The importance of uniform terminology, coding and standardization of the data

Uniform terminology, coding, and standardized data entry protocols are necessary for assuring accurate information retrieval. The health informatics componentss need to be using compliance plan in place. Here are some guidelines for assurring the acurracy of terminology, coding, and data entry.

Conduct internal monitoring through periodic chart audits

Develop written coding and documentation standards and procedures, and implement them;

Designate one of your staff members as a compliance of-cer to monitor your practice's compliance

Respond appropriately to potential violations by investigating and disclosing them, as• Develop open lines of communication by discussing at staff meetings how to avoid erroneous or fraudulent conduct or by using a community bulletin board to keep employees

Develop a CPT utilization report. Separate your Medicare patients from your otherpatients for a more appropriate analysis. A useful template is available online at http://www.aafp.org/fpm/20020700/codingfrequencycomparison.xls.

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