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Integrity safeguards ensure PHI remains accurate and unaltered. Daily checks (e.g., hashing, checksums) confirm records have not been tampered with. Confidentiality focuses on privacy, availability on uptime, and accountability on tracking. Integrity checks are critical for reliable coding and audit readiness.

The Office of Inspector General (OIG) investigates fraud, waste, and abuse in federal healthcare programs. CMS oversees Medicare administration, OCR enforces HIPAA, and NCHS maintains coding standards. Coders may encounter OIG reviews when improper coding or billing patterns are suspected. Awareness of OIG’s oversight role is critical for compliance.

Pathology cannot be coded as malignancy without provider confirmation. Since the discharge note only states “uterine mass,” coder must query provider to confirm malignancy. If confirmed, assign C54.x malignant neoplasm of uterus. This preserves compliance and ensures accurate oncology reporting.

For inpatient coding, coders code conditions diagnosed by the provider even if not supported by labs, provided no conflicting documentation exists. A negative culture does not exclude UTI if the provider documents it and treats with antibiotics. Hematuria is a separate, clinically relevant condition. Therefore, both UTI and hematuria must be coded. Only if conflicting documentation exists would a query be required.

Pathology findings cannot be coded as malignancy unless confirmed in provider documentation. Since the final diagnosis lists only “renal mass,” coder must query provider. If confirmed, assign C64.x malignant neoplasm of kidney. This ensures accuracy and compliance.