Health care organizations should update their clinical coding compliance policies at least once annually, and such policies should outline the entire coding process from receiving care to submitting claims, according to a white paper from the American Health Information Management Association, Health Data Management reports.
The white paper recommends 16 specific policies and processes that should be part of health care providers' coding compliance plans (Goedert, Health Data Management, 10/31).
Among other recommendations, AHIMA stated that:
- Coding compliance policies should identify health records and clinical documentation that require a mandatory review by coding staff;
- All coders should review clinical documentation to identify all diagnoses and procedures requiring coding;
- When outsourcing coding work, the outsourced staff should be directed to follow the organization's coding compliance policies; and
- If an organization uses computer-assisted coding, the CAC vendor should understand which documentation is to be used to ensure accurate and compliant clinical coding (Clinical Innovation & Technology, 10/31).