Provider organizations should update their coding compliance policy at least once annually, and the policy should outline the entire process from point of service to the billing statement or claim form, according to a new white paper from the American Health Information Management Association.
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.
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