Health information management and coding practice
We support coding review with structured clinical notes, code lookup, signed records and a coding query between coder and physician, keeping professional judgement with the people responsible for the record.
Set by American Health Information Management Association
Subject type: professional guidance from the American Health Information Management Association. It is not a technical conformance standard. This page uses that practice context to explain the Care records available for review.
What is built
- Structured clinical documentation brings relevant encounter information into the note.
- Clinicians can look up ICD-10 and CPT codes by name or number.
- Clinical notes can be completed as coded, signed records.
- The medical record retains the patient context for review.
- Claims and approvals use the selected Care plan’s coded clinical information.
- Within claims, a coder can raise a query to the encounter’s physician, with the answer and its resolution recorded.
The record and the accountable role
The treating clinician completes and signs the clinical note. The clinician or coding professional selects the codes, and your information management team reviews documentation quality. Care keeps the note, the coded record, the signature and the patient context together for that review. It does not make the coding decision.
Illustrative example: a signed, coded note and a query
This example uses synthetic data. A clinician documents a consultation for a synthetic patient, Sara Nasser, looks up a diagnosis by name and a procedure by number, selects the codes and signs the note. A reviewer opens the note, the codes and the signature in the patient record. When the claim is prepared and the coder needs clarification, the coder raises a query on the claim. It goes to the physician of the encounter, who answers, and the coder then resolves it. The exchange is kept with the claim.
Scope and limits
Lookup helps a professional find a code. It does not establish that the code is supported by the record. A generated claim is not proof of coding accuracy or payer acceptance. Automatic code suggestions, automated coding and denial prediction are not part of the confirmed Care scope. The query needs an encounter with a physician to route to. This page does not describe an AHIMA certification, an endorsement or a licence to publish proprietary guidance inside the application. Where insurance work is relevant, review Claims and approvals within Care Clinics Pro or Care Hospitals.
Official source
AHIMA. AHIMA publishes practice guidance for health information management and coding professionals. Cite the specific guidance your team follows when you review the records.
What to bring to a records demonstration
Bring one consultation that needs coding, with its signed note and the claim that follows. We will walk through the available scope, including the coding query, and agree what your own review process still has to cover. The aim is an understandable evidence trail for qualified reviewers, not the removal of their judgement.
What we claim, precisely
The system holds the evidence; the facility's accountable person attests. Nothing here asserts that a facility is compliant.
Common questions
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No AHIMA software certification or endorsement is claimed. This page describes documentation and coding evidence relevant to professional information-management practice, with review and accountability retained by your organisation.
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No. The confirmed capability is code lookup by name or number. The clinician or coding professional must decide whether a selected code is supported by the clinical documentation.
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Claims and approvals are included in Care Clinics Pro and Care Hospitals. Structured documentation and coding review should be demonstrated within the Care plan and workflow your facility intends to use.
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No. A signature and coded record provide evidence for review, but the content still needs professional assessment. Documentation quality and code selection remain responsibilities of the appropriate facility team.
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Within claims, a coder can raise a query on a claim. It is routed to the physician of the encounter, who responds, and the coder then resolves it. The exchange is recorded with the claim. A claim with no encounter physician cannot be queried.
Not answered here? Contact the team
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