The outline provided below is an example of content for a hospital
coding program, but the outline can be adapted to coding in any setting -
keep in mind that it is essential that the policies are specific to the
organization. Just as no organization should have a "canned"
compliance plan, no organization should have 'canned" coding
policies.
- Ethical Standards of Coding – your guidelines should reference the AHIMA Standards of Ethical Coding generally (include a copy if possible) and your organization’s Standards of Conduct that apply to coding tasks specifically.
- Documentation Policy
- Cardinal Rule for All Coding: a coder may not code a condition/diagnosis/procedure unless it is clearly documented by the physician.
- Medical Abbreviations
- Medical staff approved
- Process for updating
- Frequency
- Type
- Addition
- Deletion
- Change
- Physician Liaison – role, functions, interface with coding staff
- Define minimum set for coding and billing purposes
- Physician Query Process
- When it is acceptable to query the physician
- Criteria for a "clinically valid" physician query
- Format of the query
- Peer review of the query process
- Auditing Policy (Outline of Information to be addressed)
- Benchmarking
- Method of sample selection (random vs. focused vs. both)
- Number and type of records to be audited
- Determine target proficiency rate
- Defining Coding Error (DRG assignment vs. overall data quality)
- Frequency of audits
- Interface with compliance staff
- Follow up
- Qualification of Coders and Auditors Policy
- HIM credentialed staff only as coders/auditors
- List acceptable credentials for each position
- Determine minimum number of CE hours in coding-related topics per year
- Required years of experience
