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October 29, 2013 / Issue 48

In this issue:

Experts share strategies for clinical documentation improvement

Experts share tips for ICD-10-CM transition

Increase in health data poised to revolutionize healthcare industry

Latest developments in privacy and security

Nuance unveils ICD-10-ready platform

Wacom and Access announce e-signature integration

Huff DRG Review releases mobile app for clinical documentation


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Experts share strategies for clinical documentation improvement

ATLANTA – The new ICD-10-CM and ICD-10-PCS coding systems – which increase the number of diagnosis and procedure codes from about 13,000 to over 141,000 – will offer much more detailed information on patient health. Physicians and other healthcare professionals must be educated not just about the new codes, but how documentation must be accurate, timely and more specific to enable coding with ICD-10. While goals of clinical document improvement (CDI) programs are geared toward clinical data integrity and reliability, an important and undeniable benefit of CDI is improved capture of data, and this enables better coding. Successful clinical document improvement (CDI) programs have many benefits including positive impact on the following:

  • Patient care;
  • Clinical data and information integrity;
  • Reliability of quality measures and demonstration of meaningful use; and
  • Timely and appropriate claims payment.

“Clinical documentation impacts both the quality of care and reimbursement and bringing physicians up-to-speed about the level of granularity included in ICD-10 is one of our most important jobs as health information management professionals,” said Theresa Jackson, RHIA, director of health information management (HIM), University of Kansas Hospital, Shawnee Mission, Kan.

“For example, in ICD-9, myocardial infarction (MI) is coded in one of two categories depending on factors such as the acuity, duration and timing of MI. In ICD-10-CM, many additional details are recorded, such as information about the type and sequence of any underlying diseases, as well as factors such as tobacco use and exposure to environmental/workplace smoke; and, where applicable, the status of administration of the clot-busting drug tPA performed at a different facility within 24 hours of admission to the current facility. This will help guide the treatment a patient receives. ICD-10 should be seen for its benefits and not as a burden.”

Jackson’s co-authors for the presentation, “Pains for Gains: Creating a Positive Culture within a CDI Program,” are Gretchen Dixon, MBA, CCS, CHCO, and Anita Archer CPC, AHIMA approved ICD-10 trainers, Hayes Management Consultant, Huntington Beach, Calif.

In a second presentation, Kristi Richison, RHIA, director of HIM, Hillcrest Medical Center, Ardent Health Services, Tulsa, Okla., will stress the importance of assembling a cohesive, multi-disciplinary team of HIM and clinical documentation specialists, coders and physicians.

“There are differences between what’s going on with the patient in real-time versus coding guidelines; there are gaps between coding and clinical speak that we must address,” she said. “At our facility, we conduct chart reviews and hold one-on-one meetings with physicians to discuss deficiencies in documentation. After another chart review, there is a follow-up meeting for which we prepare a physician dashboard that includes the number and type of documentation queries, response rates, and issues such as missing discharge summaries, physical exam results and other omissions that can influence revenue.”

Co-author of Richison’s presentation is Ann M. Meehan, RHIA, vice president, HIM, Ardent Health Services, Nashville, Tenn.

Other strategies for successful CDI to be shared by the presenters include:

  • Gain the buy-in of leadership, including the CEO,CFO, CMO, and CMIO.
  • Conduct specialty-specific training and enlist a physician advocate for each specialty; Provide education tools for physicians by specialty, including online training; one-on-one meetings to discuss specific cases and queries; and presentations at department meetings.
  • Expand the staff of clinical documentation specialists (CDS), as needed.
  • Promote coder/CDS collaboration through tactics such as pairing each coder with a CDS for coder training and the handling of queries.
  • Perform chart reviews and implement dual coding to identify gaps in documentation well in advance of ICD-10 implementation.
  • Provide opportunities for greater CDS visibility to and interaction with clinical staff.

Richison and Jackson will describe their organizations’ CDI programs during presentations at the 85th Annual Convention and Exhibit of the American Healthcare Information Management Association (AHIMA), October 26-30, in Atlanta.

“As the industry’s leading authority on ICD-10 preparedness, AHIMA is committed to making a wide range of tools available to HIM professionals as they work to make the transition from ICD-9 to ICD-10, including presentations at Annual Convention that address the tasks such as CDI that must be accomplished before the ICD-10 compliance deadline in 2014,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA.

For more on AHIMA, visit

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Experts share tips for ICD-10-CM transition

ATLANTA – With less than one year to go before the compliance deadline for ICD-10-CM and ICD-10-PCS, experts will discuss implementation challenges, successes and strategies at AHIMA’s 85th Annual Convention and Exhibit October 26-30, in Atlanta.

“At Convention, the American Healthcare Information Management Association (AHIMA) offers attendees the opportunity to hear from experts on implementation processes and receive guidance about best practices for organizations of all sizes,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. “As the industry’s leading authority on ICD-10-CM preparedness, AHIMA is excited to help all healthcare stakeholders with the transition to ICD-10-CM, a more robust coding system that will lead to improved patient care documentation and granular data.”

Presenters will share insights on the elements of an effective implementation plan, including payer and vendor collaboration and related revenue cycle system preparation; training and testing; and clinical documentation improvement.

According to the presenters, the first and most important step for ICD-10-CM implementation is to obtain senior executive and clinical staff buy-in. Recognition and understanding are critical at the executive level, that significant and careful planning are needed for a successful transition. Commitment is needed to assure that the right mix of time, staff, and technological/technical resources are available.

Payer collaboration/RCM

“This affects not just hospitals and their physicians/staff, it affects payers and the health providers’ billing systems; implementation strategies must address these issues that affect reimbursement,” said Donielle Bailey, RHIA, ICD-10 Project Coordinator, Rex Healthcare, Raleigh, N.C. Bailey’s co-presenter for “How to Prepare Your Documentation and Complete ICD-10 Education Before Time Runs Out,” is Tom Ormondroyd, BS, MBA, Precyse, Alpharetta, Ga.

“Collaboration with payers, vendors and others who affect successful implementation is one of the most important things we’re doing,” said Danielle Reno, MHA, CHC, CCS, CCS-P, ICD-10 Program Director, Sutter Health, Sacramento, Calif. “We have to look at every aspect of the process.” Co-presenters with Reno for the panel discussion, “The Good, the Bad, the Reality: 365 Days until ICD-10 Adoption (Take Two),” are Christine Armstrong, MBA, RHIA, Deloitte Consulting, Los Angeles; and Virginia Sullivan, PMP, Scripps Health, San Diego.

According to the presenters, implementation challenges include:

  • Preparing system staff and vendors who play a role in the revenue cycle (e.g. accounts receivable, billers, radiology, laboratory, clearinghouses and fiscal intermediaries);
  • Setting up the IT infrastructure with payers;
  • Ensuring you have enough coders and training them for the transition;
  • Determining how claims will be adjudicated;
  • Implementing systems, tools and key performance measures to track potential under payments and claims denials;
  • Collaborating with payers to develop processes for coding records when the care spans the transition from ICD-9-CM to ICD-10-CM;
  • Developing a testing plan and scripts to test applications;
  • Facilitating necessary vendor upgrades to conduct testing; and
  • Ensuring physicians and coders have ability to dual code ICD-9-CM/ICD-10 prior to going live.


“The time to panic is not now, but it’s getting close,” says Cindy Seel, MSA, RHIA, HRS, Baltimore, who will present “Transitioning Physicians to ICD-10: Seven Steps to Take Now.” The seven steps include:

  1. Developing implementation and training plans;
  2. Providing specialty-specific education programs;
  3. Tailoring training models to the organization’s clinical staff and leveraging lessons learned;
  4. Identifying of key documentation needs to reduce physician queries and increase productivity, including strengthening clinical documentation improvement (CDI), programs with peer-led education, dual coding and end-to-end testing based on a continuous PDCA (plan-do-check-act/adjust) cycle;
  5. Training coders and providers to start using the ICD-10-CM in advance of implementation;
  6. Recognizing the potential (mis)uses of Generic Equivalent Mapping (GEMS); and
  7. Providing training for physicians’ office staffs.

While each of the steps described for implementation of ICD-10 is important, the presenters emphasized that a key element for success is the collaboration and coordination of all stakeholders as they work through the testing and implementation process.

For more on AHIMA, visit

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Increase in health data poised to revolutionize healthcare industry

ATLANTA – The proliferation and availability of health data and their potential to dramatically shift the quality of care given to patients illustrates the vital role information governance plays in the future of healthcare.

At the American Health Information Management Association's (AHIMA) 85th Annual Convention and Exhibit in Atlanta Oct. 26-30, healthcare leaders will address approaches to how data are captured, collected and managed and will outline steps for ensuring the integrity of health information, opportunities and challenges facing the industry, and the value of sound health information management principles and practices.

“The vast amount of health data that are being collected bring the potential to really revolutionize the way care is delivered and improve patient quality outcomes,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA. “But this potential can only be realized if the data are accurate, timely, complete and of the highest integrity. HIM professionals play a critical role in assuring the availability and appropriate accessibility of high quality, usable, and understandable data. HIM professionals recognize, support, and implement the value and benefits of health information and governance strategies. We understand that an organization’s information is an increasingly vital asset to its business, administrative and clinical operations. As a vital asset, information must be governed.”

Noting in her presentation that 90 percent of the world’s data was created in the last two years and is predicted to grow by a factor of 50, Pamela Lane, MS, RHIA, CPHIMS, deputy secretary for Health Information Exchange and the director of the California Office of Health Information Integrity (CalOHII) will identify several ways increases in data will improve healthcare.

Lane’s co-presenter for “How Big is Big Data?,” is Karen Boruff, CPHIT, CPC, project manager at Hubbert Systems Consulting.

Examples of how data will improve healthcare include supporting research by identifying health trends across large populations; empowering patients by providing them with accurate, up-to-date information; and reducing provider costs and increasing efficiency.

An example is the work the CalOHII is doing to advance electronic health information exchange. This will ensure patient information is available when and where it is needed for care, while ensuring data are protected and exchanged under strict privacy and security standards.

“By advancing the interoperability and integrity of health data, we’re able to use the information to influence positive health outcomes,” Lane said. “So it’s no longer just about preventing illness, it’s about promoting wellness through patient access to information.”

As data collection from electronic health records (EHRs) and other sources continues to grow and the demand for quality health information increases, HIM professionals are at the forefront of initiatives to ensure the security, access and integrity of health information. In her presentation, “The Effects of the Changing Healthcare Landscape in Your Organization,” Diana Warner, MS, RHIA, CHPS, FAHIMA, director of HIM Practice Excellence at AHIMA, will address best practices for information governance.

“Now is the time for HIM professionals to lead,” Warner said. “The skills HIM professionals bring to the table are essential in reshaping and driving change within organizations.”

A presentation by Linda Kloss, MA, RHIA, FAHIMA, principal, Kloss Strategic Advisors, and Karen Lawler, MPS, RHIS, CHPS, FABC, director, HIM department and privacy officer, Stamford Hospital titled, “Health Information Management in 2016: Guiding Principles and a Governance Framework for a Digital Age,” also examines trends in the changing HIM landscape and offers a model for enterprise information management that builds on the principles of information governance.

In addition to presenting at AHIMA’s Convention, AHIMA will illustrate the expanding role of HIM professionals in meeting the complex demands for health information at ARMA’s 58th Annual Conference and Expo on Oct. 29. AHIMA’s Lesley Kadlec, MA, RHIA, director of HIM Practice Excellence will present “The State of Information Governance in Healthcare.”

“With the implementation of EHRs and advancement of technologies such as mobile devices, it’s essential that HIM professionals manage the data and ensure interoperability for the seamless exchange of information,” Kadlec said. “It’s an important and exciting time to be part of health information management.”

For more on AHIMA, visit

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Latest developments in privacy and security

ATLANTA – For years, the final compliance date for the Health Information Technology for Economic and Clinical (HITECH) Act’s sweeping updates to the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security rule was a dominant narrative in the healthcare industry and especially within the health information management (HIM) privacy and security circles.

Now that the Sept. 23 deadline has passed, the focus has shifted to real-time implementation challenges of the new requirements while maintaining compliance. The Final Rule provides patients increased access to their health information which allows them to play a more active role in managing their healthcare. Discussions of these developments along with burgeoning privacy and security topics will take center stage at the American Health Information Management Association's (AHIMA) 85th Annual Convention and Exhibit Oct. 26-30 in Atlanta.

“We are excited to bring together thought leaders from across the healthcare spectrum for an important conversation about the complex and fast-changing world of privacy and security,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA.

On Oct. 29, Kirk J. Nahra, JD, Wiley Rein LLP, will present, “Next Generation Privacy and Security Issues.” “I expect there will be pressure to implement more rigorous security standards for breaches; this will likely include a call for broader encryption and for enforcement and adverse notice publicity to put real pressure on developing better practices,” Nahra said.

The explosive growth in mobile devices provides patients greater access and control over their health information, but also highlights evolving privacy and security technological tensions.

“Part of the mobile device debate is about the limits of HIPAA,” Nahra said. “The idea of covered entities and business associates excludes whole segments of the health care industry that are consumer directed or otherwise outside of HIPAA. Going forward, more attention will be paid to this gap.”

Nahra will also highlight the role of health information exchanges and health insurance exchanges in his AHIMA Convention presentation.

AHIMA’s Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA, director of HIM Practice Excellence, will participate with Adam Green, JD, MPH, of Davis Wright Tremaine in a wide-ranging question and answer session on the final HITECH Omnibus Rule on Oct. 30.

“It is incumbent upon the health information professional to meet the challenge of ensuring personal health information is protected, whether in paper or electronic form,” Dinh Rose said. “The AHIMA convention’s privacy and security track will help prepare you to do just that.”

For more on AHIMA, visit

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Nuance unveils ICD-10-ready platform

ATLANTA – Nuance Communications, Inc. (NASDAQ: NUAN) today announced a significant enhancement to its Clintegrity 360 platform that integrates clinical documentation improvement (CDI) and computer-assisted coding (CAC) into one seamless process. This single, web-based solution creates a natural and efficient way for clinicians to create more complete and accurate clinical documentation, while supporting downstream revenue cycle and quality reporting processes. Nuance Clintegrity 360 will be demonstrated in booth #1226 at the 2013 American Health Information Management Association (AHIMA) Convention and Exhibits, October 27-30.

A single platform for CAC, CDI and regulatory compliance

Healthcare organizations can now efficiently manage these complex initiatives with a single intelligent system that integrates advanced technology, workflows and information in a meaningful way, connecting physicians, clinical documentation improvement specialists and coders to drive clinical accuracy, compliance and revenue integrity from end-to-end. Powered by Nuance’s Clinical Language Understanding (CLU) technology, Clintegrity 360 provides computer-assisted solutions for coders, CDI specialists and physicians.

“With the increasing pressure healthcare provider organizations are feeling from ICD-10, Meaningful Use and various forms of value-based reimbursement and medical necessity requirements, customers are rethinking their entire clinical documentation chain,” said Peter Durlach, senior vice president of marketing, product management and strategy, Nuance. “In this new era of healthcare, clinical documentation is playing an even more strategic role in the delivery and reimbursement of high quality care, and our Clintegrity 360 platform is designed to help our customers operate successfully in this new environment.”

Clintegrity’s single platform provides:

  • ICD-9 and ICD-10 Computer-Assisted Coding & Compliance – Computer-assisted coding and compliance for inpatient and outpatient settings enables providers to improve coder productivity up to 89 percent, reduce time-to-bill up to 80 percent and improve overall coding accuracy. With Clintegrity 360™ | Computer-Assisted Coding, provider organizations can educate their coders on ICD-10 in real-time by having the system automatically suggest both ICD-9 and ICD-10 codes for the same patient case. In addition, the solution automatically highlights the evidence used in selecting codes and maintains an audit trail to support compliance, quality and auditing requirements.
  • Computer-Assisted CDI – By combining Nuance’s core CLU technology with the proven J.A. Thomas clinical CDI guidelines and program, Clintegrity 360 also delivers computer-assisted CDI to help organizations achieve higher quality care, more appropriate reimbursement, enhanced medical necessity compliance while also improving CDI team productivity with auto-suggested high-value clarifications.
  • Computer-Assisted Physician Documentation – This enables organizations to automatically prompt physicians in real-time with high confidence CDI clarifications directly within their Electronic Health Record’s (EHRs) native physician documentation workflow. Because these clarifications are automatically presented at the point of documentation, physicians learn how to document more appropriately, and this improves their responses rates and satisfaction while the productivity of the CDI team can also increase by as much as 50 percent.
  • Shared Visibility and Communication about Patient Cases – Clintegrity enables coders to have a real-time view into the complete CDI process for more accurate and concurrent coding. Additionally, coders and CDI team members share a common view of the patient case, and can communicate within Clintegrity – thereby improving coding throughput and accuracy while minimizing disruptive physician queries.

For more information on Nuance Clintegrity 360, visit:

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Wacom and Access announce e-signature integration

ATLANTA – Access, a leading provider of paperless electronic signature, e-forms and clinical data bridge solutions, has integrated support for the new Wacom STU-530 and STU-430 Signature Pads into its electronic patient signature offering. Wacom’s full line of signature pads and interactive displays are now supported by the Access solution, enabling a smoother distribution of forms across a healthcare network.

The new Signature Pads can be seen live at AHIMA 2013 in Wacom’s booth (#710). AHIMA attendees can also see Access solutions at the Access booth (#1935).

With an electronic forms management system on hand, healthcare providers can improve upon the manual process of filing, copying and archiving that wastes paper and slows patient processing. This streamlined process begins with Access’s e-forms on demand solution, which ensures all new and updated forms are integrated with the proper electronic health record (EHR). For forms that require patient consent, the Signature Pads are then used to add an electronic handwritten signature, complete with biometric profile across all relevant files.

“Limiting the frequency at which hospitals have to print, scan and store documents, prevents unnecessary costs and gives providers more time for patients,” says Michael Marcum, Vice President of Vertical Markets for Wacom Technology Services, Corp. “Now the entire registration, consent, and authorization process is optimized for the modern medical environment.”

“As healthcare costs continue to rise, efficiency tools are becoming even more important to organizations under pressure,“ says Tim Elliott, Access founder and CEO. “Combining our e-Signature solution with Wacom’s Signature Pads is a simple way for medical providers to remove many of the hurdles that slow them down.”

For more on Wacom, visit

For more on Access, visit

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Huff DRG Review releases mobile app for clinical documentation

ATLANTA – Huff DRG Review Services, a physician-directed MS-DRG management company providing clinical documentation and educational programs for the healthcare industry, announced that their widely held documentation handbook for physicians is now available via affordable download onto iPads, iPhones and other smart devices. Garry L. Huff, M.D., CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer, President and CEO of Huff DRG Review, made the announcement at the opening of AHIMA’s 85th Annual Convention and Exhibit. The company will demonstrate their new mobile clinical documentation tool for physicians, CDocT, at AHIMA Booth #1917.

For more on Huff DRG Review Services, visit

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                    October 2013 HMT digital book



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