AHIMA releases core clinical documentation guidelines for coding

The American Health Information Management Association has outlined core clinical documentation guidelines for coding medical diagnoses and procedures in 2013 and 2014.

In a new white paper, AHIMA says healthcare providers should have a "high integrity" coding compliance policy that should be updated at least once a year. The paper provides guidance on identifying source documents as a designated clinical documentation set.

Although AHIMA has issued guidance for compiling a coding compliance document, it has not previously defined what core medical record documents or clinical documentation should be used, according to the paper.

The paper delves into inpatient coding, outpatient coding, same-day or ambulatory surgery, observation records, emergency department coding and computer-assisted coding.

In a summary, the document notes providers will rely on their coding compliance policies not just when coding records, but during audits, when outsourcing coding work and when doing computer-assisted coding. With computer-assisted coding, the vendor will need to customize a system around the policy, AHIMA says.

The guidance comes as the Office of Inspector General at the U.S. Department of Health & Human Services announces plans to more closely scrutinize several areas of billings to Medicare Part A and B. Among areas to be examined are the coding of diagnoses and services provided at certain hospitals since 2008. Hospitals counter that the codes for 747 Medicare severity diagnosis-related groups (MS-DRG) increasingly are complex and difficult to manage.

It also comes as providers transition to ICD-10 medical coding, which must be in place by Oct. 1, 2014. HHS' Centers for Medicare & Medicaid Services recently gave the healthcare industry a break by pushing back the compliance date from 2013 to 2014.

To learn more:
- read the white paper

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