PAGE: 1 of 4 / REPLACES POLICY DATED: 3/6/98, 4/16/99, 8/1/2000, 1/1/2001
APPROVED: April 9, 2002 / RETIRED:
EFFECTIVE DATE: June 1, 2002 / REFERENCE NUMBER: HIM.COD.006
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 Administration
Radiology Department Ancillary Departments
Facility Health Information Management Laboratory Department
Corporate Health Information Management Services Human Resources Department
Registration/Admitting/Scheduling Service Centers
Ethics and Compliance Officers External Coding Contractors
Case Management/Quality Resource Management Internal Audit & Consulting Services
Ambulatory Surgery Centers/Business Office/Medical Records
PURPOSE: To ensure that all personnel involved in the performance of final coding or formalized auditing of coding processes are aware of coding guidelines and coding guideline changes, which may impact complete, accurate and consistent coding.
POLICY: Each person involved in the performance of final coding or formalized auditing of coding processes must complete a minimum of thirty (30) Coding Education (CE) hours per calendar year. Any associated costs will be the responsibility of the facility. A minimum of fifteen (15) CE hours must be accomplished by formal coder education (e.g., attendance at workshops provided by Health Information Management Services or external organizations, attendance at exit conferences after a coding review, annual review of Company coding policies and procedures) and the remaining hours may be accomplished by informal coder education (e.g., reading Coding Clinic, reading Health Information Management Update, reading CPT Assistant, coding-specific carrier bulletins, Medicare Keynotes etc.).
NOTE: Continuing education requirements outlined in the Continuing Education Requirements Policy, GOS.GEN.007, do not replace this policy. GOS.GEN.007 indicates that any person involved in the performance of billing and/or billing-related services (such as outpatient coding) must complete a minimum of eight (8) education hours per calendar year.
Therefore, if an individual is responsible for inpatient coding only and is not involved in outpatient coding, the inpatient coder must meet the annual requirement for 30 hours of continuing education as outlined in this policy. The total number of hours required annually for inpatient coders is 30.
If an individual is responsible for outpatient coding only, the outpatient coder must obtain the 30 hours of continuing education as required by this policy. The eight (8) hours of billing continuing education required in GOS.GEN.007 may be used to fulfill the 30 hour requirement. The total number of hours required annually for outpatient coders is 30.
If an individual is responsible for both inpatient and outpatient coding, the coder must obtain the 30 hours of continuing education as required by this policy AND the eight (8) hours of billing continuing education required in GOS.GEN.007, for a total of 38 hours annually.
DEFINITION:
Coding: Coding is a function by which there is an assignment of a numeric or an alphanumeric 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 (Current Procedural Terminology) or HCPCS Level II or III (Healthcare Common Procedure Coding Systems).
PROCEDURE:
1.The coder’s (inpatient, outpatient or solo practitioner) direct supervisor will maintain an education file for each coder and will track education obtained using the Learning Management System (LMS).
a)The education file must be monitored semi-annually by the coder’s direct supervisor to evaluate individual coder education needs.
b)The education file must contain, at a minimum, the following:
i)Copies of credential certification (where applicable),
ii)Copies of CE forms from educational workshops,
iii)Copies of attendance forms from exit conferences, and
iv)Acknowledgment of annual review or re-review of all Company coding policies and procedures.
v)See Attachment A for a sample continuing education tracking form.
c)The coder’s direct supervisor will be responsible for providing specific information related to coding continuation education compliance to the facility ECO or Corporate Responsible Executive, whichever is applicable.
2.Formal Coder Education
a)Examples of formal education include: AHIMA educational seminars, coding audio conferences, AHIMA annual meeting, exit conferences with HIMS or Internal Audit & Consulting Services, or other coding reviews, annual review of HIMS Policies and Procedures, college courses related to coding such as medical terminology, Anatomy & Physiology, etc, independent study courses, facility-provided educational sessions, e.g., physician presentations, local coding roundtable meetings, state association meetings, etc.
b)The coder’s direct supervisor will assign time for each coder to attend at least fifteen (15) hours of formal coder education per calendar year.
c)Educational requirements are for all designated employees if hired before October 3rd of the given year. PRN employee’s proof of CE hours should be outlined in their contractual agreement.
d)Attendance at formal education sessions must be pre-approved by the coder’s direct supervisor.
- Informal Coder Education
b)Health Information Management Services will supply, at a minimum, Health Information Management Update, Coding Clinic for ICD-9-CM, and CPT Assistant to each Health Information Management Department.
i)The Health Information Management Director (HIM Director) will date stamp or write the received date on the upper right corner of each publication. Internal publications will include a space for the date received.
ii)The HIM Director will route the publications to each coder in the facility.
(1)The coder’s direct supervisor will assign appropriate time for each coder to complete the reading of publications based on the needs of the department. All coders must read the publication within 30 days of facility receipt and receive appropriate CE credit.
(2)After reading the publication, the coder will sign and date it. Internal publications will include a space for the signature and date.
c)The Health Information Management Department must maintain all of the routed publications.
- Health Information Management Services will monitor the education files and publications.
REFERENCES:
The American Health Information Management Association (AHIMA):
- Registered Health Information Administrator Continuing Education requirement of 30 hours per two year cycle
- Registered Health Information Technician Continuing Education requirement of 20 hours per two-year cycle
- Certified Coding Specialist Continuing Education requirement of annual self-assessment
Coding Orientation and Training Policy, HIM.COD.005
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
4/2002
ATTACHMENT A
CODER CONTINUING EDUCATION TRACKING FORM
Sample Only
Coder Name: ______Title: ______
Department: ______Supervisor: ______
For each educational activity please specify program title or resource, date of completion or attendance and number or hours received. Informal education hours (e.g., Coding Clinic review, Health Information Management Update review, carrier coding bulletin review, etc.) should be reported as actual time spent reviewing the document. For example, a one-hour review of Coding Clinic should be reported as 1 hour earned.
Informal Education
AHA CODING CLINIC /CPT ASSISTANT
/HIMS UPDATE
/ MISCELLANEOUS (specify item) /HOURS EARNED
/ TOTALDATE REVIEWED / 1st QUARTER / JANUARY / JANUARY
DATE REVIEWED / 2ND QUARTER / FEBRUARY / FEBRUARY
DATE REVIEWED / 3RD QUARTER / MARCH / MARCH
DATE REVIEWED / 4TH QUARTER / APRIL / APRIL
DATE REVIEWED / MAY / MAY
DATE REVIEWED / JUNE / JUNE
DATE REVIEWED / JULY / JULY
DATE REVIEWED / AUGUST / AUGUST
DATE REVIEWED / SEPTEMBER / SEPTEMBER
DATE REVIEWED / OCTOBER / OCTOBER
DATE REVIEWED / NOVEMBER / NOVEMBER
DATE REVIEWED / DECEMBER / DECEMBER
TOTAL INFORMAL CE HOURS:
Formal Education
PROGRAM ATTENDED / DATE / CE HOURSAnnual Review of HIM.COD.001
Annual Review ofHIM.COD.002
Annual Review of HIM.COD.003
Annual Review of HIM.COD.004
Annual Review of HIM.COD.0006
Annual Review of HIM.COD.010
Annual Review of HIM.GEN.001
TOTAL FORMAL CE HOURS
COVERING CALENDAR YEAR: ______TOTAL CE HOURS:
This form must be maintained in the Employee’s Department Education File.
Attachment to HIM.COD.006