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 ICD-10 Resources page for the latest information.

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CHIA accepts original, unpublished manuscripts about current issues and best practices in health information management.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

Increased Error Rate for Medicare Part B; shows need for APC audits - published September 2011
The last ICD-9-CM procedure code set update: October 1, 2011 - published September 2011
ICD-10-CM “Present on Admission Reporting Guidelines” - published May 2011
Sepsis, SIRS - published April 2011
Coding Malnutrition - published April 2011
ICD-10-PCS Implementation - published 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.