COLUMBIA/HCA
DEPARTMENT: Health Information
Management Services
PAGE: 1 of 2
APPROVED: March 16, 1999
EFFECTIVE DATE: April 16, 1999
POLICY DESCRIPTION: Coding Orientation and
Training
REPLACES POLICY DATED: March 6, 1998
RETIRED:
REFERENCE NUMBER: HIM.COD.005
SCOPE:
All personnel responsible for performing, supervising or monitoring coding/claims processing of
inpatient and outpatient services including, but not limited to:
Emergency Department
Radiology Department
Health Information Management Services
Registration/Admitting/Scheduling
Case Management/Quality Resource Management
Laboratory Department
Human Resources Department
Health Information Management
Ancillary Departments
Administration
Internal Audit & Consulting Services
Business Office
Ethics and Compliance Officer
PURPOSE:
To orient all new coders to the company’s coding policies and procedures, tools and resources,
and education and training programs.
POLICY:
The Company will provide an orientation and training session to all personnel involved in the
final ICD-9-CM and CPT- 4 coding process to ensure an awareness of the support provided by
the Company to effectively classify our patients for purposes to include but not limited to vital
statistics, mortality reporting, physician profiling, outcome measurements and for many third
party reimbursement systems, including Medicare.
PROCEDURE:
1. 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 prior to
performing any coding:
a) The Company’s Coding Documentation Policy for Inpatient Services (Refer to Policy
Number HIM.COD.001)
b) The Company’s Coding Documentation Policy for Outpatient Services (Refer to Policy
Number HIM.COD.002)
c) All Facility specific coding policies and procedures.
2. The Company’s HIM/Coding Policy and Procedure Manual will be reviewed and
acknowledged within two weeks of employment.
3. The name and phone number of the Health Information Management Services Department
Consultant will be provided.
4. Guidelines for use and phone numbers for the Coding Help Line and the Ethics Line will also
be provided.
04/16/1999
COLUMBIA/HCA
DEPARTMENT: Health Information
Management Services
PAGE: 2 of 2
APPROVED: March 16, 1999
EFFECTIVE DATE: April 16, 1999
POLICY DESCRIPTION: Coding Orientation and
Training
REPLACES POLICY DATED: March 6, 1998
RETIRED:
REFERENCE NUMBER: HIM.COD.005
5. The availability of the following resources will be reviewed, as applicable to position
responsibility, and made available to the coding staff prior to coding:
a) ICD-9-CM Coding Book
b) Physician’s Current Procedural Terminology Book (CPT)
c) AHA Coding Clinics for ICD-9-CM Coding (1984-present)
d) Coding Classification 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
6. The following videotapes with workbook will be reviewed, as applicable to
position/responsibility, within two weeks of employment
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 ICD-9-CM/CPT-4 Physician Presentation
h) CPT 4/HCPCS Modifiers Video
7. All coders will be given an orientation to all applicable computer systems (i.e., Columbia
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. Health Information Management Services and/or Internal and Audit & Consulting Services
will monitor the education files.
REFERENCES:
04/16/1999
Attachment A
Orientation Checklist
Scope: All 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 check and initial under the appropriate
column for each designated task. The date the task was achieved must be completed by the
supervisor. The supervisor will indicate NA (not applicable) in the date column for any resource
and/or videotape not reviewed due to the fact it is not applicable to position responsibility.
Coder’s Name: ______________________________________________________________
Hire Date: __________________________________________
Prior to beginning the coding process:
Supervisor
Coder
Date
1. Orientation to the facility
__________
___________
_____________
2. Orientation to the department
__________
___________
_____________
3. Review of Coding/Documentation
Policy for Inpatient Services
__________
___________
_____________
4. Review of Coding/Documentation
Policy for Outpatient Services
__________
___________
_____________
6. Name and phone number of
Health Information Services
Consultant
__________
___________
_____________
7. Guidelines and phone number
for Coding Helpline
__________
___________
______________
8. Guidelines and phone number
for Ethics Line.
__________
___________
______________
9. Availability of following resources:
a. ICD-9-CM Code Book
__________
___________
______________
b. CPT Code Book
__________
___________
______________
c. Coding Clinic
__________
___________
______________
5. Review of Facility Specific
Coding Policies and Procedures
Attachment to HIM.COD.005
Supervisor
Coder
Date
d. CPT Assistant
__________
___________
_______________
e. DRG Definition Manual
__________
___________
_______________
f. Coding Handbook
__________
___________
_______________
g. Medical Dictionary
__________
___________
_______________
h. Medical Acronyms and
Abbreviations List
__________
___________
_______________
i.
Anatomy and Physiology
__________
___________
_______________
j.
Drug Reference Tool
__________
___________
_______________
__________
___________
_______________
Coding Classification Update __________
___________
_______________
m. Inpt Coding Reference Manual__________
___________
_______________
n. Outpt Coding Reference Man. __________
___________
_______________
o. Medicare Keynotes
__________
___________
_______________
10. Orientation to Computer System
__________
___________
_______________
11. Overview of Coding quality and
quantity reports
__________
___________
_______________
Within Two Weeks
1. Remainder of the Company’s
HIM/Coding Policy and
Procedure Manual
__________
___________
_______________
2. Review the following coding
videotapes:
a. Complete and Accurate Coding
Using Diagnostic Test Findings:
Laboratory Test
__________
___________
________________
___________
________________
___________
________________
k. Disease Process Book
l.
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
___________
___________
________________
Attachment to HIM.COD.005
Supervisor
Coder
Date
f. Anatomy and Physiology:
Cardiovascular System
___________
___________
________________
g. Arthroscopic Shoulder and
Knee Procedures
___________
___________
________________
h. CPT-4/HCPCS Modifier
___________
___________
________________
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