DEPARTMENT: Regulatory Compliance Support / POLICY DESCRIPTION: Coding References and Tools
PAGE: 1 of 3 / REPLACES POLICY DATED: 3/6/98, 4/16/99, 8/1/00, 6/1/02, 3/1/04, 8/1/04 (HIM.COD.003), 3/6/06, 7/1/06
EFFECTIVE DATE: December 1, 2007 / REFERENCE NUMBER: REGS.COD.003
SCOPE: All 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 Regulatory Compliance Support Administration
Case Management/Quality Resource Management Ethics and Compliance Officers
Laboratory Department Materials Management
Human Resources Department Registration/Admitting/Scheduling/Patient
Information Technology & Services Access
Shared Services CentersShared Services Division - Health Information Management
PURPOSE: To ensure that quality coding reference materials and tools are purchased, maintained and accessible to all coding personnel, in a consistent and timely manner.
POLICY: Corporate Regulatory Compliance Support (Regs), with assistance, as needed, from the Corporate Materials Management, Corporate Legal, Corporate Financial Service Division– Health Information Management and Corporate Information Technology & Services (IT&S) Departments, will approve and oversee the purchase of coding reference materials and tools.
Definition:
Coding – Coding is a function by which there is an assignment of a numeric or an alphanumerical classification to identify diagnoses and procedures. This classification 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 (Healthcare Common Procedure Coding Systems).
PROCEDURE:
  1. Minimum required reference materials and tools are listed on Attachment A (acute medical/surgical facilities). The facility Health Information Management (HIM) or Coding Director should ensure access to the references for all coding personnel.
  1. Minimum required reference materials according to job classification and responsibility (e.g., clinicals, oncology, radiology, E&M, etc.), must be made available at the coder’s remote location either electronically or in hard copy as appropriate (reference Attachment A).
  1. Based on time sensitivity, items that contain official coding guidelines that are available via paper format prior to being released in an electronic format must be made available to all coders according to their job title. (e.g., CPT Assistant, AHA Coding Clinic, AHA Coding Clinic for HCPCS).
  1. Minimum required reference materials and tools, and electronic version of coding references must be updated on a concurrent basis, (i.e. quarterly, semi-annually, annually, or as required per the specific material/tool on Attachment A).
  1. Required reference materials and tools (listed in Attachment A) will either be purchased by the facility or as a part of a group purchasing contract. The required reference material and tools which are part of group purchasing contracts will be distributed directly to the facility.
  1. Regs will inter-company bill facilities for the reference materials and tools which are distributed directly to the facility. The rates for these products are included in the Budget Directives provided to the facility’s Chief Financial Officer.
  2. If a facility HIM or Coding Director is not receiving these reference materials and tools, contact Regs via e-mail at Regs Helpline.
  1. The facilityHIM or CodingDirector can directly purchase any reference materials and tools on the approved but not required reference list found in Attachment B. Other coding reference material may be purchased but Regs does not review the product for validity of coding advice.
  1. For those approved but not required products which are not distributed by Regs, the facility HIM or CodingDirector with assistance from facility Purchasing, should ensure that reference tools are purchased and available.
  2. The standard protocol must be followed to place the order, pay for the product and ensure receipt.
  1. A grouper/MS-DRG or APC software product with the online electronic coding reference library will be required for all acute medical/surgical facilities. Purchase of additional on-line or electronic coding references (such as coding reference plus)is a facility decision.
  1. If the HIM or Coding Director or coder believes that an external reference should be included on the required or approved reference material and tool listing, the following protocol must be followed:
  1. The Director should prepare a memorandum to Regulatory Compliance Support Department, Attn: Coding Compliance, OneParkPlaza, Bldg 2-3W,Nashville, TN, 37203.
  2. The memorandum should include the name and description of the reference material or tool, brochure (if applicable), purpose, and cost.
  3. Regs will determine whether the reference is a valuable resource for complete, accurate, and consistent coding.
  4. If approved, the reference will be added to the required or the approved reference materials and tools listings.
  5. If not approved, a written denial outlining the reasons will be completed by the Regs team and returned to the facility HIM or Coding Director.
  1. Regs will create and maintain listings of all required references and tools as well as approved references and tools. These listings will be reviewed at least once per year during the annual policy and procedure review process and updated as appropriate.
  1. Compliance with this policy, including the auditing and reporting of the availability and accessibility of the required reference materials and tools will be monitored by the Regs Department, Internal Audit, or other reviewers as required.

10/2007

ATTACHMENT A

REQUIRED INTERNAL/EXTERNAL CODING REFERENCE MATERIALS AND TOOLS

ACUTE MEDICAL/SURGICAL HOSPITALS/HOSPITAL BASED PROGRAMS

INPATIENT/OUTPATIENT CODING

FACILITY PURCHASE

  1. International Classification of Diseases 9th Edition, Clinical Modification (ICD-9-CM),any edition, updated to current version (IP/OP)
  1. Current Procedural Terminology (CPT), any edition, updated to current version (OP only)
  1. Medical Dictionary, hardcopy and/or electronic (IP/OP)
  1. Medical Acronyms and Abbreviations List, current version, hardcopy and/or electronic (IP/OP)
  1. Anatomy and/or Physiology Book/Information,current version, hardcopy and/orelectronic (IP/OP)
  1. Drug Reference Tool, including Clinical Pharmacology, MicroMedix or a nursing drug book,current version, hardcopy and/or electronic (IP/OP)
  1. Disease Process Manual (e.g., Merck Manual or Current Medical Diagnosis and Treatment),one of the two most recently published versions, hardcopy and/or electronic (IP/OP)
  1. Healthcare Current Procedural Classification System (HCPCS) Level II National Codes and Healthcare Current Procedural Classification System, current version (OP only)
  1. 3M Electronic Coding References Plus(strongly recommended) (IP/OP)
  1. ICD-9-CM Coding Handbook with Answers, current version (IP/OP)
  1. DRG Expert, current version, Ingenix (IP only)
  1. DRG Desk Reference, current version, Ingenix (IP only)
  1. Coder’s Desk Reference,Ingenix (sole-provider) (OP only)

COMPANY PURCHASE/PRODUCE AND DISTRIBUTE

1.Diagnosis Related Group Definitions Manual, current available, hardcopy and/or electronic version, Approved Vendor: 3M (IP only)

2.AHA Coding Clinic for ICD-9-CM, hardcopy and/or electronic version (1984 – present)

Approved Vendor: AHA (sole-provider) (IP/OP)

3.CPT Assistant, hardcopyand/or electronic version (1990 – present)

Approved Vendor: AMA (sole-provider) (OP only)

4.AHA Coding Clinic for HCPCS, hardcopy and/or electronic version (2001 – present)

Approved Vendor: AHA (sole-provider) (OP only)

5.Medicare Keynotes,hardcopyand/or electronic version (currently available) (IP/OP)

6.DRG Grouper/Software, current version, (3M), including online electronic coding reference package (IP only)

7.APCGrouper/Software, current version, (3M), including online electronic coding reference package (OP only)

8.Interventional Radiology Reference Book, current version(OP only)

Attachment to REGS.COD.003

ATTACHMENT B

APPROVED EXTERNAL CODING REFERENCE MATERIALS AND TOOLS

Clinical Specialty Series:

Current Diagnosis & Treatment in Orthopedics published by Appleton and Lange

Color Atlas of Endourology by Albala & Grasso II published by Lippincott-Raven

Atlas of Head & Neck Surgery - Otolaryngology by Baily, Calhoun, Coffey & Neely

Published by Lippincott-Raven

Fourth Edition Clinical Gastroentrology by Howard M. Spiro published by McGraw-Hill
Anatomy and/or Physiology

Human Anatomy and Physiology,7th Editionpublished by Marieb

A.D.A.M. Student Atlas of Anatomy, Todd R. Olson, published by Williams & Wilkins

The Anatomical Chart Series, Classic Library Edition, published by the Anatomical Chart

Company

Atlas of Human Anatomy,4thEdition, by Frank H. Netter, M.D.

Clinical Laboratory Tests, Values and Implications
Professional Guide to Signs and Symptoms published by Springhouse

General Surgery Textbook

Current Surgical Diagnosis and Treatment published by Appleton and Lange
General Internal Medicine Textbook
Current Medical Diagnosis and Treatment publishedby Appleton and Lange

Griffith’s Five Minutes Medical Consultby Mark Dambro

CPT Specialty Books by Body System

Coding Companion Series (examples:Spine and Above/Hip and Below) published by Ingenix

Complete Global Service Data for Orthopaedic Surgerypublished by the American Academy of Orthopaedic Surgeons

Interventional Radiology Coderby Jeff Majchrzak, BA, RT(R), NMTCB

CPT Specialty Books – General

Principles of CPT Coding published by the American Medical Association

Ingenix APC Expert published by Ingenix

CPT Made Easy published by Aspen

CPT Coding Workbook & CPT Instructor Edition (Includes: Coding Workbook Teaching Tips and Exercise Answers)published by MedLearn

Attachment to REGS.COD.003