An internal coding audit at Community Hospital shows that the cause of improper coding is lack of
proper physician documentation to support reimbursement at the appropriate level. Coders have found
that coding issues are a result of physician documentation needing clarification. The HIM department
staf has met periodically with each clinical specialty to improve communication and provide targeted
education, but documentation problems still persist. Which of the following actions would be the most
reliable and consistent method to improve communication and documentation?
Allow coders to make clinical judgments in absence of physician documentation
Revise medical staf bylaws to include documentation requirements
Implement a standardized physician query form so that coders can request clarification
from physicians about documentation issues
Suspend medical staf privileges after a specified number of documentation problems
Which organization is responsible for ensuring compliance with the HIPAA Privacy and Security Rules?
To decrease risk exposures in a health care facility, which of the following can be used to track and