COLUMBIA/HCA
DEPARTMENT: Health Information
Management Services
PAGE: 1 of 2
APPROVED: March 16, 1999
EFFECTIVE DATE: April 16, 1999
POLICY DESCRIPTION: Coding References
and Tools
REPLACES POLICY DATED: March 6, 1998
RETIRED:
REFERENCE NUMBER: HIM.COD.003
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
Materials Management
Information Systems
Health Information Management
Ancillary Departments
Administration
Internal Audit & Consulting Services
Business Office
Ethics and Compliance Officer
Legal
Human Resources Department
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:
Health Information Management Services, with assistance from Corporate Materials
Management, the Corporate Legal Department and Corporate Information Systems, will
approve and oversee the purchase of coding reference materials and tools.
PROCEDURE:
1. Minimum required reference materials and tools are listed on Attachment A.
2. The facility Health Information Management Director can directly purchase any reference
materials and tools on the approved reference list.
a) For those required products which are not distributed by HIMS, the facility HIM
Director with assistance from facility Purchasing, must ensure that reference tools are
purchased and available.
b) The facility standard protocol must be followed to place the order, pay for the product
and ensure receipt.
3. Reference materials and tools 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 Health Information Management Director is not receiving these reference
materials and tools, contact HIMS support staff at 615-344-1830.
c) For reference materials and tools which are distributed directly by HIMS, the facility
04/16/1999
COLUMBIA/HCA
DEPARTMENT: Health Information
Management Services
PAGE: 2 of 2
APPROVED: March 16, 1999
EFFECTIVE DATE: April 16, 1999
4.
5.
6.
7.
8)
POLICY DESCRIPTION: Coding References
and Tools
REPLACES POLICY DATED: March 6, 1998
RETIRED:
REFERENCE NUMBER: HIM.COD.003
will be intercompany billed the discounted rate of the product. The discounted rate for
these products are included in the Budget Directives provided to the facility’s Chief
Financial Officer.
A grouper/DRG software product will be required for all acute medical/surgical facilities.
Health Information Management Services and Internal Audit & Consulting Services will be
auditing and reporting the availability and accessibility of required reference materials and
tools.
Approved, but not required, reference materials and tools are listed on Attachment B.
If the facility’s Health Information Management 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 Health Information Management Director should prepare a memorandum to
Health Information Management Services Department, Attn: Coding Services Director,
One Park Plaza, Nashville, TN, 37202 .
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 IS (if 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 listing.
e) If not approved, a written denial outlining the reasons will be completed by the HIMS
Coding Services Director and returned to the facility Health Information Management
Director.
HIMS will create and maintain a listing of all required references and tools as well as
approved reference and tools. These listings will be updated a minimum of once per year
during the annual policy and procedure revision process.
REFERENCES:
04/16/1999
ATTACHMENT A
REQUIRED INTERNAL/EXTERNAL CODING REFERENCE MATERIALS AND TOOLS
FACILITY PURCHASE
1. International Classification of Diseases 9th Edition, Clinical Modification (ICD-9-CM), any edition,
updated to current year
2. Current Procedural Terminology (CPT-4), any edition, updated to current year
3.
Medical Dictionary
4.
Medical Acronyms and Abbreviations List- updated within the last 3 years
5.
Anatomy and Physiology Book - published within the last 5 years
6. Drug Reference Tool - including MicroMedix or a nursing drug book-published within the last year
7. Disease Process Manual (e.g., Merck Manual or Current Medical Diagnosis and Treatment)
8.
HCFA Current Procedural Classification System (HCPCS) Level II National Codes and HCFA Current
Procedural Classification System Level III Local Codes (obtain from local FI or carrier)
COMPANY PURCHASE/PRODUCE AND DISTRIBUTE
9.
Diagnosis Related Group Definitions Manual, current version
Approved Vendor: 3M
10. ICD-9-CM Coding Handbook with Answers
Approved Vendor: AHA (sole-provider)
11. AHA Coding Clinic for ICD-9-CM, 1984 - present -paper and/or electronic version
Approved Vendor: AHA (sole-provider)
12. CPT Assistant, 1990 - present-paper and/or electronic version
Approved Vendor: AMA (sole-provider)
13. Coding Classification Update Newsletter/ ASC Newsletter
14. Inpatient Coding Reference Manual – current year
15. Outpatient Coding Reference Manual – current year
16. Medicare Keynotes, currently available and/or electronic version
Attachment to HIM.COD.003
17. DRG Grouper/Software, current version, 3M )
18. Videotape series, total of 7
19. Coder’s Desk Reference
Approved Vendor: Medicode
Attachment to HIM.COD.003
ATTACHMENT B
APPROVED EXTERNAL CODING REFERENCE MATERIALS AND TOOLS
Clinical Cardiology and Other Specialty Series
(e.g., Appleton and Lange)
Clinical Laboratory Tests, Values and Implications
(e.g., Springhouse)
General Surgery Textbook
(e.g., W.B. Saunders Company, Little Brown & Company)
General Internal Medicine Textbook
CPT Specialty Books by Body System
(e.g., Medicode)
Global Orthopedic Services Manual
Attachment to HIM.COD.003