AHIMA issues coding compliance report
An annually updated coding compliance strategy is an essential element of a provider's overall compliance program, according to a white paper released by the American Health Information Management Association (AHIMA).
Defining the Core Designated Clinical Documentation Set for Coding Compliance, authored by AHIMA's past-president Bonnie S. Cassidy, MPA, includes the following recommendations:
The policy should provide instructions for the entire process – from the point of service to the billing statement or claim form.
- 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 an 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.
Access the complete white paper online.