The guidelines should be developed and managed on an ongoing basis by
the HIM department representative - usually the coding or data quality
manager. This individual should have the final responsibility for
finalizing the guidelines, ensuring they are updated and gathering the
right individuals and groups together to provide appropriate and necessary
feedback into the initial as well as ongoing development process. In
addition to the HIM manager, other individuals or groups that should be
involved in coding guideline development include:
- The Coding Staff
– input from this group is particularly
key in identifying areas where they may have questions or unclear
guidance and need to have clear-cut guidelines for reference.
- The Medical Staff
– key members of the medical staff in
various services should be identified as individuals who will assist the
HIM manager in clarifying clinical and documentation concerns. In
addition, these individuals can serve as a resource in ensuring that all
policies are clinically validated. This concept is discussed in detail
below.
- The compliance officer
– while generally not a content
expert (although in a growing number of facilities the compliance
officer is in fact also an HIM professional), the compliance officer
should be brought into the guideline development process as a
"consultant" to put the compliance stamp of approval on the
guidelines.
- Clinical Committees
– the number and specific type of
clinical committees within each health care organization will vary.
However, these committees, like the Tissue and Mortality Committees, can
be used as Clinical Expert references during the guideline development
process.
- The Medical Staff as a Whole
– you will need to develop
some guidelines that will apply to your medical staff as a whole –
usually because it is already their practice and you are just clarifying
the practice via a documented guideline. (i.e. in the case of urosepsis,
a medical staff can determine that the term, as used within that
organization, signifies sepsis with its origin in the urinary tract.)
When you do develop guidelines like this, your medical staff will need
to vote on the guideline. And, a record of this vote must be kept within
the ‘administrative" section of the guidelines.
- Medical Record/HIM Committee
– final approval for the
guidelines must come from some organized, recognized committee within
the organization. Generally, the Medical Record/HIM Committee is the
best place for this activity – but, again, this may vary based on the
organization. Minimally, this committee must approve the guidelines
initially, approve updates on some regular basis, and provide an annual
review and re-approval.
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