Coding Toolkit for the Physician Practice Setting

Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.


AHIMA has dozens of toolkits available for free to its members on various different topics ranging from health data analysis to computer-assisted coding to breach management? Toolkits are a member benefit that can help support your work in a range of areas. One of the newest additions to the AHIMA toolkit library is the Physician Coding Toolkit. This post gives an overview of some of the resources found in this toolkit.

Coding

The toolkit defines the various coding systems used in the physician practice setting, including CPT, HCPCS Level II, NDCs, CDT, RVUs and ICD. Various coding guidelines are covered, too, such as NCCI, NCDs, LCDs, ICD, E/M documentation, Medicare, commercial, and provider. If that all looks like alphabet soup to you, brushing up on the coding systems might be a good idea. These should all be very familiar terms to those working in a physician office setting.

Electronic Health Record (EHR)

The majority of physician practices use some type of electronic health record (EHR). Most every physician practice is using some type of EHR. There are many valuable tools built into EHRs that can help with the workflow of the practice, such as templates, macros, standing orders, and problem lists. The toolkit goes into much more detail on these tools.

Workflow and Professional Development

Various workflow processes are described, including a sample workflow diagram. Also included are tips on keeping staff current with professional development.

Tools

Other helpful tools found in this toolkit are a sample policy and procedure template, an example of standing orders, a sample physician attestation statement and log, copy and paste guidelines, an example physician superbill, and sample E/M templates.

Toolkit Free to AHIMA Members

AHIMA members can click here to get their free copy of this valuable resource. Nonmembers can click here to purchase the Physician Coding Toolkit.

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director of HIM practice excellence, coding and CDI products development at AHIMA. She has over 15 years experience in HIM and coding, with her most recent focus being in ICD-10-CM/PCS, and has presented numerous times at the regional, state, and national levels on HIM and coding topics. She was previously a director of HIM practice excellence, focusing on coding products, resources, and education, at AHIMA. Melanie is an AHIMA-approved ICD-10-CM/PCS trainer and an ICD-10 Ambassador.

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