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eNews from MdHIMA

Issue 53 - January/February 2016

President's Message

Welcome to 2016, a year that promises to be exciting, energetic, and very busy for our CSA! I hope everyone is staying warm and enjoying the winter season. I started off the New Year with a trip to the very cold and windy, city of Chicago, for the AHIMA National Convention Program Committee meeting. Everyone is very excited about their upcoming visit to our state and Charm City, on October 15th through October 19th, 2016. The Committee worked for two days reviewing abstracts and selecting speakers. AHIMA staffers participated and shared updates and promise this will be one of our best National Conventions! MdHIMA will be ready to welcome AHIMA to Baltimore and show off our great hospitality and charm!

We hope to have a great turn out for convention and will need all MDHIMA members to actively participate and volunteer in order for this event to be successful. We need about 50 or more volunteers per day at greet locations to assist members of AHIMA during educational tours. We are actively searching for locations to offer tours during the convention and we need suggestions on healthcare facilities that may be able to offer great educational tours near Baltimore. Please contact me to volunteer or suggest an educational venue. I can be reached at

MDHIMA Committees and Board members are also actively working this winter not only to keep warm and dry from the snow but to keep our members informed and educated.
  • Annual Meeting Committee: Scheduled a joint meeting with DCHIMA on Friday May 6, 2016 at The Hotel at Arundel Preserve. Additional information will be posted.
  • Bylaws & Policy Committee: Reviewing and Updating Bylaws & Polices.
  • Data Quality Committee: Hosting a meeting on February 15, 2016 at HSCRC.
  • Delegates: Reviewing practice policies and tool kits from AHIMA. All Delegates will attend the AHIMA Leadership Symposium and Hill Day on April 4 and 5 in Washington, DC.
  • Educational Committee: Collaborated with AHIMA and DCHIMA to bring an Information Governance (IG) meeting to Gaithersburg on February 5 and are actively planning the Quarterly Business Meeting on March 15 in Silver Spring.
  • Fundraising Committee: Accepting donations for the Silent Auction please contact #MdhimaGives
  • Membership Committee: Reviewing our membership roster and will make contact with members missing emails or not receiving updates.
  • Nominating Committee: Calling for Nominations Deadline February 19, 2016.
  • Website/Newsletter Committee: Updating website and working on keeping members informed.
  • Board Members Strategic Planning Meeting: Scheduled on February 20, 2016 we will continue to review our mission, vision and strategic direction of the organization as we accelerate into the future. #MdhimaLeads
As always we welcome your feedback and encourage you to keep up with the changes in our profession. Share your insight, ask questions and get engaged on our AHIMA Engage website. This is a great tool to stay informed and keep up with industry information. For more information on engage and how to set up your engage site log onto and select Maryland as one of your communities.

We also welcome you to volunteer, participate and serve your organization. #MdhimaServes

Tasha Green, MS, RHIA, CHTS-TR
2015-2016 MdHIMA President

“Everybody can be great. Because anybody can serve. You don't have to have a college degree to serve. You don't have to make your subject and your verb agree to serve... You don't have to know the second theory of thermodynamics in physics to serve. You only need a heart full of grace. A soul generated by love.” Martin Luther King, Jr.

Leadership Symposium

Please join AHIMA for the 2016 Advocacy Leadership Symposium on April 4, and Hill Day on April 5, in Washington, DC.

Hill Day provides members the opportunity to interact and advocate for HIM with their Congressmen. To advocate effectively during Hill Day, please be sure to register for upcoming Hill Day training webinars.

Hill Day 1:1–"What to expect on your visit."
Register Here
Monday, February 22, 2016
12 Noon | Eastern Time (New York, GMT-05:00) | 1 hr

Exercising Your Voice
Register Here
Tuesday, March 15, 2016
1 p.m. | Eastern Time (New York, GMT-04:00) | 1 hr

Additionally, there are two meetings being offered immediately before and after the Advocacy Leadership Symposium and Hill Day. We encourage you to make the most of your time in Washington DC, by coming in early to advance your coding skills or staying an extra day to gain the tools needed to implement, lead, and manage an Information Governance program at your organization. Select the links for more information.

Coding Complex Cases in ICD-10-CM/PCS Workshop, April 2-3

Leadership Forum: Driving Information Governance, April 6

Christina Donahue-Taylor, RHIT, CCS

Tips on How to Talk to a Physician

Often the best moments of physician education take place in the elevator, in the stairwell, in the parking lot, or in the cafeteria. In business circles, this is often referred to as the “elevator pitch” — a condensed discussion of a particular point which lasts only as long as an elevator ride might. These opportunities are invaluable not only in terms of the education they potentially provide but also for the rapport and respect which may develop due to the well-conducted interaction there.

Follow these steps to keep your verbal interactions brief and to respect not only the physician’s limited time but also his or her knowledge of the patient’s condition.
  1. Make sure you have your clinical information summarized. Use the SBAR (situation, background, assessment, recommendation) format.
  2. Organize your thoughts in a structured manner. Regardless of whether you deliver a verbal query or a written query, this will help keep the message concise and to the point.
  3. Know what you want to ask, what specific terminology is required, and the rationale for the query. Knowing why you are asking the question helps you prioritize the relative importance or urgency of the query and helps the physician understand why you are asking for clarification. Determine if the goal of the interaction is:
  • Improved severity of illness and risk of mortality representation
  • Greater specificity (acute or chronic, acute-on-chronic)
  • Cause and effect/due to relationships of diagnoses
  • Clarifying whether a condition was present on admission
If the physician approaches you for CDI-related information, he or she is demonstrating a strong motivation to learn and an interest in the CDI program’s mission. It also illustrates his or her willingness to trust you and a respect for the information previously provided. Responding to his or inquiry in a positive, competent manner reinforces that particular physician’s perception of you as a resource—one he or she will no doubt come back to for answers in the future. If you are unsure of the right answer, be honest, tell him or her that you will do the research, and be sure to follow up with a well-sourced answer in a timely manner.

Note: This excerpt was taken from the online materials in The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

Christina Donahue-Taylor, RHIT, CCS

Accurate Documentation is Essential – Knowing When to Query your Providers

October 2, 2015 | Libman Education

By Pamela J. Haney, MS, RHIA, CCS, CIC, COC
Director of Training and Education for Libman Education

ICD-10 is finally a reality. We have learned to code diagnoses with ICD-10-CM, mastered the root operations in ICD-10-PCS, and we are ready to put our new skills to work.

Documentation challenges plagued us in ICD-9 but become more challenging with ICD-10 due to the increased specificity of the classification system. According to the Office of the Inspector General (OIG), “policies must create a mechanism for HIM/Coding professionals to communicate effectively and accurately with the clinical staff… for proper and timely documentation.” This means we must have a process in place to work with our clinicians to clarify ambiguous documentation. A key part of the query process is knowing when to query!

To identify the correct ICD-10 codes, we must identify conditions that require clinical evaluation, therapeutic treatment, further diagnostic studies, procedures or consultation, extended the patient’s length of stay or increase nursing care and/or monitoring.

A well-designed query will be vitally important for successful coding in ICD-10. Query guidelines to keep in mind:
  • The condition or diagnosis must already be established in the medical record
  • All payer types should be queried, not just those that have an impact on reimbursement
  • The query should just state the facts
  • Queries should not lead the provider to a specific diagnosis
When should coders query the provider? There are a few key questions to ask that may help determine if a query should be initiated:
  • Is there conflicting information in the medical record? Sometimes documentation in the progress notes may conflict with information in the discharge summary or even another provider’s documentation.
  • Is there incomplete information in the medical record such as missing test results, progress notes or discharge summary?
  • Are there any significant reportable conditions or procedures performed that require additional information to be coded correctly?
  • Is there documentation of an unspecified diagnosis when clinical reports suggest a more specific diagnosis? It may be helpful to request further specificity or the degree of severity of a documented condition.
Just as important as knowing when to query is knowing when NOT to query providers. Queries should not question a provider’s clinical judgment, when the benefit is strictly for reimbursement, or for clinically insignificant findings or irrelevant information.

Queries are an essential communication tool for accurate documentation and quality coding. They should be fact-based to clarify documentation and improve data integrity. Designing a solid query process will help support providers to continually improve their documentation for ICD-10 success.

Christina Donahue-Taylor, RHIT, CCS​

Patient National Identifier Contest to Win $1 Million

We are inviting innovators from around the world to participate in the CHIME National Patient ID Challenge for the creation and adoption of a solution which will ensure 100 percent accuracy in identifying patients in the United States.

Accurate identification can greatly reduce the risk of preventable medical errors and significantly increase the quality of care. The goal of the challenge is to develop a national patient identification solution that will be private, accurate and safe.

The incentive challenge has two phases:
  1. Concept Blitz Round: Design concept for solving the national patient identification challenge
  2. Final Innovation Round: Build prototypes that demonstrate the functionality and performance of the design concept
The top three submissions in the concept blitz round shall receive a prize of $30,000 USD each. The winner of the final innovation round shall receive a prize of $1,000,000 USD. The final date to submit an entry for the concept blitz round is April 8, 2016. The final date to register for the final innovation round is July 12, 2016. No entry fee is required.

You may visit the National Patient ID Challenge page for complete challenge guidelines and to register as an innovator by clicking here:

Christina Donahue-Taylor, RHIT, CCS​

Public Relations Update

We have sent off a Proclamation request for HIP Week to the Governor of Maryland and the Mayor of Baltimore. We will be in attendance at MedStar St. Mary’s Hospital 2016 Educational Development Fair on March 1st.

Julie Brooks

It’s Silent Auction Time!

Every year MDHIMA awards scholarships to deserving students. The scholarships are awarded to students that have maintained high academic standards and assist students with the financial cost of their education. Scholarships are funded from the proceeds of donations by our members for the Silent Auction, held during the annual meeting each year.

Please support our Scholarship Fund!

List of Suggested Items include: Electronic Devices, Gift Cards, Jewelry, Handbags /Purses, Office equipment, Art, Wine Baskets, Getaway Vacations, Sporting event tickets and Memorabilia.

For more information or to donate items, contact Dana Carcamo at


MdHIMA Gives

The fundraising committee is active this year and looking at new and innovative ways to raise money for our scholarship fund. We are actively planning events & activities, online giving opportunities and the silent auction for our annual meeting. Please contact Dana Carcamo at if you are interested in volunteering and participating with our fundraising committee.

#giveback #mdhimagives

Dana Carcamo, RHIA, CCS

­­­­­­­­­­­MdHIMA WELCOMES the following New December Members

Antigonene Davis
Chelsea Collison
Brian Rozelle
Joy Morris
Sampoorna Kolluru
David Bennett
Tolulope Amiola
Babajide Osotimehin
Geneva Bryan
Temitayo Ogundipe
Felicia Tunstall
Margaret Sommers
Abidemi Tiamiyu
Denise Ravariere
Tammy Morris
Tedros Abrahaley
Patrice Woods
Geri Ozirsky, RHIA

Save the Date!

2016 Annual Meeting

May 6, 2016
The Hotel at Arundel Preserve
Hanover Maryland

Time to Relax and Earn Some CEU’s

Quarterly Educational/ Business Meeting
March 4, 2016

The Living Legacy Foundation
1730 Twin Springs Rd.
Baltimore, MD 21227

Topics of Presentation:
  • The Organ Donation Process
  • State of MD Chronic Disease Prevention Program
  • Compliant Queries
  • Revenue Cycle Management
  • C.R.I.S.P Program
Details for registration coming soon!

Christina Donahue-Taylor, RHIT, CCS

February is Information Governance Month

AHIMA Upcoming Webinars
Webinars are 60 minutes in length and begin at 12 noon CT or 1pm EST

February 16 - Making a Case for Information Governance (FREE for IG Month) 2 CEUs

February 17 - Advances in Information Governance–Who, What, and How Much it will Cost (FREE for IG Month) 2 CEUs

February 23 - IG Pilots Lessons Learned and Keys to Success (FREE for IG Month) 2 CEUs

That's 6 FREE CEU’s from AHIMA - Learn about the next Chapter in HIM Information Goverance

Registration for live webinars closes 24 hours before the event. After that time you may purchase a recorded version. Please see website for details.

After attending a live or webinar replay you are eligible to receive 2 AHIMA CEUs. Click here for additional details on registration and how to earn CEUs.

Christina Donahue-Taylor, RHIT, CCS

Follow MdHIMA on Facebook!

Be sure to visit the MdHIMA page on Facebook. You will find links to our current legislative initiatives and educational offerings as well as postings on what our committees are up to! Stay connected… Go to and be sure to “like” our page!

­­­­­­­­Are you looking for your CEU’s?

If you are on the roster to receive updates and CEU’s, check your email spam folder! Many emails are bounced back due to an unrecognized email address error, which occurs when your company tries to control spam.

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Please remember that this e-Newsletter belongs to you and is an excellent source of communication!  If you would like to submit information to be included in the next publication or if you would like to let the membership know what is going on with you or your facility and employees, please don’t hesitate to send a submission to Arlene Gioia, Chair and Jenea Butler, Co-Chair of the e-Newsletter at the following email: and

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