Reference no: EM133788048

Question

You are to develop a comprehensive internal policy and procedure for coding and billing for your Coding Compliance Program. Policies address what must be done and processes outline how to achieve compliance with the policy. Issues that should be addressed in the policy include: Medical record documentation requirements What documentation should be available at the time the record is coded? All physician documentation? All test results? What procedures do you have in place to ensure that medical record documentation is adequate and appropriate to support the coded diagnoses and procedures? Physician query process Coding diagnoses not supported by medical documentation Upcoding Unbundling Coding medical records without complete documentation Correct use of encoder software Use of official resources such as the Official Guidelines for Coding and Reporting, CPT Assistant, and AHA Coding Clinic Be sure to include the course of action coders should take when the coding situation is not addressed in official coding guidelines. Complete the process for using scrubber software Education and training plan Auditing and monitoring