Electronic Health Records

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AHIMA Releases Recommendations For Coding Compliance Policies

By Jennifer Bresnick

- A white paper produced by the American Health Information Management Association (AHIMA), offers guidance on identifying source documents and clinical documentation that make up the core of a designated clinical documentation set.  AHIMA suggests that this documentation be reviewed and updated annually to ensure up-to-date information and uniform coding standards, the use of which “reduces administrative costs, enhances data quality and integrity, and improves decision-making, all of which leads to quality healthcare delivery and information.”

The AHIMA position statement stresses the need for health information management (HIM) professionals to follow nationwide standards and adhere to the principle of “only reporting codes that are consistently supported by authenticated clinical documentation in accordance with code set rules and guidelines.”  Coding compliance policies serve as a guide for organizations that use diagnosis and procedure codes so they can perform reporting activities correctly.

For more detailed information on the required components of a coding compliance policy, please see AHIMA’s white paper.




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