What makes an effective coding quality program?

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    Coding compliance requires demanding skills and attention to the all-important details. HIM departments are expected to make sure patient care is appropriately documented, check for medical necessity, identify conditions present on admission, flag patient safety indicators (PSIs)—and more.

    Market and technology trends add to the strain. Coding and clinical documentation improvement (CDI) managers may need to develop more new skills to manage diagnosis coding for hierarchical condition categories (HCC) risk-adjustment and clinical validation of chronic conditions, besides becoming fluent in both facility and professional coding.

    And the stakes for coding quality are high: Claims that fail to pass scrutiny can be rejected by payers fully or in part, impacting revenue, denials and delays.

    To keep up with compliance demands, most health systems follow a coding compliance program. The benefits of such a program (PDF, 916 KB) are many.

    For example, an effective coding quality program can help:



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    Reveal the gaps in a coder’s knowledge, showing where further education can spell better performance

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    Improve the accuracy of patient risk stratification, which is fundamental to quality rankings, public report cards and improved performance under value-based care models

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    Increase the validity of quality outcomes data

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    Verify that thorough coding and documentation processes are followed, especially for patient conditions governed by coding and reporting guidelines

But what really makes an effective coding quality program?

The following common questions and answers highlight best practices for creating an optimal coding quality program.

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