DEPARTMENT: Health Information Management Services / POLICY DESCRIPTION: Coding Orientation and Training
PAGE:1 of 4 / REPLACES POLICY DATED: 3/6/98, 4/16/98, 8/1/00, 1/1/01, 6/1/2002, 12/15/2002
EFFECTIVE DATE: March 1, 2004 / 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 Human Resources Department
Ethics and Compliance Officers External Coder Vendors
Case Management/Quality Resource Management Patient Access
Ambulatory Surgery Centers/Business Service Centers
Office/Medical Records
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 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 CIA Billing Continuing Education Requirements Policy, GOS.GEN.007. Refer to specific policies for the applicability and education requirements.
For newly purchased facilities, timelines for completion of coding education and training requirements will be the same as defined in this policy unless otherwise directed by the Company’s Acquisition/Transition team.
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 (Healthcare Common Procedure Coding Systems).
PROCEDURE:
1.All new employees involved in the final ICD-9-CM and CPT 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:
  1. The Coding Documentation for Inpatient Services Policy, HIM.COD.001.
  2. The Coding Documentation for Outpatient Services Policy, HIM.COD.002.
  3. The Query Documentation for Inpatient Services Policy, HIM.COD.012
  4. The Coding Documentation for Skilled Nursing Facilities/Units Policy, HIM.COD.010.
  5. The Coding Documentation for Rehabilitation Facilities/Units Policy, HIM.COD.013
  6. The Company’s Special Coding Practices on ICD-9-CM Code 482.83 Policy.
  7. All facility-specific coding policies and procedures.
2.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.
3.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.
4.Guidelines for use and phone numbers for the 3M Nosology Coding Help Line and the Ethics Line will also be provided.
5.The required resources will be reviewed, as applicable to position responsibility, and made available to the coding staff prior to coding. Unless otherwise noted, the references mentioned below must reflect the most currently published edition:
  1. ICD-9-CM Coding Book
  2. Physician’s Current Procedural Terminology Book (CPT)
  3. AHA Coding Clinics for ICD-9-CM Coding (1984-present)
  4. Health Information Management Update (May 1995 to present)
  5. DRG Definition Manual
  6. Coder’s Desk Reference
  7. ICD-9-CM Coding Handbook with Answers
  8. Outpatient Coding Reference Manual
  9. CPT Assistant (1990-present)
  10. Medicare Keynotes (also available electronically)
  11. Medical Dictionary
  12. Medical Acronyms and Abbreviations List
  13. Anatomy and Physiology Book
  14. Drug Reference Tool
  15. Disease Process Book DRG Expert, current year, St. Anthony’s Publishing
  16. DRG Auditor, current year, St. Anthony’s Publishing
  17. DRG Companion, current year, St. Anthony’s Publishing
  18. Interventional Radiology Coding User’s Guide, current year, Society of Interventional Radiology, the American College of Radiology, the Radiology Business Management Association, and the American Healthcare Radiology Administrators
6.The following videotapes with workbook should be reviewed, by full time, part time and solo practitioners as applicable to position responsibility, within two weeks of employment. External coding vendors other than solo practitioners may also be included at the discretion of the facility:
  1. Complete and Accurate Coding Using Diagnostic Test Findings “Laboratory Test”
  2. Complete and Accurate Coding Using Diagnostic Test Findings “Imaging”
  3. Complete and Accurate Coding Using Diagnostic Test Findings “Cardiology”
  4. Anatomy and Physiology “Respiratory System”
  5. Anatomy and Physiology “Gastrointestinal System”
  6. Anatomy and Physiology “Cardiovascular System”
  7. Arthroscopic Shoulder and Knee Procedures ICD-9-CM/CPT Physician Presentation
7.All coders will be given an orientation to all applicable computer systems (i.e., Clinical Patient Care System (CPCS) and 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 for full time and part time employees and solo practitioners 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 CIA Billing Continuing Education Requirements Policy, GOS.GEN.007, and must be entered in the Learning Management System (LMS). External coding vendors other than solo practitioners may also be included at the discretion of the facility.
12.Corporate Health Information Management Services will monitor the education files.
13.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 Documentation for Inpatient Services Policy, HIM.COD.001
Coding Documentation for Outpatient Services Policy, HIM.COD.002
Coding Continuing Education Requirements Policy, HIM.COD.006
Coding Documentation for Skilled Nursing Facilities/Units Policy, HIM.COD.010
Query Documentation for Inpatient Services Policy, HIM.COD.012
Coding Documentation for Rehabilitation Facilities/Units Policy, HIM.COD.013
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
CIA Billing Continuing Education Requirements Policy, GOS.GEN.007
The Company’s Special Coding Practices on ICD-9-CM Code 482.83 policy

2/2004

Attachment A

Orientation Checklist

Scope: All full-time and part-time employees, and solo practitioner responsible for performing the final inpatient or outpatient coding process must have an orientation checklist completed. External coding vendors other than solo practitioners may also be included at the discretion of the facility

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 because it is not applicable to position responsibility or is not mandatory because the individual is an external coding vendor (other than solo practitioner). For any items determined NA, written documentation denoting the reason the item was NA must be provided.

Coder’s Name: ______

Hire/Transfer Date: ______

Coding Start 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

4.Review of Query Policy for Inpatient Services

5.Review of the Query Handbook

6.Review of Coding/Documentation Policy for Skilled Nursing Facilities/Units

7.Review of Coding/Documentation Policy for Rehabilitation Facilities/Units

8.Review of Special Coding Practices for ICD-9-CM Code 482.83 Policy

9.Review of Coding/Documentation______ Policy for Outpatient Services ______

10.Review of Facility Specific

Coding Policies and Procedures ______

11.Name and phone number of

Corporate HIMS Consultant ______

Attachment to HIM.COD.005

SupervisorCoderDateN/A

12.Guidelines and phone number ______

for 3M Coding Helpline, Ethics Line,

HIMS P&P Helpline and

Billing Helpline.

13.Location of following resources:

a. ICD-9-CM Code Book______

b.CPT Code Book______

c.Coding Clinic ______

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______

14.Orientation to Computer System ______

15.Overview of Coding quality and

quantity reports______

Within Two Weeks (as applicable)

1. Remainder of the

HIM/Coding Policies in the

Ethics and Compliance Policy

and Procedure Manual______

SupervisorCoderDateN/A

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______

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