PAGE:1 of 4 / REPLACES POLICY DATED: March 6, 1998, April 16, 2000, August 1, 2000
APPROVED: December 18, 2000 / RETIRED:
EFFECTIVE DATE: January 1, 2001 / REFERENCE NUMBER: HIM.COD.005
SCOPE: All full-time, part-time, and solo-practitioner contract personnel responsible for performing, supervising or monitoring coding of inpatient and outpatient services including, but not limited to:
Emergency Department Facility Health Information Management
Radiology Department Ancillary Departments
Corporate Health Information Management Services Laboratory Department
Registration/Admitting/Scheduling Internal Audit & Consulting Services
Ethics and Compliance Officer Human Resources Department
Case Management/Quality Resource Management
Ambulatory Surgery Centers/Business Office/Medical Records
Business Office/Central Business Office/Medicare Service Center/
Financial Service Center/Revenue Service Center
PURPOSE: To orient all new coding personnel to Company and facility coding policies and procedures, tools and resources, and education and training programs.
POLICY: The Company will provide an orientation and training session to all new coding personnel involved in the final ICD-9-CM and CPT- 4 coding process. The orientation process will include review of policies, procedures, tools and resources provided by the facility and Company. Coding is performed for reporting vital statistics, mortality reporting, physician profiling, outcome measurements and for many third party reimbursement systems, including Medicare.
Completion and documentation of coding education and training requirements must be met within 90 days of employment or transfer into a coding position. Applicable training requirements are outlined in the Coding Continuing Education Requirements Policy, HIM.COD.006, and/or in the Continuing Education Requirements Policy, GOS.GEN.007. Refer to specific policies for the applicability and education requirements.
DEFINITION:
Coding: Coding is a function by which there is an assignment of a numeric or an alphanumerical classification to identify diagnoses and procedures. These classifications or “codes” are assigned based upon a review of the source document (medical record). The classifications utilized for this purpose include: ICD-9-CM (International Classification of Disease – 9th edition – Clinical Modification); CPT-4 (Current Procedural Terminology) or HCPCS Level II or III (HCFA Common Procedure Coding Systems).
PROCEDURE:
- All new employees involved in the final ICD-9-CM and CPT-4 coding process or current employees transitioning to a coder position will review the following policies, as applicable to the treatment setting, prior to performing any coding:
b)The Company’s Coding Documentation for Outpatient Services Policy, HIM.COD.002.
c)The Company’s Coding Documentation for Skilled Nursing Facilities/Units Policy, HIM.COD.010.
d)All facility-specific coding policies and procedures.
- The HIMS/Coding Section of the Company’s Ethics and Compliance Policies and Procedures Manual will be reviewed and acknowledged within two weeks of employment.
- The name and phone number of their facility’s Health Information Management Services Consultant will be provided, and the employee will be oriented to the HIMS P&P Helpline and the Billing Helpline.
- Guidelines for use and phone numbers for the 3M Nosology Coding Help Line and the Ethics Line will also be provided.
- The required resources will be reviewed, as applicable to position responsibility, and made available to the coding staff prior to coding:
b)Physician’s Current Procedural Terminology Book (CPT)
c)AHA Coding Clinics for ICD-9-CM Coding (1984-present)
d)Health Information Management Services Update (May 1995 to present)
e)DRG Definition Manual
f)ICD-9-CM Coding Handbook with Answers
g)Inpatient Coding Reference Manual
h)CPT Assistant (1990-present)
i)Medicare Keynotes (electronically available)
j)Medical Dictionary
k)Medical Acronyms and Abbreviations List
l)Anatomy and Physiology Book
m)Drug Reference Tool
n)Disease Process Book
- The following videotapes with workbook will be reviewed, as applicable to position responsibility, within two weeks of employment:
b)Complete and Accurate Coding Using Diagnostic Test Findings “Imaging”
c)Complete and Accurate Coding Using Diagnostic Test Findings “Cardiology”
d)Anatomy and Physiology “Respiratory System”
e)Anatomy and Physiology “Gastrointestinal System”
f)Anatomy and Physiology “Cardiovascular System”
g)Arthroscopic Shoulder and Knee Procedures ICD-9-CM/CPT-4 Physician Presentation
7.All coders will be given an orientation to all applicable computer systems (i.e., Clinical Patient Care System (CPCS) 3M Coding and Reimbursement System) prior to coding.
8.An overview and explanation of the appropriate use of the applicable reports used by the facility to monitor quality and quantity of coding will be reviewed within two weeks of employment.
9.The Health Information Management Director or direct supervisor will complete the attached orientation checklist.
10.Documentation of the completed orientation checklist must be filed in the employee’s department education file.
11.Documentation of the training must be completed within 90 days of employment or transfer into a coding position, as required by the Coding Continuing Education Requirements Policy, HIM.COD.006, and/or the Continuing Education Requirements Policy, GOS.GEN.007, and must be entered in the Learning Management System (LMS).
12.Until LMS is in operation at the facility, the coding supervisor must use the tracking method located on the Company’s intranet at the Governmental Operations Support website (which has been developed for the express purpose of interfacing with LMS).
13.Corporate Health Information Management Services and/or Internal and Audit & Consulting Services will monitor the education files.
14.For any questions regarding this policy please contact the HIMS P&P Helpline at 1-800-690-0919 or by e-mail at: HIMS P&P Helpline.
REFERENCES:
Coding Continuing Education Requirements Policy, HIM.COD.006
Coding Continuing Education Requirements for Company-Owned Physician Practices Policy,
HIM.PHY.006
Coding Orientation and Training for Company-Owned Physician Practices Policy, HIM.PHY.005
Continuing Education Requirements Policy, GOS.GEN.007
12/2000
Attachment A
Orientation Checklist
Scope: All full-time, part-time, per diem and contract personnel responsible for performing the final inpatient or outpatient coding process must have an orientation checklist completed.
Directions: The supervisor and/or the coder should date and initial under the appropriate
column for each designated task. The supervisor will indicate NA (not applicable) for any resource and/or videotape not reviewed due to the fact it is not applicable to position responsibility. For any items determined NA, written documentation denoting the reason the item was NA must be provided.
Coder’s Name: ______
Hire Date: ______
Prior to beginning the coding process:
SupervisorCoderDateN/A
1. Orientation to the facility ______
2. Orientation to the department______
3. Review of Coding/Documentation______
Policy for Inpatient Services
- Review of Coding/Documentation______ Policy for Outpatient Services ______
5. Review of Facility Specific
Coding Policies and Procedures ______
6.Name and phone number of
Corporate HIMS Consultant ______
7. Guidelines and phone number ______
for 3M Coding Helpline, Ethics Line,
HIMS P&P Helpline and
Billing Helpline.
- Location of following resources:
a. ICD-9-CM Code Book______
b. CPT Code Book______
c. Coding Clinic ______
Attachment to HIM.COD.005
SupervisorCoderDateN/A
d. CPT Assistant ______
e. DRG Definition Manual______
f. AHA Coding Handbook______
g. Medical Dictionary______
h. Medical Acronyms and ______
Abbreviations List
i. Anatomy and Physiology ______
j. Drug Reference Tool______
k. Disease Process Book______
l. Health Information Management
Services Update______
m. Coding Reference
Manual(s): St Anthony’s______
n. Outpatient Coding Reference
Manual______
o. Medicare Keynotes______
10. Orientation to Computer System ______
11. Overview of Coding quality and
quantity reports______
Within Two Weeks
1. Remainder of the
HIM/Coding Policies in the
Ethics and Compliance Policy
and Procedure Manual______
2. Review the following coding
Videotapes as applicable to treatment setting:
a. Complete and Accurate Coding
Using Diagnostic Test Findings:
Laboratory Test______
b. Complete and Accurate Coding
Using Diagnostic Test Findings:
Imaging______
SupervisorCoderDateN/A
c. Complete and Accurate Coding
Using Diagnostic Test Findings:
Cardiology______
d. Anatomy and Physiology:
Respiratory System______
e. Anatomy and Physiology:
Gastrointestinal System______
f.Anatomy and Physiology:
Cardiovascular System______
g. Arthroscopic Shoulder and
Knee Procedures______
Coder’s Name: ______
Coder’s Signature: ______
Supervisor’s Signature: ______
Supervisor’s Title: ______
Date Completed: ______
This form must be maintained in the Employee’s Department Education File.
Attachment to HIM.COD.005