Updated on: March 17, 2016

Update Coding Compliance Policy in light of Upcoming Challenges

Original story posted on: May 10, 2013

MONTREAL – Whether medical records are paper, electronic, or a hybrid, your coding policy should be reviewed and updated at least annually by way of a “high-integrity” coding compliance policy that’s part of a larger information governance program, according to Bonnie S. Cassidy (MPA, RHIA, FAHIMA, FHIMSS), who recently spoke before members of the International Federal of Health Information Management Association (IFHIMA) at its meeting this week in Canada.


Cassidy, the senior director of HIM innovation for Nuance, addressed the issue of best practices related to creating a coding compliance policy and testing that policy against upcoming challenges in clinical documentation and associated coding. Cassidy spoke before the group yesterday.

“It does not matter if your medical record is paper-based, hybrid or electronic, a high-integrity coding compliance policy should be written and updated at least once per year as part of your information governance framework,” Cassidy said. “It is essential for your coding compliance policy to include your identified clinical documentation record set for coding compliance, which will strengthen your organization’s overall compliance program.”

According to Cassidy, there are four key areas where organizations will rely on having an identified clinical documentation record set for coding compliance. These include the following:

  1. Coding: Organizations that use diagnosis and procedure codes to report healthcare services must have formal policies and corresponding procedures in place that provide instruction on the entire process, from the point of service to the billing statement or claim form. Coding staffers need to be informed about where in the medical record they need to focus to obtain the appropriate clinical documentation for coding.
  2. Coding Audits: A coding compliance policy also serves as a guide for establishing the criteria for performing effective coding and billing functions, and it provides documentation of the organization’s intent to report services accurately. By adhering to the policy, guesswork on clinical documentation and associated coding is eliminated, allowing for a more accurate evaluation and audit of each encounter.
  3. Outsourcing Coding Work: A coding compliance policy should include facility-specific documentation requirements, payer regulations and policies, and contractual arrangements for coding consultants and outsourced services. The HIM professional who is in charge of enforcing the policy must ensure that outsourcing partners follow the organization’s best practices on their own clinical documentation record set for coding compliance.
  4. Computer-Assisted Coding (CAC): When working with your business partners to build a technology-enabled coding process, organizations should utilize the clinical documentation record set for coding compliance in order to create a customized solution. Using the record set provides each facility vendor with a strong foundation for building a CAC solution with compliance in mind.

IFHIMA (formerly known as IFHRO) and the Canadian Health Information Management Association (CHIMA) are hosting the 17th annual IFHIMA conference today this week at the Palais des congrès de Montréal in Quebec.


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.