Defining the Core Documentation Set for Coding Compliance

A new white paper from AHIMA’s thought leadership series offers guidance on examining coding compliance policy and testing it against upcoming challenges in clinical documentation and associated coding. “Defining the Core Clinical Documentation Set for Coding Compliance,” authored by Bonnie Cassidy, MPA, RHIA, FHIMSS, FAHIMA, lays out strategies for organizations to take the next steps in that process. “Whether your medical record is paper-based, electronic, or hybrid, a high-integrity coding compliance policy should be written and updated at least once per year as part of an information governance framework,” Cassidy says.

For an excerpt of the paper’s key focus areas, read below. To read the full paper, follow the link to download a PDF.

Paper Excerpt

A coding compliance policy is essential to your organization’s overall compliance program. The four key areas where you will rely on your coding compliance policy are:

1. Coding: Organizations using diagnosis and procedure codes to report healthcare services must have formal policies and corresponding procedures in place that provide instruction on the entire process—from the point of service to the billing statement or claim form.

2. Coding audits: Coding compliance policies serve as a guide to performing coding and billing functions and provide documentation of the organization’s intent to correctly report services.

3. Outsourcing coding work: Policies should include facility-specific documentation requirements, payer regulations and policies, and contractual arrangements for coding consultants and outsourcing services. The outsourcing vendor does not tell you what documents they will use to code your encounters; you, the HIM professional, are in charge of this process and should have your outsourcing partner follow your best practice or coding compliance policy.

4. Computer-assisted coding: In selecting a business partner to build a technology enabled coding process, use and provide your coding compliance policy for your vendor to create a customized and trained CAC solution for you. You do not need to load your entire EHR into a CAC system when you have already identified your core designated clinical documentation or record set that is the foundation of your clinical coding compliance.



  1. The link to the full PDF does not work. Can this please be emailed to me? Thanks

    Sean M. Weiss
    VP and Chief Compliance Officer
    DoctorsManagement, LLC

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  2. Hi Sean,

    Thank you for bringing this to our attention. The link has been updated and should now work.

    Sarah Sheber
    Assistant Editor

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  3. Hello,
    The link provided is not working properly. After it loads, the pdf does not open.


    Post a Reply
  4. Hi Lynne,

    The URL is current, have you tried opening in a different browser?

    Post a Reply

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