Required Internal/External Coding Reference Materials and Tools
PAGE: 1 of 3 / REPLACES POLICY DATED: 3/6/98, 4/16/99, 8/1/2000
EFFECTIVE DATE: June 1, 2002 / REFERENCE NUMBER: HIM.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 Health Information Management Services Administration
Case Management/Quality Resource Management Ethics and Compliance Officers
Laboratory Department Patient Access
Materials Management Human Resources Department
Information Technology & Services Registration/Admitting/Scheduling
Service Centers
Ambulatory Surgery Centers/Business Office/Medical Records
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 Health Information Management Services (HIMS), with assistance from the Corporate Materials Management, Corporate Legal 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 or III (Healthcare Common Procedure Coding Systems).
PROCEDURE:
- Minimum required reference materials and tools are listed on Attachment A (acute medical/surgical facilities) or Attachment B (Ambulatory Surgery Centers (ASC)). The facility Health Information Management (HIM) Director or ASC Administrator should ensure access to the references for all coding personnel.
- The facility HIM Director or ASC Administrator can directly purchase any reference materials and tools on the approved reference list found in Attachment C.
b) The facility standard protocol must be followed to place the order, pay for the product and ensure receipt.
3.Reference materials and tools (listed in Attachments A and B) which are part of group purchasing contracts will be distributed directly by HIMS.
a)These materials/tools must be obtained directly through HIMS.
b)If a facility HIM Director, ASC Administrator or Business Office Manager is not receiving these reference materials and tools, contact HIMS via e-mail at HIM P&P Helpline.
c)For reference materials and tools which are distributed directly by HIMS, the facility will be inter-company billed the discounted rate of the product. The discounted rates for these products are included in the Budget Directives provided to the facility’s Chief Financial Officer.
4.A grouper/DRG or APC software product will be required for all acute medical/surgical facilities.
5.HIMS will be auditing and reporting the availability and accessibility of required reference materials and tools.
6.Approved, but not required, reference materials and tools are listed on Attachment C.
7.If the facility’s HIM Director or coder believes that an external reference should be included on the required or approved reference materials and tools listing, the following protocol must be followed:
a)The facility HIM Director should prepare a memorandum to Health Information Management Services Department, Attn: Health Information Management Senior Manager , One Park Plaza, Nashville, TN, 37203.
b)The memorandum should include the name and description of the reference material or tool, brochure (if applicable), purpose, and cost.
c)HIMS with assistance from the Health Information Management Services Steering Committee (and others as applicable) will determine whether the reference is a valuable resource for complete, accurate, and consistent coding.
d)If approved, the reference will be added to the required or the approved reference materials and tools listings.
e)If not approved, a written denial outlining the reasons will be completed by the HIMS Health Information Management Senior Manager and returned to the facility HIM Director.
- HIMS will create and maintain listings of all required references and tools as well as approved reference and tools. These listings will be reviewed at least once per year during the annual policy and procedure review process and updated as appropriate. Compliance with this policy may be monitored by the HIMS Department, or other reviewers as required.
4/2002
ATTACHMENT A
REQUIRED INTERNAL/EXTERNAL CODING REFERENCE MATERIALS AND TOOLS
ACUTE MEDICAL/SURGICAL HOSPITALS/HOSPITAL BASED PROGRAMS
FACILITY PURCHASE
- International Classification of Diseases 9th Edition, Clinical Modification (ICD-9-CM), any edition, updated to current year
- Current Procedural Terminology (CPT), any edition, updated to current year
- Medical Dictionary
- Medical Acronyms and Abbreviations List- updated within the last 3 years
- Anatomy and Physiology Book - published within the last 5 years
- Drug Reference Tool - including MicroMedix or a nursing drug book-published within the last year
- Disease Process Manual (e.g., Merck Manual or Current Medical Diagnosis and Treatment)
- Healthcare Current Procedural Classification System (HCPCS) Level II National Codes and Healthcare Current Procedural Classification System Level III Local Codes (obtain from local FI or carrier)
COMPANY PURCHASE/PRODUCE AND DISTRIBUTE
1.Diagnosis Related Group Definitions Manual, current version
Approved Vendor: 3M
2.ICD-9-CM Coding Handbook with Answers
Approved Vendor: AHA (sole-provider)
3.AHA Coding Clinic for ICD-9-CM, -paper and/or electronic version (1984 – present)
Approved Vendor: AHA (sole-provider)
4.CPT Assistant, paper and/or electronic version (1990 – present)
Approved Vendor: AMA (sole-provider)
5.Health Information Management Update
6.Outpatient Coding Reference Manual – current year
7.Medicare Keynotes,paper and/or electronic version (currently available)
8.DRG Grouper/Software, current version,(3M )
9.HIMS Videotape series, total of 7
10.Coder’s Desk Reference: Medicode (sole-provider) (company will purchase and distribute every 2 years)
11.APC Grouper/Software, current version, (3M)
12.Interventional Radiology Coding User’s Guide – published by SCVER, ACR, RBMA, AND AHRA
13.DRG Expert, current year, St. Anthony’s Publishing
14.DRG Auditor, current year, St. Anthony’s Publishing
15.DRG Companion, current year, St. Anthony’s Publishing
ATTACHMENT B
REQUIRED INTERNAL/EXTERNAL CODING REFERENCE MATERIALS AND TOOLS
AMBULATORY SURGERY CENTERS
FACILITY PURCHASE
1.International Classification of Diseases 9th Edition, Clinical Modification (ICD-9-CM), any edition, updated to current year, volumes 1, 2, & 3
2.Current Procedural Terminology (CPT), any edition, updated to current year
3.Healthcare Current Procedural Classification System (HCPCS) Level II National Codes and Healthcare Current Procedural Classification System Level III Local Codes (obtain from local FI or carrier)
4.Medical Dictionary
5.Medical Acronyms and Abbreviations Reference- updated within the last 3 years (e.g., Coder’s Desk Reference published by Medicode, Common Medical Abbreviationsby Luis R. DeSousa published by Delmar Publishers)
6.Anatomy and Physiology Book - published within the last 5 years
7.Drug Reference Tool - including MicroMedix, Physician’s Desk Reference or a nursing drug book-published within the last year
8.Disease/Treatment Manual (e.g., Current Surgical Diagnosis and Treatment, Current Diagnosis and Treatment in Orthopedics) published within the last 5 years
COMPANY PURCHASE/PRODUCE AND DISTRIBUTE
1. CPT Assistant, paper and/or electronic version
Approved Vendor: AMA (sole-provider)
2.Health Information Management Update
- Outpatient Coding Reference Manual – current year
- Coder’s Desk Reference: Approved Vendor: Medicode (sole-provider) (company will purchase and distribute every 2 years)
- HIMS Video Tapes (available upon request if applicable to facility needs)
ATTACHMENT C
APPROVED EXTERNAL CODING REFERENCE MATERIALS AND TOOLS
Clinical Specialty Series:
Current Diagnosis & Treatment in Gastroenterology – published by Appleton and Lange
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 Physiology
Human Anatomy and Physiology, 4th Edition- published 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, 2nd Ed. 1997, 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 – published by Appleton and Lange
Griffith’s Five Minutes Medical Consultby Mark Dambro
CPT Specialty Books by Body System
Coding Illustrated Series (examples: The Spine, Hip and Knee) – published by Medicode
Coder’s Desk Reference – Pathology/Laboratory – published by Medicode
Complete Global Service Data for Orthopaedic Surgery - published by the American Academy of OrthopaedicSurgeons
Interventional Radiology Coderby Jeff Majchrzak, BA, RT(R), NMTCB.
CPT Specialty Books – General
CPT Coding Companion – published by the American Medical Association
Principles of CPT Coding – published by the American Medical Association
St. Anthony’s Guide to APC and ASC Groups – published by St. Anthony’s
CPT Made Easy – published by Aspen
CPT Coding Workbook & CPT Coding Workbook Teaching Tips and Exercise Answers - published by MedLearn
Complete Coding Tutor, published by St. Anthony’s
Coding in Context, Case Studies for Advanced Practice, published by AHIMA
Attachment to HIM.COD.003