The American Health Information Management Association in a new white paper urged clinical coding professionals to develop strict diagnosis and procedure coding compliance protocols to ensure the integrity of clinical data.
In particular, the white paper called on health care organizations to develop coding policies that specify which medical record documents and clinical documentation require mandatory review by coders. In addition, it said coders should review clinical documentation in electronic health records and paper records to identify all diagnoses and procedures requiring coding.
AHIMA said accurate health record documentation—both electronic and paper-based—is necessary for the most accurate coding.
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