Strengthen coding processes to ensure compliance

Article Overview

This article reviews audit-based challenges affecting inpatient coding compliance and explains why facilities need strong clinical documentation improvement and coding validation processes. It is aimed at coding compliance professionals, CDI teams, HIM staff, and auditors who work with ICD-9-CM and ICD-10-CM/PCS policies. The discussion covers audit findings, documentation standards, competing clinical definitions, additional-diagnosis validation, and the role of official guidance and facility policy in defending coded diagnoses.