Coding and Data Quality (CDQ)

This site is a resource for coding and data quality issues. Here CHIA will continue to post articles and resources that address coding classification official guidelines, medical record documentation topics, payer guidelines, and data reporting. Use these resources as a means to more fully understand and improve the quality of medical coding, clinical documentation, and to help educate your medical staff and other healthcare colleagues on these issues.

Are you ready for ICD-10? Visit our Training Tools and ICD-10 Resources page for the latest information, including ICD-10 coding tips.

Watch CHIA’s Coding Roundtable Webinar Recording

CHIA Coding Roundtable webinar aired on October 24 is now available for playback here: Coding Roundtable Webinar

Coding and Data Quality Articles Solicited

CHIA accepts original, unpublished manuscripts about current issues and best practices in health information management. CHIA encourages members and other individuals to submit manuscripts for publication in the CHIA Journal and/or on this site. See CHIA Publication Guidelines for details.

Insights to Coding Data Quality - Featured Articles

All articles were published in the CHIA Journal
Spinal Surgery Webinar question on vertebral corpectomy procedures - February 2014
Review of the Medicare Outpatient Prospective Payment System Final Rule for 2014 - February 2014
Readiness for ICD-10 includes physician query inventory and checklist - December 2013/January 2014
Readiness for ICD-10 includes coding policy/procedure inventory and checklist - December 2013/January 2014
CMS releases OPPS Final Rule - December 2013/January 2014
Reliability of documentation – What is a coder to do? - November 2013
Medicare overpayments to hospitals for mechanical ventilation greater than 96 hours - November 2013
CMS issues new admission and medical review guidance - November 2013
2014 CPT code update - November 2013
Property and Casualty/Workers Compensation readiness for ICD-10 - October 2013
OIG recommends transfer policy for hospice providers - October 2013
IPPS proposal FY2015 The Hospital-Acquired Condition Reduction Program - October 2013
Planned readmission discharge status codes - September 2013
D-day for coders – October 1, 2014 - September 2013
AHA Coding Clinic guidance: Code number in lieu of a diagnosis - September 2013
CMS proposes new ICD-9-CM procedure codes for FY2014 - August 2013
Medicare program Part B billing in hospitals – Update - May 2013
Current DRG grouping algorithms - April 2013
CMS responds to RAC myths - April 2013
Physician queries: Comply with new AHIMA guidance - March 2013
Changes to Hospital Acquired Conditions for FY2013 - March 2013
AHA Coding Clinic guidance: Code number in lieu of a diagnosis - March 2013
2013 CPT Overview - February 2013
CHIA participates in California ICD-10 Collaborative - December 2012/January 2013
Medi-Cal planning to use DRGs in mid-2013 - December 2012/January 2013
How much revenue are you losing due to incorrect patient status codes? - October 2012
CPT colonoscopy coding - October 2012
Transitioning people to ICD-10 - September 2012
Reporting patient data to OSHPD - September 2012
CDI and ICD-10 readiness - August 2012
Rehabilitation coding - April 2012
ICD-10-CM “Present on Admission Reporting Guidelines” - May 2011
ICD-10-PCS Implementation - Dec 2010/Jan 2011

Coding Classification Authorities

Specific organizations are recognized as the national authorities on coding classifications and advice. Classification changes and associated guideline development are the responsibility of the various medical code set maintenance organizations. Therefore, neither AHIMA nor CHIA may issue coding guidelines independently.

The ICD-9-CM and ICD-10-CM/PCS classification systems are maintained by the National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS).

The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel.

The Healthcare Common Procedure Coding System (HCPCS) is under the authority of CMS.

The American Hospital Association’s Central Office serves as the official U.S. Clearinghouse on medical coding for the proper use of the ICD-9-CM systems and Level I HCPCS (CPT-4 codes) for hospital providers and certain Level II HCPCS codes for hospitals, physicians and other health professionals.

The ICD-9-CM coding guidelines are clarified through unanimous agreement by the Cooperating Parties of the ICD-9-CM Coding Clinic. The Cooperating Parties are NCHS, CMS, AHIMA and the American Hospital Association (AHA). Therefore, neither AHIMA nor CHIA may issue coding guidelines independently. AHIMA and the other Cooperating Parties can only refer coders seeking official ICD-9-CM coding advice to the AHA.