Health Information Management

Construct and maintain a hospital-specific coding manual

HIM-HIPAA Insider, May 19, 2009

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Every hospital should develop and maintain its own internal coding manual. It’s an essential tool to ensure good coding quality and compliance. Although your department must have all the official manuals (i.e., the CPT Manual, the ICD-9-CM Manual, and the HCPCS Manual), an internal coding manual provides much more information, including the following:

  • Reference guide for coders
  • Backup in case of a compliance audit
  • Source for policies and procedures
  • External/internal audit information
  • Definitions of coding terminology

The following is a checklist you can use as a guide to help develop your own coding manual:

  • Coding scope of service and ethical standards
  • Coding protocols (use of coding manuals, encoder, and medical record as the source document)
  • Coding accuracy
  • AHIMA’s standard of ethical coding
  • Definitions of coding terms
  • Coding classification systems
  • Use of outside consultants
  • Orientation checklist
  • System-wide corporate compliance
  • Rebill policy
  • Job descriptions
  • Other policies
  • Tips for the medical staff
  • Resources

Editor’s note: This article was adapted from HCPro’s book, The HIM Director’s Handbook, by Jean S. Clark, RHIA. For more information, visit the HCPro Web site.



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