperable information and communication technology solutions in healthcare. As performed in other industries, methodology should
be based on merging two domains of knowledge: medicine
and computer science. This enables overall computer science
and information and communication technology methodologies to work in the healthcare environment. In merging these
two domains, there is a need for an overarching interoperability framework under which an interoperability methodology
will be employed.
Figure 1 on page 52 presents interoperability building blocks
for the proposed interoperability framework. The three pillars
of interoperabilitysemantic, technical, and functional
serve as pillars of the interoperability framework. Under and
across each pillar, computer science interoperability methodology will focus on the following activities:
1. Defining needs and priorities for interoperability
2. Defining and developing interoperability components for
semantic, technical, and functional interoperability
3. Testing interoperability components
4. Certifying interoperability components
5. Deploying interoperability components
6. Evaluating deployment outcomes
Accountability and leadership are positioned above the
methodology to ensure effectiveness of the framework. The
foundation for this framework is comprised of the following
three building blocks:
1. Policy (regulatory framework and governance)
2. Technology (standards-based technology including both
HIT and information communication and technology in
3. People (healthcare and HIT workforce and consumers
Journal of AHIMA June 15/51

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Figure 1: Building Blocks of Interoperability

Let Your Voice Be Heard

AHIMA invites other interoperability stakeholders to comment on the proposed definitions and approach for interoperability. The association also invites you to work together
with AHIMA on executing the proposed approach for HIT
interoperability. For more information about AHIMAs work
on standards and interoperability, please contact Anna Orlova, PhD, AHIMAs senior director for standards, at anna.

1. Office of the National Coordinator for Health Information Technology. Connecting Health and Care for the
Nation: A Shared Nationwide Interoperability Roadmap.
2. Institute of Electrical and Electronics Engineers (IEEE).
Standards Glossary.
52/Journal of AHIMA June 15

3. Health Level Seven. Coming to Terms: Scoping Interoperability for Healthcare. February 7, 2007.
w w
4. Ibid.
5. Healthcare Information Technology Standards Panel.
6. International Organization for Standardization. ISO/TC
215 Health informatics.
7. AHIMA. AHIMA Comments on Connecting Health and
Care for the Nation: A Shared Nationwide Interoperability Roadmap. Letter to Office of the National Coordinator for Health IT. April 2, 2015.
Anna Orlova ( is senior director of standards at

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Evaluating the Information

Governance Principles for Healthcare:
Compliance and Availability
By Galina Datskovsky, PhD; Ron Hedges, JD; Sofia Empel, PhD; and Lydia Washington, MS, RHIA

Editors Note: This is the third in a series of four articles that discuss the eight Information Governance Principles for Healthcare.

AHIMAS NEW INFORMATION Governance Principles for

Healthcare (IGPHC) provide a framework for healthcare organizations to leverage information in order to achieve the organizations goals and conduct their operations effectively while
ensuring compliance with legal requirements and other duties
and responsibilities.
IGPHC is a set of eight principles that, when considered in
whole or in part, is intended to inform an organizations information governance (IG) strategy. The following is the third of
four articles that explores the meaning and intent of the principlesfocusing on the Compliance and Availability principles.

Compliance Principle

The compliance principle is indisputable. It states: An information

governance program shall be constructed to comply with applicable laws, regulations, standards, and organizational policies. In a
healthcare context, such compliance requires particular attention
to laws that govern the privacy of patients as well as the confidentiality of information about them and treatment they receive.
Billing compliance, in which coded and other types of data and
information is used to substantiate payment to providers for healthcare services and avoid allegations of possible fraud or abuse, is also
a major area of healthcare compliance. The compliance principle is
intended to enable an organization to demonstrate that its activities
are being conducted in a lawful and ethical manner and that its information management systems comply with legal and regulatory
requirements. According to IGPHC, every organization should:
K now what information should be entered into its records
to demonstrate its activities are being conducted in a lawful manner.
Enter that information into its records in a manner consis54/Journal of AHIMA June 15

tent with laws and regulations.

 aintain its information in the manner and for the time
prescribed by law or organizational policy.
Maintain information to facilitate patient care.
Develop internal controls to monitor adherence to rules,
regulations, and program requirements, thus assessing
and ensuring compliance.
Healthcare organizations are subject to myriad rules and
regulations, some that are imposed externally by law and others that are self-imposed for the benefit of the business. A failure to comply with any of these rules and regulations could
have serious consequences for an organization, such as reputational harm, monetary loss, and, in extreme instances, criminal penalties. These consequences highlight the importance
of compliance. An organizations information management
and governance systems and processes canand should
be a means to demonstrate its compliance with the rules and
regulations applicable to it. An organization can also fail to
provide quality services when compliance is not appropriately
taken into account.

Availability Principle
The availability principle is straightforward: An organization
shall maintain information in a manner that ensures timely,
accurate, and efficient retrieval. After all, if the ability to retrieve information is impairedeither because retrieval is untimely or incompleteboth trust in the organization and its
operations will be diminished. When the right information is
not available at the right time, patient care may be compromised. Availability is important to various stakeholders within

and outside any healthcare organization. According to IGPHC,

those stakeholders include:
The healthcare team, patients, and other caregivers
Authorized members of the workforce and others authorized consistent with regulations
Legal and compliance authorities for discovery and regulatory review purposes
Internal and external reviewers for purposes including
but not limited to: payer audit, financial audit, case management, and quality assurance
The nature of information within healthcare organizations todayincluding information available from affiliatescomplicates
availability. Organizations must search for information in continually increasing volumes of data, as well as multiple information systems, including manual systems. The proliferation of various types
of electronic information likewise complicates availability. In an
electronic environment, availability requires organizations to:
1. Understand and use metadata to describe, explain, locate,
and retrieve information
2. Back up information on a periodic basis to ensure against loss
3. Guard against obsolescence of existing hardware or software
4. Dispose of obsolete or redundant information in an appropriate manner
5. Maintain information in such a way as to facilitate retrieval of the right information in a timely manner
Availability is essential, but ensuring availability is no simple
task. Healthcare information for patient care must be managed
for maximum searchability using metadata, indexing, and other
tools. Increasingly, it must be available from outside the four
walls of an organization enabled through the use of standards
for interoperability and health information exchange. Time is
of the essence in providing patient care in both emergency and
non-emergency situations, and it is incumbent upon healthcare
organizations to ensure speedy retrievability of patients accurate health history, diagnostic results, and previous treatment
information, no matter where it is located in order to provide
efficient and cost effective care.

Compliance and Availability are Related, Improve IG

Information must be created and maintained in a manner consistent with the rules by which a healthcare organization operates. That consistency should be measured through the systems
and processes by which an organization manages information.
To be measured and utilized effectively, information must be
made available in a manner that is trustworthy. Trustworthiness reflects an organizations ability to meet its goals and, at
the same time, to demonstrate its compliance with the rules by
which it operates. The principles of compliance and availability
thus operate in tandem to establish trust by patients, regulators,
and others with whom the organization interacts.
In the second installment of this series, the authors noted that
information must have integrity to be useful and to be depended on for decision-making and that information must be pro-

tected to maintain integrity.

Similarly, compliance and availability enable information to
be trustworthy. Compliance ensures that information is created and maintained in an environment that complies with the
rules of the road under which healthcare organizations function. Availability allows for the meaningful retrieval and use of
information. Information that is consistent with rules and regulations and that can be accessed in a timely and reliable manner
furthers information governance under the IGPHC.
Galina Datskovsky ( is CEO, North America,
at Covertix. Ron Hedges ( is a former US Magistrate
Judge in the District of New Jersey and is currently a writer, lecturer, and
consultant on topics related to electronic information. Sofia Empel (sofia. is director, information governance, at Connolly
iHealth. Lydia Washington ( is senior director of HIM practice excellence at AHIMA.

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practice guidelines for managing health information

Electronic Documentation Templates

Support ICD-10-CM/PCS Implementation

Editors Note: This Practice Brief supersedes the October 2012 Practice Brief Electronic Documentation Templates Support ICD-10CM/PCS Implementation.
IMPROVING PATIENT CARE continues to take center stage
in the healthcare industry, as demonstrated by an increased
emphasis on health IT and electronic health record (EHR)
implementation in programs like the American Recovery and
Reinvestment Acts (ARRA) meaningful use EHR Incentive
Program, the Accountable Care initiative, Patient-Centered
Medical Homes, and the Medicaid Chronic Care Management
program. These, and other initiatives, all require strategic organization-wide planning for ICD-10-CM/PCS implementation.
The implementation of ICD-10-CM/PCS will require organizations to capture detailed information at the point of care.
Since ICD-10-CM/PCS provides increased specificity in its code
sets, clinical documentation to support that specificity is critical. Specifically, providers dont need to provide a higher volume of clinical documentation, but rather need more precise
documentation (i.e., laterality, specificity, anatomic sites, etc.)
with the focus on quality, not quantity. Proper documentation
can be facilitated through the effective use of EHR templates
and prompts and the data repurposed throughout the EHR to
support the collect once, use many times concept.
The meaningful use EHR standards and certification criteria
have enhanced organizations ability to capture and exchange
standardized, structured clinical content. Templates can also
help support the capture of clinical content in a standardized and
structured manner. Prompts or clinical decision support rules
relevant to clinical specialties will result in meaningful patient
data as well as improvements in patient care. The added level of
specificity in ICD-10 is needed to bolster clinical decision support tools that provide alerts and reminders to clinicians during
patient care. This is an important patient safety consideration.
Leveraging these data collection tools will improve clinical
documentation, leading to a higher quality of care for the patient through a better understanding of complications, better
design of clinically robust algorithms, and better tracking of the
outcomes of care. Greater detail and specificity offer many advantages, including the ability to discover previously unrecognized relationships in data and the impact on public health by
detecting developing epidemics in their early stages.
Prior to ICD-10 implementation, healthcare organizations
will need to communicate with their EHR vendors and identify
methods for updating and/or creating templates that facilitate
compliance with new documentation requirements and code
56/Journal of AHIMA June 15

assignment. In some instances this may require upgrading to

a new version of the EHRs software. Providers need to factor
in the level of effort required to modify or create the content
needed to support the transition process. By employing the features available in custom template design, an organization or
physician practice can modify the EHR to better fit their unique
workflow needs.
Templates add an advantage by reminding providers to ask
patients specific questions. The structured note will assist the
physician with reminders to ensure his or her documentation
is as complete and accurate as appropriate for ICD-10-CM/PCS
coding guidelines. In a physician practice, for example, the ability to utilize different templates will allow the provider to simply
choose by specialty (i.e., the check-up or diabetes patient
template) at the start of the encounter. In the hospital setting,
reviewing and updating the provider query template/form is
just one example of the type of template that will require attention. Determining the vital documentation opportunities now
will allow organizations to begin providing focused education
and training.
This Practice Brief identifies best practices that ensure clinical documentation remains accurate when leveraging data
tools like EHR templates and prompts. These best practices
are designed to support and guide HIM professionals, providers, physician practice staff, clinicians, and other healthcare
stakeholders through an effective transition to ICD-10-CM/
PCS documentation requirements that ultimately improve the
quality of healthcare.

Defining Templates and Prompts

Templates and prompts can be useful tools to ensure complete
EHR documentation at the point of care. A template is an EHR
documentation tool utilized for the collection, presentation,
and organization of clinical data elements. Prompts are a function of a template designed to trigger the provider to specify required or missing documentation.
Careful, thoughtful design and the ongoing review of EHR templates and prompts is essential to successful implementation. In
the facility setting, a collaborative approach that includes health
information management services (HIMS), clinical documentation improvement (CDI) and quality staff, providers, and information technology (IT) representatives is recommended when

Practice Brief

implementing templates and prompts. Utilization of data from

the CDI program will place a facility in a better position to design the specific prompts required for the template and result in
more complete documentation.
Documentation areas with significant impact may require the
design of new templates to capture the new or more detailed
information required. Templates should be designed to capture
specific information needed for clinical care and accurate reporting of the clinical encounter. This will prevent faulty template design that captures documentation in a way that makes
all patients look the same.
There are advantages and disadvantages to using these tools.
Templates and prompts can assist in improving the quality of
care delivered and the completeness of documentation.1 Alternatively, providers may feel as though there are additional steps
and increased workload as the electronic prompts force their
documentation requirements. Proper education, monitoring,
and training will help support the use of these tools.

Customized Template Benefits

THE ABILITY TO utilize different templates allows a single
EHR solution to be flexible. Important benefits of template
usage include:
Easy, standardized organization of clinical data
Single-page views of patient data for quick reference
Ability to quickly manage an entire patient population
Time savings versus having to browse through multiple patient files/pages
Increased percentage of chart completion
Standardized data capture, which helps to ensure accurate coding and reporting
More complete data fields, which can lead to fewer
under-billed appointments
Source: EHR 105: EHR and EHR Templates. 2011.

Streamlining Workflow Processes

There may be ways to streamline the workflow process to mitigate some of the potential productivity losses that are expected to come with ICD-10-CM/PCS implementation. Designing
workflows now may reduce the need for coding staff to initiate
physician queries for missing or additional information in order
to code a patient record. Deloitte published an article that discusses the importance of developing and executing strategies
that include physician engagement and adoption of technology-driven templates and code selection tools. The article states:
[T]he development of enhanced electronic health record (EHR)
templates to support clinical documentation needs can help ease
provider adoption of the new code set. Finally, many organizations are considering the inclusion of the following top five elements in their EHR templates: laterality, devices, episode of care,
trimester, and root procedure.2

In the outpatient setting, there are many advantages to creating templates in the EHR, there are also benefits to utilizing an
EHR with integrated practice management, billing, and documentation tools. To take full advantage of the EHRs efficacy, a
practice should look to the variety of methods for customization, according to an article posted on
Leveraging the use of tailored elements in a custom template design is a popular method for customizing the EHR. The
unique features developed through the customization of EHRs
allows practices to create an EHR best suited to their specific
needs. Some studies have found that an involved customization
is important in order for the adoption of any EHR to be successful for a given practice.4 Many EHRs allow providers to modify
generic templates or to create their own unique sets of templates with ICD, HCPCS, and CPT codes. This process can be
labor-intensive, and these templates will need to be updated or
replaced to meet the ICD-10 specificity requirements.5
When discussing the improvements that will need to be made

in preparation for ICD-10, Mike Davis, managing editor for the

Advisory Board Company, said in a Healthcare Information and
Management Systems Society (HIMSS) article that the answer
will call for the creation of discrete encoded data to support the
ICD-10 coding process.6 Many dictation and transcription services are currently able to produce much of the physician documentation through new technology solutions, such as natural
language processing (NLP), which work to mine text from the
transcribed documents. Additionally, clinical vocabulary solutions can help code the resulting discrete data to a medical
terminology such as SNOMED CT and pass the patient data to
computer-assisted coding (CAC) applications, which can assist
with coding quality and efficiency.
These workflow enhancements will need to be considered as
facilities move toward structured template documentation for
physicians. Beverly Dellinger, RN, clinical applications analyst
at Wellspan Health, adds, When clinical documentation workflows are adequately analyzed and weak points properly identified, the implementation of templates can add value by making
the documentation process comprehensive, standardized, and
produce timely display of documentation results.

Documentation Considerations for ICD-10-CM/PCS

Physician documentation must be more granular to support the
increased specificity in ICD-10-CM/PCS. Documentation from
the operative report is critical in the selection of the appropriate ICD-10-PCS code. In order to make a code assignment, the
following will need to be included in physician documentation:
Body System: Body system in which the affected body part
belongs (central nervous system, endocrine system, etc.)
Type of Operation: Provider must clinically describe the
procedure performed to the extent necessary for a coder
to accurately translate the clinical description of the procedure to the appropriate root operation (i.e., resection,
Journal of AHIMA June 15/57

Practice Brief

excision, etc.)
Body Part: Specific part of the body and laterality where
the procedure was performed (i.e., appendix, liver, right
leg, etc.)
Approach: The approach taken to accomplish the procedure (i.e., open, laparoscopic, etc.)
Device: The type of device (if any) that remains in the
body upon completion of the procedure (i.e., grafts, implants, etc.)
Documentation areas for consideration when assigning ICD10-PCS code(s) include:
Root Operation: Selection of the root operation is dependent on properly determining the objective of the
procedure (i.e., what will be accomplished through the
procedure?) A thorough explanation of the purpose of the
procedure is necessary. For example, the terms excision
and resection were used somewhat interchangeably in
ICD-9-CM. In ICD-10-PCS, however, these terms represent completely different procedures.
Site: Does the operative report state the specific site of
the procedure? The body part selections and laterality are
much more specific in ICD-10-PCS. Documentation must
specify what body part was affected by the procedure.
Some of the specific body parts identifiable in ICD-10PCS are the anterior tibial artery, abdominal sympathetic
nerve, and the thorax muscle, left.
Devices: Devices that remain in the body after the completion of the procedure must be documented. These include devices such as drains, non-autologous tissue substitutes, radioactive elements, and infusion pumps.
Qualifiers: Qualifiers are represented as the seventh
character in an ICD-10-PCS code. These will vary depending on the ICD-10-PCS code. Some examples include the
types of pacemakers, graft materials, and hip prostheses.
Qualifiers can also represent anatomical locations which
are relevant to that particular procedure.7

Lack of Specificity Prevalent

Educating providers on clinical documentation is as crucial as it
is delicate. Physicians need a range of human and technological
support to guide them to the documentation needed for the increased specificity of ICD-10-CM/PCS. There are multiple reasons that the documentation in the record may not be specific
enough. Providers can perceive their documentation as clear
in its intent. However, they may be missing critical documentation needed for coding. One should note that physicians are
taught medicine during their education; documentation is not
necessarily a part of their medical curriculum. For example, the
physician may state that the patient was grunting, often meaning the patient was in acute respiratory failure. However, a coder
cannot assume a diagnosis using such a general term. There is
a difference in acuity by stating the disease more specifically.
Ensuring clear and concise documentation while the patient
58/Journal of AHIMA June 15

is still in the hospital is crucial to ensuring high quality care.

Utilizing templates and clinical documentation specialists can
provide the specificity needed to bridge the gap between the
clinical language used in physician documentation and the
classification language used in coding.
Stephanie Hays, medical coding quality consultant at Vanderbilt University Medical Center, based in Nashville, TN, says her
facilitys CDI program, in collaboration with the informatics
department, is involved with a project that evaluates clinical
documentation templates and then incorporates prompts that
capture details required in ICD-10-CM/PCS. The project will
reduce the need to query providers by collecting required details
up front, within their existing tools and templates, Hays says.
Improved templates will allowproviders to remain focused on
patient careduring the challenging transition to ICD-10.

HIMs Role in Template Design

While an interdisciplinary team is generally formed whenever
electronic template-based provider documentation is considered, HIM professionals are critical to the selection process
when looking to develop or revise electronic templates in preparation for ICD-10-CM/PCS and should be involved in the template development and management process. The heightened
specificity of ICD-10-CM/PCS will require clinicians to become
more precise in their documentation, and the electronic templates and their associated alerts and reminders must support
this change. HIM professionals should be involved with the
design process to ensure well written templates are developed
that focus on documentation specificity. This specificity has the
potential to enhance computer-assisted coding accuracy and
coder productivity. Refer to Appendix A in the online version of
this Practice Brief in AHIMAs HIM Body of Knowledge for more
information on policy considerations.
As part of the design process, guidelines for the data entered
into each field must be determined, as well as guidelines for
allowing a comment area for yes and no answers. Quality
initiatives should also be incorporated. Included with the proposed template, a standardized form signed by the requestor
and the department head or service chief must be submitted to
the workgroup or committee responsible for the implementation of the template. The request form should include the purpose of the template, proposed implementation timeline, and
individuals responsible for testing the usability, training, and
dissemination of the new or revised template. Refer to Appendix
B online for a sample request form.
The requesting party should submit the formatted template
following standardized guidelines approved by the appropriate
organizational authority. The use of guidelines will add standardization and clarity when establishing templates. The guidelines should include:
Requirements of indentation

Practice Brief

Documentation Considerations for ICD-10-CM


More specific documentation of the site of an
injury, such as a fracture
Laterality of injury
Episode of care 7th character:
-- Initial encounter for care of fracture
-- Subsequent encounter for fracture with
routine healing
-- Subsequent encounter for fracture with
delayed healing
-- Subsequent encounter for fracture nonunion
-- Subsequent encounter for fracture with
-- Sequela

Under dosing

New concept for ICD-10-CM that refers
to taking less of a medication than is prescribed by a provider or a manufacturers
May be classified as due to financial hardship or the age-related debility of a patient
Source: Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS
Coding Handbook. Chicago, IL: AHA Press, 2012: 501.

Categories S52, S72, and S82 are impacted by the

Gustilo Fracture Classification
-- Fractures delineate displaced or nondisplaced
as well as type of fracture, such as
comminuted, spiral, segmental, etc.
Source: Simmons, Cortnie. The Musculoskeletal System and ICD-10CM. ICD-Ten: Top Emerging News. April 2011.

Causes of

Episode of care 7th character

-- Initial encounter
-- Subsequent encounter
-- Sequela


New category for reporting medical devices associated with adverse incidents in diagnostic and
therapeutic use

Source: Barta, Ann. Obstetric Coding in ICD-10-CM/PCS.

Journal of AHIMA 81, no. 6 (June 2010): 68-70.

Source: Kostick, Karen. Coding for External Causes of Mortality in

ICD-10-CM. Journal of AHIMA 82, no. 7 (July 2011): 56-58.


Acute myocardial infarction (AMI) time frame is

four weeks or less
Certain AMI codes classify the responsible artery
Subsequent AMIs require historical time frame
(within four weeks)
Angina terminology changes such as with arteriosclerotic heart disease with documented spasm
Source: Barta, Ann. The Circulatory System and ICD-10-CM/PCS.
Journal of AHIMA 82, no. 5 (May 2011): 62-64.

Indication of a required field

Verification of spelling of terms
Usage of abbreviations or reference to a legend of abbreviations
Review for proper grammar and word tense
Default values must be used with great caution to avoid inaccurate information. Coding nomenclature should not be included in a template. Note titles should be mapped to a standardized

Episode of care
First, second, or third trimester of
7th character to be assigned with multiple
gestations; identifies fetus to which the
code applies
Twin pregnancy may be classified as


Laterality classification is available for

some neoplasms
Significant changes in terms describing
forms of lymphoma and leukemia
Significant changes in terms describing
polycythemia vera
Additional codes for liver cell carcinoma
Source: Bielby, Judy. Coding Neoplasms in ICD-10-CM.
Journal of AHIMA 82, no. 10 (October 2011): 72-74.

format for consistency and ease of retrievable documentation. A

review process must be established and maintained on a regular basis to keep up a master list of templates, to ensure that the
template is being used, that information is still relevant, and
to identify needed updates. Templates and note titles no longer used should be deactivated but not deleted so a historical
library is maintained for templates existing prior to the classification system update to ICD-10-CM/PCS. Refer to Appendix C
online for more information.
Journal of AHIMA June 15/59

Practice Brief

Talking with Physicians About Templates

Templates developed using evidence-based medicine should
be designed to capture free text as well as structured data to accommodate the multiple specialties and subspecialties of medicine. In this way, the user will be able to identify common data
elements with the option of adding significant clinical findings
for an individual patient.
With the implementation of EHRs, most clinicians are now
accustomed to the direct entry of clinical data into electronic
systems. As a result, dictation for transcription of clinical notes
and reports has decreased. However, the formats designed by
the physicians, medical scribes, and medical transcriptionists
for transcribed reports may be a good starting point for the creation of clinical templates in the EHR. A well-designed template
will recognize that EHRs are primarily data-centric rather than
Working through the health record quality review committee, clinicians can ensure data elements supporting evidencebased medicine and quality care are captured in the EHR. This
clinician-to-clinician approach, as well as identifying a physician champion for each clinical service, is an effective way to
design and educate clinicians on the use of templates for the
EHR. The physician champion should be involved in the review
of current patient-specific paper forms to be considered for
conversion to electronic versions. Physician champions have
been trained and can solicit cooperation from their peers. Physicians need to know that the accuracy of their documentation
goes hand-in-hand with their physician profile performance reporting and benchmarking data, as well as profiling for patient
care. Improved documentation of diagnoses and procedures
that specifically affect ICD-10 code assignment will accurately
capture severity, acuity, and risk of mortality data. Motivating
physicians to improve their documentation requires getting
physicians to understand that proper documentation aligns
with a better understanding of the patients history and current
status, and this information aligns with better quality care, says
Thomas Payne, MD, in a Healthcare Financial Management Association report.9

The Role of the EHR Vendor

Changes in regulations governing documentation, core measures, physician queries, medical necessity, and the implementation of ICD-10-CM/PCS all speak to the need for accurate,
thorough, and precise documentation. The desire to meet the
meaningful use requirements is expediting the adoption of EHR
systems by hospitals and providers nationwide.
EHR vendors utilize a wide number of methods to assist providers with documentation, including templates, macros, cloning of records, and free text entry. Vendor template models also
vary significantly, with some instituting ICD codes within templates, while others draw from a core terminology engine like
SNOMED CT. Providers are strongly encouraged to engage their
vendors as soon as possible to plan and implement an update
process that addresses vendor-specific strategies tied to the
60/Journal of AHIMA June 15

transition to ICD-10-CM/PCS. In some cases, providers will be

required to modify significant numbers of their existing templates to meet the documentation and coding requirements of
HIM professionals must be involved in the implementation
and update of the EHR. For example, if the EHR provides dropdown boxes for ease of documentation of personal, family, social, and historical clinical conditions, HIM would have valuable input in the creation of the selections.
Templates are an ideal documentation tool to facilitate required documentation and, in some models, code selection.
However, care must be taken to ensure that the templates are not
too prescriptive and are not complicated or time-consuming to
use. Depending on the vendor model, the presence of accurate
billing codes may also require validation. To this end, physician
participation must take place throughout the template development period.

Patient Considerations
The patient audience is equally important to consider when developing documentation tools. Patients are increasingly experiencing visits where physicians face a computer and work their
way through the EHR during the encounter instead of engaging
in face-to-face conversation. The careful design of templates
and effective physician training may help reduce patient perception that a physician is focused on the computer rather than
the individual.
Daily progress note documentation is the responsibility of the
medical staff. The documentation should include required elements and updated diagnoses and procedures when applicable. The collaboration between vendor and hospital client base
should result in documentation tools that:
Reduce the amount of duplicative documentation by physicians
Contain key fields that will assist with accurate and specific code assignments
Automatically reproduce data on a coding worksheet to
assist with coding
Populate a discharge summary with diagnoses and procedures from progress notes, post-procedure notes, consultations, operative reports, and other specified documentation

Include required fields for Joint Commission requirements and medical staff rules and regulations for specific
documents (i.e., post-procedure notes, discharge summaries, etc.)
Include free text options to allow the healthcare provider(s)
to include additional patient-specific information
Vendors traditionally provide a basic EHR system that includes
limited design workflows and templates. Ultimately, it is the responsibility of the healthcare provider to enhance and maintain
additional workflows and templates. EHR vendors should have
an understanding of the importance of documentation for primary and secondary data use, such as:

Practice Brief

Medical necessity
Continuing care
Patient safety
Regulatory requirements
Charge capture
Quality measurement and reporting

Templates assist with the standardization of essential elements in clinical documentation. This standardization will,
in turn, result in the capture of data at the level of specificity
needed to support the timely display of results, expedited chart
searching, coordination of care among healthcare providers,
and improved patient outcomes.10 Well-formatted templates
also support quality programs such as the Accountable Care
initiative, the Patient-Centered Medical Home initiative, the
Medicare Chronic Care Management program (which requires
the EHR to generate and maintain health summaries and care
plans), and others.
Documentation templates should be designed to reflect clinical accuracy and ensure documentation integrity. Now is the
time for healthcare facilities to merge meaningful use and ICD10-CM/PCS planning initiatives to develop templates, prompts,
and overall systems that facilitate and encourage documentation needed for patient care, severity of illness, intensity of services, accurate code assignment, and reimbursement as well as
a variety of healthcare quality and reporting requirements.

Three appendices are available in the online version of this
Practice Brief, located in AHIMAs HIM Body of Knowledge at
Appendix A: Electronic Note Title and Template Policy
Appendix B: Request Form for Note Title and Templates
Appendix C: Checklist for Template Review

1. Klauer, Kevin. The Problem with Prompts. Emergency
Physicians Monthly. July 19, 2010.
2. Deloitte. Navigating the ICD-10 transition: Implementation imperative for hospitals and medical groups. 2013.
pg. 5.
3. EMR 105: EMR and EHR Templates.
4. Bennett, Kevin J. and Christian Steen. Electronic Medical
Record Customization and the Impact Upon Chart Completion Rates. Family Medicine. May 2010.
5. Stearns, Michael. EHRs and the ICD-10 Transitions:
Planning for 2015. Physicians Practice. June 9, 2014. www.
6. Davis, Mike. ICD-10 Will Drive Enterprise Improvement
Opportunities. Healthcare Information and Management
Systems Society. December 15, 2010.
7. Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS Coding
Handbook. Chicago, IL: AHA Press, 2012: 501.
8. Kallem, Crystal; Burrington-Brown, Jill; Angela K. Dinh.
Data Elements for EHR Documentation. Journal of AHIMA 78, no. 7 (July-August 2007): web extra. http://library.
9. Healthcare Financial Management Association. Educational Report: Will Your Data Support Value-Based Payment? May 1, 2012. p. 5.
10. Dellinger, Beverly. Personal interview. June 19, 2012.

Doty, Laura and Marion G. Kruse. Preparing for ICD-10
While in an ICD-9 World: The Importance of Clinical
Documentation and Coding Integrity (CDCI) Programs
Being Early Adopters of ICD-10. AHIMA Convention
Proceedings, 2011.
Capanna, Alaina and Valerie Watzlaf. Clinical Documentation
Improvement and Use of Templates and Standards. AHIMA
Convention Proceedings, 2011.
EHR Templates. 4MedApproved. August 2, 2012.
Rashbaum, Kenneth N. EHR templates: Time-saver or
patient safety risk? Medical Economics. January 10, 2012.
w w

Patty Buttner, RHIA, CDIP, CCS
Sarah L. Goodman, MBA, CHCAF, COC, CCP
Tammy R. Love, RHIA, CCS, CDIP
Melissa McLeod, CCDS, CCS, CPC, CPC-I
Michael Stearns, MD, CPC

Katherine Andersen, RHIT, CCS, CRCS-I, CRCS-P
Angie Comfort, RHIA, CDIP, CCS
Susan Clark, BS, RHIT
Marlisa Coloso, RHIA, CCS
Kathy Downing, MA, RHIA, CHPS, PMP
Dwan Thomas Flowers, MBA, RHIA, CCS
Lesley Kadlec, MA, RHIA
Faith McNicholas, RHIT, CPC, CPCD, PCS
Janice Noller, RHIA, CDIP, CCS
Cindy C. Parman, CPC, CPC-H, RCC
Andrea Romero, RHIT, CCS, CPC
Journal of AHIMA June 15/61

Practice Brief

Authors (Original)
Jill S. Clark, MBA, RHIA, CHDA
Theresa A. Eichelmann, RHIA
Jan C. Fuller, MBA, RHIA, CPHIMS
Stephanie Hays, RN, CDIP, CPHQ
Becky B. Lobdell, MBA, RHIA
Nita Mangat
Maria Muscarella, RHIA
Kathleen Peterson, MS, RHIA, CCS
Carole Uknes, MHA, RHIA, CCS-P
Diana M. Warner, MS, RHIA, CHPS, FAHIMA

Acknowledgements (Original)
Sue Bowman, RHIA, CCS
Linda Darvill, RHIT
Beverly Dellinger, RN
Julie Dooling, RHIT
Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P
Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
Mary Beth Haugen, MS, RHIA
Pamela Heller, RHIA, CCS-P
Doreen Koch, RHIT
Priscilla Komara
Betty Lanzrath, MA, RHIA
Tammy R. Love, RHIA, CCS, CDIP
Jennifer McCollum, RHIA, CCS
Mary Reeves, RHIA
Theresa Rihanek, MHA, RHIA, CCS
Angela Dinh Rose, MHA, RHIA, CHPS
Allison Viola, MBA, RHIA
Jane Walters, MA, RHIA
Traci Waugh, RHIA
Lou Ann Wiedemann, MS, RHIA, CPEH, FAHIMA

The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.
62/Journal of AHIMA June 15


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Coding Notes

How Deep Do You Dig into

ICD-10-PCS Coding?
By Karen Kostick, RHIT, CCS, CCS-P, and Gina Sanvik, RHIA

ALL CODING PROFESSIONALS require the right clinical documentation at the right time in order to assign an accurate code.
This article reviews just what that requirement entails for ICD10-PCS coding.

ICD-10-PCS Scope of Work

On October 1, 2015, hospital inpatient procedures will be reported using the International Classification of Diseases Tenth
Revision Procedure Coding System (ICD-10-PCS). The 2015
Draft ICD-10-PCS code set contains 71,924 procedure codes,
compared to the 3,883 ICD-9-CM Volume 3 procedure codes.
Since almost all hospital inpatient admissions include procedures, the facility-specific ICD-10-PCS procedure requirements
define which of the 71,924 procedure codes will be reported by
the coding professional. Defining the facility-specific inpatient
procedure scope of work indicates which of the ICD-10-PCS
system sections (i.e., Medical and Surgical, Obstetrics, Administration, etc.) will be applied to report procedures.
The ICD-10-PCS coding system was developed to collect data,
determine payment, and support the electronic health record
for all inpatient procedures performed in the United States. One
of the sources that hospital inpatient facilities use to define the
facility-specific ICD-10-PCS procedure requirements is the Uniform Hospital Discharge Data Set (UHDDS) reporting criteria.
The UHDDS guidelines are used by hospitals to report inpatient
data elements in a standardized manner. The UHDDS guidelines state all significant procedures are to be reported and a
significant procedure is defined as one that is:
1. Surgical in nature, or

64/Journal of AHIMA June 15

2. Carries a procedural risk, or

3. Carries an anesthetic risk, or
4. Requires specialized training
It is important to note that the UHDDS is a minimum common core of data on individual hospital discharges and is not
intended to serve the entire facility-specific inpatient procedural coded data requirement needs. Any additional ICD-10-PCS
procedure coding requirements beyond the hospital inpatient
UHDDS requirements are to be defined within facility health
information management (HIM) coding compliance programs
and facility-specific inpatient procedure coding policies.

ICD-10-PCS Document Types

Although no federal requirements define the specific health record
document types that must be present at the time of coding, the Office of Inspector Generals (OIG) Compliance Program Guidance
for Hospitals indicates that the documentation necessary for accurate code assignment should be available to coding staff.1
Within the hospital inpatient setting, facility HIM coding
compliance plans support this OIG guidance through defining
a core set of hospital inpatient procedure document types for
ICD-10-PCS coding.
Also, based on ICD-10-PCS specificity and the facility providers procedure documentation practices, it may be necessary
to review two procedure document types in order to assign an
ICD-10-PCS code. For example, ICD-10-PCS codes to report
the placement of a peripherally inserted central catheter (PICC
line) infusion device specify where the inserted catheter resides.

Coding Notes

Figure 1: ICD-10-PCS Character Code Structure



Body System

Root Operation

Body Part




The American Hospital Associations (AHAs) Coding Clinic indicates when the providers operative note documentation does
not specify the end placement of the infusion device, the imaging report may be used to identify the required body part for the
ICD-10-PCS code assignment. This scenario illustrates how the
use of two procedure document types provide all the required
documentation necessary for the accurate ICD-10-PCS code assignment and emphasizes the need for facilities to define all the
appropriate procedure document types for ICD-10-PCS coding.

ICD-10-PCS Document Data Elements

In ICD-10-PCS, procedure codes consist of a seven character
code structure, with each character code including specific values. ICD-10-PCS coding is applied at the procedure document
type level where a code is assigned based on specific values for
each of the seven characters (see Figure 1 above).
The coder should be guided by the procedure document report information. This information will drive the code assignment. For the coding professional, the depth of the ICD-10-PCS
coding system is in the selection of the character code values for
each of the seven characters, which is governed by the ICD-10PCS system conventions, ICD-10-PCS coding guidelines, facility-specific procedure coding policies, and official advice from
the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS.
The following ICD-10-PCS coding example illustrates how
one hospital inpatient primary procedure may include multiple
ICD-10-PCS codes and require applying multiple ICD-10-PCS
character code level governing rules and official guidance for
code assignment.

ICD-10-PCS Coding Example

The procedure performed for the purposes of this example is an
attempted percutaneous robotic-assisted laparoscopic total hysterectomy, converted to an open total abdominal hysterectomy.
The ICD-10-PCS code assignment for this example is:
0UT90ZZ, Resection of uterus, open approach (for the
0UTC0ZZ, Resection of cervix, open approach (for removal of the cervix)
0UJD4ZZ, Inspection of uterus and cervix, percutaneous
endoscopic approach (for the attempted laparoscopic hysterectomy)
8E0W4CZ, Robotic assisted procedure of trunk region,
percutaneous endoscopic approach (for the attempted
robotic-assisted surgery)
ICD-10-PCS codes 0UT90ZZ and 0UTC0ZZ are assigned based
on the following Character 3 root operation coding guidelines
and advice for this procedure: Medical and Surgical Section of the

2015 ICD-10-PCS Official Guidelines for Coding and Reporting:

Multiple procedures B3.2a: During the same operative episode, multiple procedures are coded if the same root operation is performed on different body parts as defined by
distinct values of the body part character. Example: Diagnostic excision of liver and pancreas are coded separately.
E xcision vs. Resection B3.8: ICD-10-PCS contains specific
body parts for anatomical subdivisions of a body part,
such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding
Excision of a less specific body part.
A HA Coding Clinic for ICD-10-PCS, Third Quarter 2013
states that in ICD-10-PCS, when coding for a total (open)
hysterectomy, two codes are reported to specify the resection of the uterus and the cervix. A total hysterectomy includes the removal of both the uterus and cervix.
ICD-10-PCS codes 0UJD4ZZ and 8E0W4CZ are assigned
based on the following Character 5 root operation coding guidelines and advice for this procedure:
Medical and Surgical Section of the 2015 ICD-10-PCS Official Guidelines for Coding and Reporting:
-- Multiple procedures B3.2d: During the same operative episode, multiple procedures are coded if the
intended root operation is attempted using one approach, but is converted to a different approach. Example: Laparoscopic cholecystectomy converted to
an open cholecystectomy is coded as percutaneous
endoscopic Inspection and open Resection.
A HA Coding Clinic for ICD-10-PCS, First Quarter 2015
states: For an attempted robotic assisted laparoscopic
hysterectomy, the AHA Coding Clinic emphasizes the
need to apply the ICD-10-PCS guideline B3.2d when the
intended root operation is attempted using one approach,
but is converted to a different approach, the procedure(s)
in the operative episode are coded to the approach ultimately used, and an Inspection procedure is coded using
the approach value of the attempted approach.

1. Office of Inspector General. Publication of the OIG Compliance Program Guidance for Hospitals. Federal Register
63, no. 35 (February 23, 1998): 8,991.

American Hospital Association. AHA Coding Clinic. Third
quarter, 2014: 5-6.
Journal of AHIMA June 15/65

Coding Notes

Code Assignment for Coding Example

0UT90ZZ Resection of uterus, open approach
Character 1

Character 2
Body System

Character 3
Root Operation

Character 4
Body Part

Character 5

Character 6

Character 7

Medical and





No Device

No Qualifier

0UTC0ZZ Resection of cervix, open approach

Character 1

Character 2
Body System

Character 3
Root Operation

Character 4
Body Part

Character 5

Character 6

Character 7

Medical and





No Device

No Qualifier

0UJD4ZZ Inspection of uterus and cervix, percutaneous endoscopic approach

Character 1

Character 2
Body System

Character 3
Root Operation

Character 4
Body Part

Character 5

Character 6

Character 7

Medical and



Uterus and Cervix


No Device

No Qualifier

8E0W4CZ Robotic assisted procedure of trunk region, percutaneous endoscopic approach

Character 1

Character 2
Body System

Character 3
Root Operation

Character 4
Body Region

Character 5

Character 6

Character 7

Other Procedures

Systems and

Other Procedures

Trunk Region


Robotic Assisted

No Qualifier

American Hospital Association. AHA Coding Clinic for ICD-9CM. July/August 1985: 3-8.
American Hospital Association. AHA Coding Clinic for ICD-10PCS. First quarter, 2015: 33-34.
American Hospital Association. AHA Coding Clinic for ICD-10PCS. Third quarter, 2013: 28.
Cassidy, Bonnie. Defining the Core Designated Clinical
Documentation Set for Coding Compliance. AHIMA
Thought Leadership Series, 2012.
Centers for Medicare and Medicaid Services. 2015 Code
Tables and Index. 2015.
66/Journal of AHIMA June 15

Centers for Medicare and Medicaid Services. 2015 ICD-10PCS Reference Manual. 2015.
Centers for Medicare and Medicaid Services. ICD-10-PCS
Official Guidelines for Coding and Reporting 2015. 2015.
The Uniform Hospital Discharge Data Set (UHDDS) Reporting of
Inpatient Data Elements. Federal Register 50, no. 147. July 1985.
Karen Kostick ( is senior technical business
analyst, CLU and CAC content, and Gina Sanvik (Gina.Sanvik@nuance.
com) is manager, CLU and CAC content, at Nuance Communications, Inc.

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Coding Notes

Injection and Infusion Coding

Offers High Stakes
By Charles Flewelling, Jr., RHIT

WITH THE CONSISTENTLY rising value of highly skilled outpatient coders, numerous HIM departments are moving to a
staffing model that employs coding professionals who are well
versed in coding both inpatient and outpatient encounters.
Coders in the profession today should possess a mastery of the
complex inpatient coding rules as well as the very specificand
equally complexoutpatient coding rules.
One of the most demanding aspects of outpatient coding is
the selection of injection and infusion (I&I) codes. This set of
Current Procedural Terminology (CPT) codes, 96360 through
96549, is utilized to capture I&I administered in the emergency
department (ED). I&I coding is also appropriate in observation
patients who have been transferred from the ED. Rarely, if ever,
are I&I codes appropriate if the patient is transferred from the
ED to inpatient status.
When approaching I&I coding, it can be helpful to think of the
code assignments in terms of playing cards or a hand of poker. Its important to determine not only what you have in your
hand, but also which cards trump the others. Coders must have
a firm grip on the definitions of several terms in order to achieve
success with I&I codesjust as a poker player needs to know
all their options when trying get their best hand possibleas
well as which I&I procedures will outrank othersjust as an
ace trumps a jack, so too does chemotherapy trump the other
procedures. This article gives an overview of the information essential to successful I&I coding.

Coders Must Master Many Term Definitions

For success with I&I codes, coders must have a firm grasp on the
68/Journal of AHIMA June 15

Hierarchy of I&I Codes

1. Chemotherapy (96401)
2. Infusions (96365)
3. Injections (96374)
4. Hydration (96360)

definitions of the following terms:

Infusion: Administration of diagnostic, prophylactic, or
therapeutic intravenous (IV) fluids and/or drugs given
over a period of time. (Examples: Banana bags, heparin,
nitroglycerin, antiemetics, antibiotics, etc.)
Injection: The act of forcing a liquid into the body by
means of a needle and syringe. Injections are designated
according to the anatomic site involved; the most common are intra-arterial, intradermal, intramuscular, intravenous, and subcutaneous. Injection delivers a dosage in
one shot rather than over a period of time.
-- I V Push (IVP): (a) An IV administration of a therapeutic, prophylactic, or diagnostic drug; (b) An infusion that runs for 15 minutes or less; (c) Any infusion
without documentation of a stop/continuing time.
-- I V Piggyback (IVPB): A method to administer medication through an existing IV tube inserted into a
patients vein, hence the term piggyback. The medication in an IV piggyback is usually mixed in a small
amount of compatible fluid, such as normal saline.

Coding Notes

Hierarchy for Subsequent or Sequential IVPs


IV Push


96365 - Initial infusion up to 1 hour

96366 - Each additional hour
96367 - Sequential infusion up to 1 hour
(use 96366 for additional hours of sequential
96368 - Concurrent infusion (report only one
per encounter)
96375 - IV push, each push of a different drug
96376 - Each IV push of the same drug at
intervals > than 30 minutes
96361 - Hydration (do not charge at the same
time of infusion); must be 31 minutes or longer
96372 - IM/SubQ Injection
90471 - IM/SubQ Vaccine

96374 - Initial push or infusion less than 16

96375 - IV push, each push of different drug
96376 - Each IV push of same drug at intervals >30 minutes
96361 - Each hour of hydration; must be 31
minutes or longer
96372 - IM/SubQ Injection
90471- IM/SubQ Vaccine

96360 - Initial hydration up to 1 hour; must be

at least 31 minutes
96361 - Hydration each additional hour; must
be 31 minutes or longer
96372 - IM/SubQ Injection
90471- IM/SubQ Vaccine
*** Note: In any case with an IVP injection,
infusion, or hydration along with an IM or
SubQ injection, the IM or SubQ injection will
require modifier -XU for unusual, overlapping
services (96372-XU)

-- Intramuscular (IM) Injection: An injection of a

therapeutic, prophylactic, or diagnostic drug into
the substance of a muscle, usually the muscle of the
upper arm, thigh, or buttock. Intramuscular injections are given when the substance needs to be absorbed quickly.
Hydration: Typically an administration of prepackaged fluids and/or electrolytes without drugs. Examples include normal saline (NS), sodium chloride (NaCl), dextrose 5 percent
in water (D5W), dextrose in normal saline (D5 saline),
dextrose in normal saline plus potassium (D5 NS+K).
The coder must also thoroughly understand the guidelines
provided by the American Medical Association (AMA) in the
use of these codes. With a complete working knowledge of
these areas, the coding professional can apply the correct
CPT codes.
In addition to the definitions listed above, other considerations to make when selecting the appropriate I&I code include payer-specific policies, vast instructional notes, and
the hierarchy system laid out in the AMAs Current Procedural Terminology reference book. Understanding the hierarchy of these procedures can be challenging for novice and
experienced outpatient coders alike. According to the CPT
guidelines, chemotherapy services are primary to therapeutic, prophylactic, or diagnostic services which are primary to
hydration services. Infusions are primary to pushes, which
are primary to injections.
Whenever chemotherapy is performed, it will trump all other services. But since infusions, injections, and hydrations are
most common in the ED setting, this article will continue the I&I
discussion without a focus on chemotherapy.
Typically, only one initial service code will be capturedeven
when multiple drugs are being administered. The exception is
when there is more than one IV access site or when there are
multiple encounters during the same date of service.
The coder will need to determine three things initially:

1. What did the patient receive?

2. How was it given?
3. How long did it take?
An initial service of an infusion will trump injections and/or
hydration. If the initial service is determined to be an injection,
then it will outrank hydration, but not infusion.
To determine the initial code, there are a few things the coder
needs to consider:
1. Was there an infusion of 16 minutes or more? If so, infusion (96365) should be coded, as it outranks both injection
and hydration.
2. If there was no infusion, was there an injection? If so, injection (96374) should be coded, as it outranks hydration.
3. If there were no infusions or injections, was there a hydration of longer than 31 minutes? If so, then hydration
(96360) should be coded.
Subsequent or sequential IVPs are then coded as appropriate.
See the sidebar above for more information on this process.

Coding Subsequent or Sequential IVPs

Courtney Johnson, RN, BSN, RHIA, CCS, coding specialist at
Baylor University Medical Center, gave the following steps for
counting infusion times in a presentation during the August
2012 Coder Summit conference call held quarterly for all Baylor
coders, auditors, HIM managers, and CDI staff.
Once the initial service code is captured, subsequent or sequential IVPs are coded as appropriate. The sidebar above illustrates how the hierarchical process for coding subsequent
or sequential IVDPs falls into place. To begin, select the most
appropriate column based on the chart documentation and the
hierarchical principle. Then, once the initial service code is chosen, make all further CPT code choices from within the column
with that code at the top.
As the coder picks the appropriate column and then follows it
down for the appropriate codes, they must also remember that
Journal of AHIMA June 15/69

Coding Notes

Scenario #1

Scenario #2


Administered Medications:
19:21 Drug: Zofran 4 mg Route: IVP; Site: left
20:54 Follow up: Response: No adverse reaction;
Nausea is decreased


Administered Medications:
19:21 Drug: Zofran 4 mg Route: IVP; Site: left
20:54 Follow up: Response: No adverse reaction;
Nausea is decreased

 9:21 Drug: morphine 4 mg Route: IVP; Site: left
20:54 Follow up: Response: No adverse reaction;
Pain is decreased

 9:21 Drug: morphine 4 mg Route: IVP; Site: left
20:54 Follow up: Response: No adverse reaction;
Pain is decreased

 9:21 Drug: NS 0.9 percent 1,000 ml Route: IV;
Rate: bolus; Site: left antecubital
20:54 Follow up: [no stop time documented]

 9:21 Drug: NS 0.9 percent 1,000 ml Route: IV;
Rate: bolus; Site: left antecubital
20:54 Follow up: IV status: Completed infusion. IV
intake: 1,000ml

Documentation from the MAR

ED Meds

Day 1

4 mg IVP
4 mg IVP

Documentation from the MAR

Day 2

ED Meds

Day 1

4 mg

4 mg IVP

4 mg

4 mg

4 mg IVP

4 mg

1,000 ml IV bolus

1,000 ml IV bolus

Day 2


Codes assigned are 96374 and 96375. In this instance,

start times are given for all infusions but none have stop
times. Each infusion is counted as 15 minutes. When these
times are subtracted from the normal saline (NS) infusion
time (15 minutes), there is no NS time to code. Many institutions give away numerous infusions due to the lack of appropriate documentation. There are also numerous facilities
that have specific staff dedicated to the job of scanning the
ED to make sure that ED documentation is complete with
both start and stop times.

Codes assigned are 96374, 96375, and 96361. The NS can

now be captured because it has a documented stop time.
Since there are still no documented stop times on the Zofran
and morphine, only assign 15 minutes for each. NOTE: some
facilities will apply only one 15-minute unit to multiple meds
if they are given at the same time, considering it as a single
infusion. Some will allot a 15-minute unit for each different
medicine given at the same time. Be sure to check with your
facility on whether this is a multiple allotment or just a single
allotment of 15 minutes. This could very well affect whether
to code 96361 for a subsequent hour of NS infusion.

it is critical to look at the chronological order of the infusions in

order to determine the correct codes.
It is just as important to pay close attention to the times of the
infusions. In order to accurately code infusions, not only must
there be a start time (usually documented), but there must be a
stop time (problematic in most EDs).
An infusion or hydration that runs alone with no IVPs interrupting will be counted by minutes from the start time to the
documented stop time.
If the patient is transferred or admitted to another patient status, count from the start time to the time that the admit order is
written. Some facilities consider admit time as the time of the
admit order. Others may count the time from the actual transfer
of the patient.

If hydration was interrupted by either an IVP or IVBP, you

must count only the time the hydration ran alone. (The time rule
still applies; it must run for 31 minutes or more alone to count.)
For each IVP that is given during hydration, subtract 15 minutes from the normal saline time, unless multiple IVPs are given
within 15 minutes of each other.

70/Journal of AHIMA June 15

Infusion and Injection Case Example Scenario

With these principles and guidelines in mind, consider the
following common occurrence in the ED. A patient is admitted complaining of acute abdominal pain. An IV is set up to
infuse normal saline, Zofran for the nausea, and morphine for
the pain. Coders for the ED see this scenario, or variations of
this scenario, numerous times a day. What are the codes that

Coding Notes

Scenario #3
Administered Medications:
19:21 Drug: Zofran 4 mg Route: IVP; Site: left
20:54 Follow up: IV status: Completed infusion
Response: No adverse reaction; Nausea is decreased
 9:21 Drug: morphine 4 mg Route: IVP; Site: left
20:20 Follow up: Response: No adverse reaction;
Pain is decreased
 9:21 Drug: NS 0.9 percent 1,000 ml Route: IV;
Rate: bolus; Site: left antecubital
20:54 Follow up: IV status: Completed infusion

Documentation from the MAR

ED Meds

Day 1

4 mg IVP

4 mg


4 mg IVP

4 mg


1,000 ml IV bolus

Day 2


Codes assigned would be 96365 and 96375. Normal

saline (NS) will not be coded due to the Zofran infusing
during the entire NS time. The total time for the infusion
of Zofran was 93 minutes, well over the initial 31 minutes
to qualify to be coded 96365.

Journal of AHIMA Continuing Education Quiz

Quiz ID: Q1538606 | EXPIRATION DATE: JUNE 1, 2016
HIM Domain Area: Clinical Data Management
ArticleInjection and Infusion Coding Offers High Stakes

should be assigned?
The three illustrated scenarios on pages 70 and 71 take this
basic premise and apply the guidelines discussed in this article,
assigning the appropriate CPT code for the infusion.
An additional two scenarios, available in the extended onlineonly version of this article in AHIMAs HIM Body of Knowledge,
change the documentation slightly to illustrate other important
factors to consider for I&I coding.

AHIMA. CPT Coding for Injections and Infusions. Audio
Seminar, May 8, 2012.
American Medical Association. CPT Professional Edition.
Chicago, IL: AMA, 2015.
Endicott, Melanie. Taking the Sting out of Injection
and Infusion Coding. Journal of AHIMA 83, no. 11
Johnson, Courtney. Injection and Infusion Coding.
Presentation during Baylor Scott and White Health Coder
Summit conference call, August 2012.
Garrett, Joyce. Basic Coding for Infusions and Injections.
Internal Presentation to Franciscan Health Services, 2008.
Charles Flewelling, Jr. ( is a corporate remote coding auditor at Baylor Scott and White Health, based in
Dallas, TX.

Read More
More Example Scenarios Online

An additional two scenarios are available in the extended onlineonly version of this article in AHIMAs HIM Body of Knowledge.




Journal of AHIMA June 15/71















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72/Journal of AHIMA June 15

A Look Ahead

Keep Informed


AHIMAs ICD-10 Academy Helps Build Expert

Trainers in Diagnosis, Procedure Coding

Upcoming AHIMA Institutes, Seminars, Workshops,

and Webinars


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Chicago, IL

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Documentation Improvement


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Minneapolis, MN


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Webinar: The Pre-Bill Review: Directing the Wheels

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Coding, Atlanta, GA



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AHIMA Volunteer Leaders


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74/Journal of AHIMA June 15

AHIMA Volunteer Leaders


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Laurine Johnson, MS, RHIA, FAHIMA
Sarver, PA
(724) 295-9429
Puerto Rico
Brunilda Velazquez, RHIA, CCS
Guayanilla, PR
(787) 505-1433
Rhode Island
Patti Nenna, RHIT
Bristol, RI
(401) 253-1686
South Carolina
Karen B. Farmer, RHIT
Greenville, SC
(864) 277-1982

E-mail changes to your listing to

Journal of AHIMA June 15/75

QualCode provides cost-effective solutions for all your

coding, reimbursement and educational concerns.

Advertising Index
AHA Central Office............................................................ 9

Medical Coding Services

Inpatient & Outpatient
- Onsite & Remote
Specialty Coding
- Wound Care

AHIMA................................................................. 20, 63, 67

Coding Compliance Audits

DRG/Coding Quality Audits
Evaluation & Management Audits
- Emergency Room
- Professional Fee Services

Amphion Medical Solutions................... inside back cover

Education & Training


Channel Publishing......................................................... 24

American Medical Association.......................................53

Caban Resources, LLC................................................... 18

Elsevier Clinical Solutions............................................... 27


First Class Solutions....................................................... 55

Fujitsu Computer Products of America.......................... 17
QualCode, Inc.


Medical Coding & Reimbursement

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

Health Language, Inc...................................................... 19

AHIMA Thanks Its Loyalty Program Members

HealthPort....................................................................... 11
In Record Time, Inc........................................................... 5


IOD Incorporated............................................................45
Just Associates, Inc........................................................ 31
MRO.................................................................................. 1

Ovation Revenue Cycle Services...................... back cover
QualCode, Inc................................................................. 76
Resurrection University...................................................33


Health Language

SourceHOV....................................................................... 7
The Coding Alliance, LLC............................................... 49

a SourceHOV company

76/Journal of AHIMA June 15

VHC................................................................................. 47

AHIMA Career Center

For classified advertising information, call Alyssa Blackwell: 410-584-1961 | e-mail:
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.

The nations largest revenue
cycle services organization
has immediate openings for
experienced remote coders.
Adreima partners with over
600 hospitals and our benefits
include competitive pay with
full benefits.

Advertise in the
AHIMA Career
Call 410-584-1961

Code Analyst IV
Medical Records
RHIA, RHIT or CCS required
Minimum 5 years hospital
coding experience
Medicare inpatients and
DRG experience required
SAMC is a 420 bed hospital and one
of the largest not-for-proft tertiary
referral centers in Alabama. Dothan is
in the southeast corner of the state, 90
miles from gulf coast beaches and 200
miles from Atlanta and Birmingham.

Exclusively Specializing
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We assist both
job seekers and employers
in the following specialties:
Executive Level | Consultants
Coders | Auditors | CDI
Directors | Managers | Vendors
Contact us in confidence:
Doug Ellie or
Perry Ellie, MA, RHIA, Fellow AHIMA

1108 Ross Clark Circle Dothan, AL 36301


Find the perfect employee.

Advertise in the AHIMA Career Center!
Contact Alyssa Blackwell at 410-584-1961 for pricing and options,
or leave her an email at

Journal of
June 15/77
15 / 77

AHIMA Career Center

The nations largest revenue cycle

services organization has immediate openings for
experienced remote coders. Adreima
partners with over 600 hospitals and our
benefits include competitive pay with full benefits.
Reasons to Join the Adreima Team:
Variety of work
Cross training in all aspects of the revenue cycle
Opportunity for growth, development,
expansion, and upward mobility
Flexibility, work from home and flexible hours

Benefits Plan:

/ Journal of AHIMA June 15

Educational reimbursement
Accreditation reimbursement
Office Setup, computer, monitor, phone
Great Benefits: 401K, medical, dental, vision, and
Contact Jena Ford, our dedicated recruiter
to learn more at






Journal of
June 15/79
15 / 79

AHIMA Career Center


A Full-time Hospital based Coder is needed in
Rural Alaska. The Bristol Bay Area Health
Corporation is located in Dillingham Alaska on the
shores of Bristol Bay, the salmon capital of the
world. The 40,000 mile region of Bristol Bay
includes the rich and vibrant cultures of Alaska
Native People and an abundance of beautiful
scenery, wildlife, outdoor activities.
Under the supervision of the Coding Supervisor
assigns ICD-9-CM/CPT-4, E&M, and HCPC codes
for reimbursement. Must be able to code Emergency
Room, Outpatient, Inpatient, Observation, Day
Surgery, Physical Therapy, and Optometry visits.
Registered Health Information Technologist (RHIT),
Certified Coding Specialist (CCS) or Certified
Professional Coder (CPC).
For more information please contact
Human Resources at 907-842-5201 or
access our website at

Want to fill your open position,

or promote your office as a
great place to work?
Advertise in the
AHIMA Career Center!
Contact Alyssa Blackwell at 410-584-1961
for pricing and options, or leave her an email

Upcoming Issues:
Clinical Documentation
Special Issue:
Information Governance
Consumer Engagement
Limited space available!
Custom Packages available to fit your
goals and budget.

80 / Journal of
June 15




Journal of AHIMA June 15/81

3M Health Information Systems.....................................82
Administrative Consultant Service, LLC. . ........................95
Amphion Medical Solutions...........................................83
Anthelio Healthcare Solutions.. ......................................84
Care Communications...................................................95
Career Step.................................................................83
Charts in Time, Inc.......................................................85
eCatalyst Healthcare Solutions, Inc... .............................85
emids, Inc.. ..................................................................86
First Class Solutions . . ...................................................86
GeBBS Healthcare Solutions, Inc...................................95
Health Information Associates.......................................87

Total reach of presentstate CDI programs:

89.9% not reviewed;
10.1% CDI-reviewed*

Just Associates, Inc.....................................................89


Maxim Healthcare Services, Inc.. ...................................95

MedData, Inc...............................................................91
MedPartners HIM.........................................................89
Microsourcing, LLC......................................................92
MRO. . ..........................................................................93
Perry Johnson & Associates, Inc. . . .................................92

*3M study of a seven-hospital,
non-prot health system,
conducted 20132015.
Percentage of cases measured
by revenue.

Precyse Solutions. . .......................................................95

Stat Solutions..............................................................95
Textware Solutions-Instant Text....................................95
The Coding Alliance, LLC..............................................95

3M 2015. All rights reserved.

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To transform your organizations
CDI program, call us toll-free at
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June 2015


Career Lfecycle Management

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Transition outpatient coders to inpatient coders
Improve coding accuracy
Re-train ICD-10 coders in ICD-9
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MEASURE training efcacy, retention, and peer performance.
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eCatalyst is

framing the
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The most important element of our service

philosophy is the unrelenting client focus.
Our success depends entirely on how we
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Chris Meyers, CEO
eCatalyst unites the knowledge, experience and
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Is your EMR sucient for the care

coordinaton requirements of today?
Do you have the technology
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could be beter?
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services and industry-leading solutons. Grounded in deep
technology expertse and an exclusive healthcare focus, our
clients experience true partnership with us as we navigate
the challenges of a rapidly changing healthcare industry.
Because healthcare is our only business, we minimize the
knowledge gap typical vendors have learning the HIT space
adding immediate value and developing partnerships that
strengthen over tme.
We custom tailor our approach to your business needs. We
partner with you by aligning a sophistcated soluton with
your unique situaton, being the expert team you rely on and
taking accountability for the success of your IT investment.

First Class Solutions, Inc. SM

Not your traditional healthcare
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Our HIM Services

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Our Areas of Expertse

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Q U A L I T Y. S E R V I C E . P E AC E O F M I N D.



For more than 20 years, HIA has been

committed to quality in everything we
do, from the training of our staff, to
relationships with our clients. As a result
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/ June
2015 AHIMA June Resource Guide Ad FINAL.pdf
3:08 PM

Audit Chaos
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Your Coding Solution

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Your Own
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Healthcare companies can leverage our unique hybrid outsourcing
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Perry Johnson & Associates, Inc.

A Global Leader in
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Revenue Cycle Management

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Medical Coders
With the current shortage of Medical Coders forecasted to get
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Build your own team of AHIMA or
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Phone: 707-773-3325
Learn More:



1016 West 8th Avenue, Suite A
King of Prussia, PA 19406
MRO empowers healthcare organizations with proven, enterprise-wide solutions for the secure, compliant and effcient exchange of Protected Health Information (PHI). These
solutions include a suite of PHI disclosure management services comprised of release of information (ROI), CMS and private payer audit management and accounting of
disclosures. MROs technology-driven services reduce the risk of improper disclosure of PHI, ensure unmatched accuracy and enhance turnaround times. MRO additionally
supports its clients current and future initiatives, including interoperability, meaningful use and health information exchange.
Release of Information
MRO is the acknowledged industry leader for staffed, shared and remote release of information (ROI) services, and its ROI
Online solution has been rated number one by KLAS for two years in a row (2013 and 2014). The company invests heavily
in the hiring, training and education of its processing center and feld staffs to ensure the best client experience. Additionally,
MROs cutting-edge technologies provide high levels of visibility and control through transparent reporting tools and
sophisticated workfows that offer industry-leading turnaround times, improved operations and the highest levels of accuracy.
MRO mitigates risk by incorporating multiple quality checks by highly trained professionals as well as proprietary, state-of-theart OCR scanning technology. By deploying ROI Online as a centralized platform, healthcare organizations can better manage
PHI disclosure, standardize processes and improve compliance throughout the healthcare enterprise. Integrations with Master
Patient Indexes (MPI) and Epic and other EMR ROI modules are available.
CMS and Private Payer Audit Management

The ROI Online platform is

very transparent and easy
to use. MRO implements
state-of-the-art and cutting
edge technology to meet
the needs of all involved,
both the hospital and
patients. MROs software
and workfow processes
are above the rest!
Ken Maiorana, HIM Director
at Georgetown Hospital

MRO offers comprehensive compliance services and tracking software for healthcare providers seeking to effectively manage
all Centers for Medicare and Medicaid (CMS) and private payer audit processes including RAC, MAC, ZPIC, UPIC and others.
Compliance services include special handling for audit requests and appeals letters, additional quality assurance checks
(including deadline and address verifcation) and expedited fulfllment through various delivery methods including electronic
submission of medical documentation (esMD) electronic delivery to CMS. Additionally, MRO provides clients with an audit
enforcement team that works with managed care companies and auditors to ensure appropriate fee invoicing and to monitor
record request limits. MRO also offers an audit tracking and reporting application AUDITRENDS Online.
Accounting of Disclosures
MROs accounting of disclosures (AOD) solutions enable healthcare organizations to enforce disclosure policies and centrally
track, manage and report all disclosures made across the entire healthcare enterprise, inside and outside of the HIM
department. AOD Online includes capabilities of capturing disclosures that are made to federal, state and local public health
databases (i.e., Offce of Infectious Diseases, Cancer Registries, etc.) and may also be able to track disclosures to HIEs as they
emerge. AOD Online also features an embedded breach assessment tool to help an organization determine if a breach has
occurred, and it offers the proper tracking of any identifed disclosures in question.
Interoperability Solutions and Services
MROs clients have access to the following interoperability solutions and services:

esMD, to rapidly and securely deliver all Medicare- and Medicaid-based review documents to CMS;
Social Security Administrations MEGAHIT interface for HIE-driven, accelerated disability determination;
MRODirect, MROs platform for the Direct Secure Messaging of PHI for the purposes of improving effciency and
effectiveness of transitions of care between healthcare providers; and
Consulting services for technology and operational support to realize interoperability.


Choosing MRO as a
vendor was a great
decision. MRO excels in
terms of professionalism
and communication. We
appreciate the weekly
calls to check in and to
provide us with turnaround
information, the availability
of management when
we need to communicate
with them and our
monthly reports from
MRO. I recommend
their services to all my
colleagues in the industry.
Cheryl Seller, HIM Director
at Mercy Nazareth Hospital



Refresher Training

LexiCode Coding Solutions

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Service, LLC
Revenue Cycle Management
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Care Communications is a nationally recognized,

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For more information please call us


At Your Service!



Maxim provides only the highest quality HIM

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HIM goals. Take advantage of our expertise
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EAST 866-265-0589

Outsource Remote Coding Specialists


We offer customized
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*Onsite or Remote Coding

*Coding Quality Reviews
*Interim HIM Management


Maxim your
HIM Partner!

Stat Solutions, Inc. is a highly respected

coding company focusing our efforts on
providing the highest level of
credentialed HIM professionals along with
the finest personalized customer service.


Instant Text is the leading expander

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Transcription or editing, it can be done
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Call: 800 355 5251
Contact: Marianne Kleen
Textware Solutions
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Voices from the ICD-10 Zeitgeist

will finally be implemented this year, prominent advocates for the transition are striking a more optimistic
tune in public statements. Overall, the ICD-10 zeitgeist
has steadily swung toward an implementation date of
October 1, 2015 after years of ICD-10 deadline delays.
Weve rounded up some of the best ICD-10 sound bites
from Congressional testimony, social media, and interview outtakes from the Journal that help demonstrate
that hopeful aura now glowing around ICD-10-CM/PCS.

Regarding physician ICD-10 skeptics who didnt

know physicians have requested new codes over
the years: They thought it was mostly bureaucrats who came up with this in an office, but
they were quite astonished when I talk about laterality and alluded to the fact that orthopedists
requested the laterality [in ICD-10]. Theres a lot
of information out there that they [physicians]
arent privy to. Paul Isaacs, MD, CDIP, senior
director of health solutions, FTI Consulting,
in an interview with the Journal of AHIMA

ICD-10 will help medical researchers

because it allows us to be more precise.
It will not result in a Nobel Prize, but
we can be a little more precise about
exactly what happened and help us
recognize patterns, John Hughes,
MD, professor of medicine at Yale
School of Medicine, in an interview
with the Journal of AHIMA

96/Journal of AHIMA June 15

In the short term, I dont think coders lives will

change much. These months leading up to implementation have already meant a lot of extra work
for them, and that will likely continue for the first
six months or so. But my hope for the long term
is that coders will embrace change as the new
normal, and expect to be constantly learning and
expanding their horizons. Rhonda Butler, CCS,
CCS-P, senior clinical research analyst at 3M
Health Information Systems, in an interview
with the Journal of AHIMA

ICD-10 is not a silver bullet. But on the

spectrum of needed systemic changes, it is
a comparatively simple onethe technological equivalent of an upgrade from a relatively simple dictionary to a more complex
one. Kristi Matus, chief financial and
administrative officer, Athenahealth, in
testimony delivered at the US House of
Representatives Energy and Commerce
Subcommittee on Health hearing titled
Examining ICD-10 Implementation

What cost $6.8 billion

dollars last year? Not
switching to ICD10. #ICD10Matters
Tweet from @

We Code With Confdence

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Code with Confdence, Contact us: 412.432.5697 or