Coding Standards

Recent data analysis and claim review findings by the Comprehensive Error Rate Testing (CERT) contractor have identified some repetitive billing and documentation errors among providers billing Medicare allowable services. Errors are related to providers incorrectly coding both ICD-9 and HCPCS. According to AHIMA's Standards of Ethical Coding, Coding professionals should:

  1. Apply accurate, complete, and consistent coding practices for the production of high-quality health care data.
  2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.
  3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.
  4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator).
  5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.
  6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.
  7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.
  8. Advance coding knowledge and practice through continuing education.
  9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.
  10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities ( examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).
  11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Coding professionals, regardless of their professional function or setting in which they work, should remember to first code to only what is supported by documentation in the chart and second ask for clarification if documentation is unclear.

AHIMA, (2008, September). AHIMA Standards of Ethical Coding. Retrieved from
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001166.hcsp?dDocName=bok2_001166.

Page Last Updated: Thursday, 15-Dec-2011 14:35:25 CST