Create a policy and procedure which includes a step-by-step process addressing the UHDDS standards and Official Coding
To create a coding policy and procedure
Step One: From the textbook, Case Studies in Health Information Management, follow the instructions to complete case 2-3 Documentation support for Principal Diagnosis. Use Official Coding Guidelines as support when appropriate
Step Two: Create a policy and procedure which includes a step-by-step process addressing the UHDDS standards and Official Coding Guidelines. Your policy and procedure should also address other official sources of coding guidance such as Coding Clinic, CPT Assistance, CMS, AMA, and NCCI (when and how they should be used). The policy and procedure should be in APA format and 2-3 pages in length (not counting title and reference pages).