Example SOPs: Clinical Coder

Clinical Coder SOPs

Creating Standard Operating Procedures for your Clinical Coder work can be difficult and take time. That’s why we’ve created these example Clinical Coder SOPs so you can jumpstart your SOP creation process. We want to help you set up your Healthcare systems and processes by taking these sample SOPs and building out your own SOPs template library. By having all your Healthcare procedures in one place, your team will have the information they need at all times. Let’s look at some Clinical Coder SOP examples.

Clinical Coder SOP Examples

1. SOP: Patient Record Review
Purpose: This SOP outlines the process of reviewing patient records to extract relevant medical information for coding purposes. It ensures accurate and complete documentation of diagnoses, procedures, and treatments. The review includes verifying the patient’s demographic information, medical history, and physician notes. This SOP is crucial for maintaining data integrity and facilitating proper coding.
Scope: All patient records within the healthcare facility.
Person Responsible: Clinical Coder
References: SOP – Medical Documentation Guidelines, SOP – Coding Guidelines

2. SOP: Code Assignment
Purpose: This SOP details the process of assigning appropriate codes to medical diagnoses, procedures, and treatments based on the information extracted from patient records. It ensures compliance with coding guidelines and standards, such as ICD-10-CM and CPT. The code assignment process involves analyzing the documentation, researching codes, and applying the most accurate and specific codes to reflect the patient’s condition and services provided.
Scope: All coding activities within the healthcare facility.
Person Responsible: Clinical Coder
References: SOP – Medical Documentation Guidelines, SOP – Coding Guidelines

3. SOP: Query Management
Purpose: This SOP outlines the procedure for managing queries related to coding discrepancies or insufficient documentation. It ensures effective communication between clinical coders and healthcare providers to clarify and obtain additional information necessary for accurate coding. The query management process includes drafting queries, sending them to the appropriate healthcare professionals, tracking responses, and updating the patient records accordingly.
Scope: All coding-related queries within the healthcare facility.
Person Responsible: Clinical Coder
References: SOP – Code Assignment, SOP – Medical Documentation Guidelines

4. SOP: Quality Assurance and Audit
Purpose: This SOP establishes a quality assurance and audit process to ensure the accuracy and compliance of coding practices. It involves periodic reviews of coded records, comparing them against established coding guidelines and standards. The quality assurance and audit process may include sample selection, coding accuracy assessment, feedback provision, and corrective actions if necessary. This SOP helps identify areas for improvement and maintain coding integrity.
Scope: All coding activities within the healthcare facility.
Person Responsible: Clinical Coder, Quality Assurance Officer
References: SOP – Code Assignment, SOP – Coding Guidelines

5. SOP: Confidentiality and Data Security
Purpose: This SOP outlines the protocols and measures to maintain patient confidentiality and data security during the coding process. It includes guidelines for handling sensitive patient information, secure storage of records, password protection, and adherence to HIPAA regulations. This SOP ensures the protection of patient privacy and compliance with legal and ethical standards.
Scope: All coding activities within the healthcare facility.
Person Responsible: Clinical Coder, Data Security Officer
References: SOP – Code Assignment, SOP – HIPAA Compliance

6. SOP: Continuing Education and Professional Development
Purpose: This SOP establishes a framework for ongoing education and professional development for clinical coders. It outlines the requirements for attending relevant workshops, seminars, and conferences to stay updated with coding guidelines, industry trends, and regulatory changes. This SOP ensures that clinical coders maintain their knowledge and skills, enhancing their ability to accurately code patient records.
Scope: All clinical coders within the healthcare facility.
Person Responsible: Clinical Coder, Training and Development Officer
References: SOP – Code Assignment, SOP – Professional Development Plan

Clinical Coder SOP Templates

Looking for SOP templates for your Clinical Coder work? We’ve got you covered. You can build out your company SOPs using the sample SOP information above (added to our template) or our team can put together a starter SOPs template based on your Clinical Coder work. Get in touch if you’ve got questions about the quickest way to build out your Healthcare SOPs library.