Among other issues, the policy should identify medical records and clinical documentation that require a mandatory review, direct outsource coders to follow the organization’s best practices or coding compliance policies, and make clear to a computer-assisted coding vendor which documents or clinical documentation are to be used in the CAC for accuracy and compliant discharge clinical coding.
The white paper clarifies source documents and clinical documentation that should make up the core designated clinical documentation set that coders will use. Further, the paper outlines 16 specific policies and processes that should be part of the coding compliance plan. It then lists 11 types of clinical documentation (face sheets, progress notes, history/physical, etc.) that coders should review to identify all diagnoses and procedures requiring coding.
The paper, Defining the Core Clinical Documentation Set for Coding Compliance, is available here.