Does your organization’s coding compliance policy address upcoming challenges in clinical documentation?
AHIMA explains why a coding compliance policy, updated at least once a year, is essential to an organization’s overall compliance program in a just released white paper, Defining the Core Designated Clinical Documentation Set for Coding Compliance, authored by past president Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS. The policy should provide instructions for the entire process – from the point of service to the billing statement or claim form.
“A well-thought out coding compliance policy anticipates the questions and issues that your organization will address. It is an essential resource to any organization’s overall compliance program,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA.
Significant points and recommendations from the white paper, part of AHIMA’s Thought Leadership Series, include:
A coding compliance policy must identify medical records and clinical documentation that require a mandatory review by your coding staff or the outsourced providers of coding for your organization.
All coders should review this clinical documentation to identify all diagnoses and procedures requiring coding to increase the accuracy and specificity of coding.
When coding is outsourced, the HIM professional should direct the outsourcing partner to follow your organization’s best practice or coding compliance policy.
If your organization uses or explores computer assisted coding (CAC), the HIM team should direct the CAC vendor as to which documents or clinical documentation are to be used in the CAC for accurate and compliant discharge clinical coding.