Health Information Management

Pay-per-view: Exploring the relationship between documentation and coding

APCs Insider, February 7, 2014

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The U.S. healthcare system is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation. This relationship then makes documentation and coding truly dependent upon each other; without one you don’t have the other. It sounds plain and simple, but of course it is not.
The use of coded data continues to be very important as the healthcare industry works to obtain information for quality measures, outcomes, research, resource management, reimbursement methodologies, and payment. Such important data requires accurate clinical coding, which requires complete and accurate clinical documentation.
As the healthcare industry in the United States transitions to ICD-10, awareness of the need for greater clinical documentation specificity and the code specificity that correlates to it is increasing. The ICD-10-CM diagnosis coding system and ICD-10-PCS procedural code system were designed to provide more clinical information via coded data.
Continue reading Exploring the relationship between documentation and coding on HCPro’s website. Subscribers to Briefings on APCs have free access to this article in the February issue.

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