Table of Contents

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Notice of Nondiscrimination Policy

Welcome

Introduction

Accreditation

Mission and Goals

Organizational Chart

Program Description

Program Length

Program Progression

Time Management

Health Information Technology Entry Level Competencies

Model Schedule

Admission Requirements

Academic Policies

Academic Misconduct

Credit for Work Experience

Grade Appeal Process

Grade Change

Grading for Professional Practice Externships

Grading Scale for HIT Core Lecture/Laboratory Courses

Incomplete Grades

Student Complaint Process

Transfer of College Credit

Health Information Technology Program Policies

Accountability Process

Attendance

Attire

Change of Name, Contact Information

Communications

Credit for Certified Coding Specialists or Certified Coding Associates

Dismissal

Electronic Devices

Emergencies

Employment

Make-up Work

Noncompliance with Policies

Policy Changes

Professional Conduct

Proof of Credentials

Repeating HIT Courses

Reinstatement

Student Records

Student Responsibility for Learning

Testing

Textbooks

Transportation

Web-enhancement

Health and Safety Policies

Background Check

HIPAA

Inclement Weather

Immunizations

Physical Examination

Professional Liability Insurance

Universal Precautions and Blood borne Pathogens Training

Professional Practice Externship Policies

PPE Attendance

HIPAA and Confidentiality

Professional Behavior

Professional Ethics

Service Work

Site Change

Universal Precautions

Student Resources

SC4 Resources

St. Clair County Community College Library

External Resources

Technology

Virtual Lab

Personal Computers

Ethics

American Health Information Management Associations Code of Ethics

Preamble, Code of Ethics

The Code of Ethics 2011 Ethical Principles and How to Interpret Them

Principles and Guidelines, Code of Ethics Interpretation

The Use of the Code of Ethics

Standards of Ethical Coding

Introduction, Standards of Ethical Coding

Standards of Ethical Coding Guidelines

How to Interpret the Standards of Ethical Coding

Notice of Nondiscrimination Policy

It is the policy of St. Clair County Community College that no person shall, on the basis of race, color, national origin, sex, handicap, age, religion, creed or marital status be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, and in employment.

Any questions concerning Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, which prohibits discrimination on the basis of sex, or any inquiries related to Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of handicap, should be directed to:

Director of Human Resources and Labor Relations
Title VI, Title IX and Section 504 Coordinator
St. Clair County Community College
323 Erie Street, PO Box 5015
Port Huron, MI  48061-5015
(810) 989-5536 or (800) 553-2427

Welcome

No one can ever reach to excellence in any one art or profession without having passed through the slow and painful process of study and preparation. -Horace

Congratulations! You have chosen to pursue a career in Health Information Management (HIM). Many have made the same decision, and have gone on to have extremely fulfilling careers. You, too, will find a huge number of possibilities, and many prospects for continued growth.

The HIM field is facing a crisis in our country. Healthcare reform, digitization of health information, new coding nomenclatures, mandated Health Information Exchange programs and aging Baby Boomers are all contributing to a major shortage of HIM professionals in the next few years. Many veterans of the field feel we are only seeing the tip of the iceberg. This allows for many opportunities for different personalities, interests and educations levels.

However, it will not be easy. As the quote above says, you can’t have excellence without study and preparation, and at times it will be painful. But, you can, and will, survive the process! The staff of the HIT program and SC4 is here to assist you in attaining success. This handbook has been designed to assist you through your journey in the HIT program. Understanding the policies and expectations of the program are vital to your success as a student. Keep in mind, it is your responsibility to know, understand and follow the guidelines in this handbook, as well as information in the SC4 catalogue, SC4 Student Handbook and the SC4 website.

Enjoy your HIT adventure!

The Health Information Technology Associate Degree program is accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).

Mission and Goals

The St. Clair County Community College Health Information Technology program is dedicated to supporting the mission and vision of the College. Health Information Technology staff and faculty strive to equip students with the tools to become highly-qualified, competent, knowledgeable and ethical Health Information Management professionals who will support a revitalization of our community. It is our goal to form committed partnerships with educators and healthcare providers in the Southeastern Michigan area to provide students with a relevant and robust education in the Health Information Management field, and produce students who will meet the needs of the global health community.

Organizational Chart

Student ⇒ Instructor(s) and Adjunct or PPE Site Coordinator ⇒ Program Director, Health Information Technology ⇒ Director of Health and Human Services ⇒ Vice President of Academic Services

Program Description

The Associate Degree in Health Information Technology (HIT) prepares students to enter the Health Information Management profession. Upon successful completion of the program, graduates will be prepared for employment in entry-level positions in a variety of healthcare settings, including acute care hospitals, skilled nursing facilities, physician practices, rehabilitation centers, clinics, private consulting firms and veterinary medicine facilities. There are also many opportunities in the non-traditional setting such as law firms, insurance companies and pharmaceutical companies. Graduates may be employed in a variety of roles, including coder, electronic health record specialist, decision support specialist, regulatory/compliance specialist and release of information specialist, to name a few. Graduates completing this program are also prepared to pursue their Bachelor of Science Degree in Health Information Management, if so desired. This is a two-year program and includes both liberal arts and HIT courses. However, a student may choose to complete any of the liberal arts courses prior to admission to the HIT program.

Program Length

The Saint Clair County Community College Health Information Technology program is a full time, two-year degree program which, when successfully completed, results in the student receiving an Associate of Applied Science degree.

In order to progress successfully through the Health Information Technology program, student must:

• Achieve a 2.0 (‘C’) or better in all core Health Information Technology courses
• Achieve a ‘Satisfactory’ rating for all Professional Practice Externships
• Take courses in the order prescribed in the model schedule

Time Management

Disciplined time management will be imperative for the successful completion of the Saint Clair County Community College Health Information Technology program. Each student’s success will be directly dependent upon his/her level of personal commitment. A general rule is that for each credit hour you take, you should expect to spend, at a minimum, two (2) to three (3) hours per week preparing for class.

Upon successful completion of the Saint Clair County Community College Health Information Technology program (‘C’ or above), students should be able to demonstrate the following entry-level Health Information Technology competencies:

1. Data Content Structure and Standards
   1. Classification Systems
      1. Apply diagnosis/procedure codes according to current guidelines
      2. Evaluate the accuracy of diagnostic and procedural coding
      3. Apply diagnostic and procedural groupings
      4. Evaluate the accuracy of diagnostic/procedural groupings
   2. Health Record Content and Documentation
      1. Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status
      2. Verify the documentation in the health record is timely, complete, and accurate
      3. Identify a complete health record according to, organizational policies, external regulations, and standards
      4. Differentiate the roles and responsibilities of various providers and disciplines, to support documentation requirements, throughout the continuum of healthcare
   3. Data Governance
      1. Apply policies and procedures to ensure the accuracy of health data
   4. Data Management
      1. Collect and maintain health data
      2. Apply graphical tools for data presentations
   5. Secondary Data Sources
      1. Identify and use secondary data sources
      2. Validate the reliability and accuracy of secondary data sources
2. Information Protection: Access Disclosure, Archival, Privacy and Security
   1. Health Law
      1. Apply healthcare legal terminology
      2. Identify the use of legal documents
      3. Apply legal concepts and principles to the practice of HIM
   2. Data Privacy Confidentiality and Security
      1. Apply confidentiality, privacy and security measures and policies and procedures for internal and external use and exchange to protect electronic health information
      2. Apply retention and destruction policies for health information
      3. Apply system security policies according to departmental and organizational data/information standards
   3. Release of Information
      1. Apply policies and procedures surrounding issues of access and disclosure of protected health information
3. Informatics, Analytics and Data Use
   1. Health Information Technologies
      1. Utilize software in the completion of HIM processes\
      2. Explain policies and procedures of networks, including intranet and Internet to facilitate clinical and administrative applications
   2. Information Management Strategic Planning
      1. Explain the process used in the selection and implementation of health information management systems
      2. Utilize health information to support enterprise wide decision support for strategic planning
   3. Analytics and Decision Support
      1. Explain analytics and decision support
      2. Apply report generation technologies to facilitate decision-making
   4. Health Care Statistics
      1. Utilize basic descriptive, institutional, and healthcare statistics
      2. Analyze data to identify trends
   5. Research Methods
      1. Explain common research methodologies and why they are used in healthcare
   6. Consumer Informatics
      1. Explain usability and accessibility of health information by patients, including current trends and future challenges
   7. Health Information Exchange
      1. Explain current trends and future challenges in health information exchange
   8. Information Integrity and Data Quality
      1. Apply policies and procedures to ensure the accuracy and integrity of health data both internal and external to the health system
4. Revenue Management
   1. Revenue Cycle and Reimbursement
      1. Apply policies and procedures for the use of data required in healthcare reimbursement
      2. Evaluate the revenue cycle management processes
5. Compliance 
   1. Regulatory
      1. Analyze policies and procedures to ensure organizational compliance with regulations and standards
      2. Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification
      3. Adhere to the legal and regulatory requirements related to the health information management
   2. Coding
      1. Analyze current regulations and established guidelines in clinical classification systems
      2. Determine accuracy of computer assisted coding assignment and recommend corrective action
   3. Fraud Surveillance
      1. Identify potential abuse or fraudulent trends through data analysis
   4. Clinical Documentation Improvement
      1. Identify discrepancies between supporting documentation and coded data
      2. Develop appropriate physician queries to resolve data and coding discrepancies
6. Leadership
   1. Leadership Roles
      1. Summarize health information related leadership roles
      2. Apply the fundamentals of team leadership
      3. Organize and facilitate meetings
   2. Change Management
      1. Recognize the impact of change management on processes, people and systems
   3. Work Design and Process Improvement
      1. Utilize tools and techniques to monitor, report, and improve processes
      2. Identify cost-saving and efficient means of achieving work processes and goals
      3. Utilize data for facility-wide outcomes reporting for quality management and performance improvement
   4. Human Resource Management
      1. Report staffing levels and productivity standards for health information functions
      2. Interpret compliance with local, state, and federal labor regulations
      3. Adhere to work plans, policies, procedures, and resource requisitions in relation to job functions
   5. Training and Development
      1. Explain the methodology of training and development
      2. Explain the return on investment for employee training and development
   6. Strategic and Organizational Management
      1. Summarize a collection methodology for data to guide strategic and organizational management
      2. Understand the importance of healthcare policy-making as it relates to the healthcare delivery system
      3. Describe the differing types of organizations, services, and personnel and their interrelationships across the health care delivery system
      4. Apply information and data strategies in support of information governance initiatives
      5. Utilize enterprise-wide information assets in support of organizational strategies and objectives
   7. Financial Management
      1. Plan budgets
      2. Explain accounting methodologies
      3. Explain budget variances
   8. Ethics
      1. Comply with ethical standards of practice
      2. Evaluate the consequences of a breach of healthcare ethics
      3. Assess how cultural issues affect health, healthcare quality, cost, and HIM
      4. Create programs and policies that support a culture of diversity
   9. Project Management
      1. Summarize project management methodologies
   10. Vendor/Contract Management
       1. Explain Vendor/Contract Management
   11. Enterprise Information Management
       1. Apply knowledge of database architecture and design

Behavior

Model Schedule

Pre-Requisites to Program Admission
Course Number	Course Title	Credit Hours	Contact Hours
BIO 271	Human Anatomy/Physiology I	4	5
HE 102	Medical Terminology	2	2
CIS 114*	Computer Applications for Healthcare Professionals	4	4
ENG 101	English Composition I	3	3
MTH 104**	Foundations of Math	4	4
	Semester Totals	17	18

1st Semester - Fall
Course Number	Course Title	Credit Hours	Contact Hours
BIO 272	Human Anatomy/Physiology II	4	5
HE 110	Pharmacology for Allied Health	2	2
HIT101	Introduction to Health Information Tech	4	4
HIT102	Legal Aspects of HIT	3	3
	Semester Totals	13	14

2nd Semester - Winter
Course Number	Course Title	Credit Hours	Contact Hours
BIO 280	Pathophysiology	4	5
HIT107	ICD-10-PCS Coding	3	3
HIT104	Ethical Challenges in HIT	2	2
HIT106	Health Information Technology II	4	4
	Semester Totals	13	13

3rd Semester - Fall
Course Number	Course Title	Credit Hours	Contact Hours
HIT 105	CPT/HCPCS Coding	3	3
HE 208	ICD-10-CM Coding I	4	4
HIT 202	Quality Management & Regulatory Compliance	4	4
HIT 205	Health Informatics	3	3
	Semester Totals	15	15

4th Semester - Winter
Course Number	Course Title	Credit Hours	Contact Hours
PS 101	Introduction to Political Science	3	3
HIT 203	Reimbursement Methodologies	3	3
HIT 204	HIT PPE	2	2
HIT 205	Legal Aspects of HIT	3	3
HIT 209	ICD-10-CM Coding II	4	4
	Semester Totals	15	15

Admission Requirements

Admission to the Saint Clair County Community College does not automatically qualify a student for admission to the Health Information Technology program.

Admission requirements for the Health Information Technology program include:

1. Meeting current requirements and completing all procedures for admission to SC4.
2. Achieving placement into MTH 104 Foundations of Math by assessment testing or ACT scores or higher.
3. Completing the following courses within the last five (5) years with a 2.0 (‘C’) or better:
   1. BIO 271 Human Anatomy and Physiology I OR BIO 160 Anatomy and Physiology for Health Care Professionals/BIO 272 Human Anatomy and Physiology II combination
   2. CIS 114 Computer Applications for Healthcare Professionals or CIS 115 Microcomputer Applications
   3. HE 102 Medical Terminology
4. Submit a secondary application for admission to an SC4 Allied Health Program

The student is responsible for his/her own learning. The Health Information Technology (HIT) faculty is available to assist and support each student in mastering the competencies of the HIT program. The faculty believes academic integrity is essential to the development of professional conduct. Students engaging in acts of academic dishonesty such as cheating or plagiarism, compromise the culture of integrity which defines the HIT profession. Students who choose to violate academic integrity erode the foundation of trust between the students, faculty, clients and community they serve.

St. Clair County Community College (SC4) considers academic honesty to be essential to all academic performance. The policy of the college states that instances of academic dishonesty will be treated as serious offenses of the Student Code of Conduct. Students involved in activities such as cheating and/or plagiarism will be subject to disciplinary action up to and including dismissal.

• Definition of Plagiarism:  Plagiarism is the appropriation of language, thoughts or ideas of another author and claiming that as one’s own. Plagiarism is work not produced by the student, or work that does not credit borrowings from the original source(s).
• Definition of Cheating:  Cheating can be, but is not limited to, a student using electronic technology, notes or other written materials not permitted by the instructor; looking at other students’ papers without the instructor’s permission; requesting answers from other students; or working with other students when independent work is required. Situations where cheating may occur are during tests, exams, quizzes or other similar methods of evaluation.

Cheating is further defined in the HIT department as fraud, deceit or dishonesty in any academic or clinical activity. It may include, but is not limited to:

• Copying, or attempting to copy, from others during testing or for an assignment;
• Communicating any testing information to, or receiving such information from, another person prior, during or following an exam or test;
• Using, attempting to use or assisting others in using materials that are prohibited or inappropriate in the context of the assignment or examination in question, such as:  books, prepared answers, written notes, concealed information or web sites (including cutting and pasting from web sites);
• Copying the work of another person, including a peer or an author of a published book, pamphlet or article, and turning it in as one’s own. Quotations, statistics and other factual data from someone else’s work must be annotated as such by documentation of the authoritative source;
• Allowing others to do one’s assignment or a portion of one’s assignment; or using a commercial term paper service;
• Altering an assignment after it has been completed or altering recorded grades;
• Resubmitting a previously written assignment for a new course without the permission of the prior and current instructor;
• Misrepresenting performance or falsifying documentation related to the performance of any activity required to complete course/curriculum objectives

Cheating will not be tolerated in class. You are not to share test questions, class/simulation activity answers, quiz information, etc. All work submitted must be original, and any sources utilized must be appropriately referenced. Violation of academic integrity codes will result in a grade of ‘E’ for the course, as well as dismissal from the HIT program. Students dismissed for academic integrity violations will be ineligible for any future readmission to the SC4 HIT program.

Students may request credit for work experience for PPEs only. Students are required to submit the following six weeks prior to the beginning of the semester in which they will be completing the PPE:

1. Letter of request
2. Resume
3. Current and past job descriptions and detail of all duties
4. Notarized letter on facility letterhead from their employer validating the resume, job description and detail of duties

Once the required documents have been reviewed, credit may or may not be granted. In the event credit is granted, students will be required to pay tuition for the PPE. If a student possesses a current CCS credential and is working in the inpatient coding arena, this will be accepted in lieu of any coding aspects of PPEs. Proof of credentials is required.

Any appeal for a change of grade, other than a final grade, must be initiated in the semester during which the student is enrolled in the course. Appeals of a final grade for the semester must be made prior to the last day of classes of the subsequent semester with the option (student) of excluding spring and summer sessions. There will be no formal grade appeals during the week of final exams or during semester breaks. Grade appeals occurring during the spring and summer sessions will adhere to the process with time lines to be established by the Dean of Students with reasonable flexibility as needed. The only grounds for a student appeal shall be as follows:

1. The grade is allegedly based on an error in calculation.
2. The grade assigned allegedly did not follow the grading criteria as stated in the course syllabus.

It shall be the responsibility of the student to prove that the grade is incorrect or unjustified. A student wishing to file a grade appeal begins by contacting the Vice President of Student Services and/or Director of Behavioral Intervention for information. Procedures for the formal appeal are available online at www.sc4.edu/consumerinformation.

Grade Change

All grade change requests must be initiated within one year following the end of the course(s) for which the grade was officially recorded. No grade change requests will be accepted following the expiration of that period of time.

Grading for Professional Practice Externships

S = Satisfactory
U = Unsatisfactory

Grading for PPEs is pass or fail. This will be determined through completion of all assignments and evaluation from clinical site coordinators.

A = 96% to 100%
A- = 94% to 95%
B+ = 92% to 93%
B = 89% to 91%
B-= 87% to 88%
C+= 84% to 86%
C= 80% to 83%
C-= 78% to 79%
D+ =76% -77%
D = 74%-75%
D-= 73%
E= 72% and below

In order to pass any one of these courses, a ‘C’ must be obtained. To attain a ‘C’, the percentage must be a whole number. Partial percentages will not be rounded up. For example, in order to obtain a ‘C’, the student must achieve no less than 80%; therefore 79.8% is not acceptable.

All requests for incomplete grades will be reviewed by the instructor and HIT administration, and will only be granted (1) if the student qualifies in accordance to the incomplete grade policy outlined in the SC4 catalogue AND (2) in the event of an extreme emergency (defined under ‘Emergencies’ in this section). Students receiving an incomplete grade will not be eligible to continue in the HIT program until such time the grade is changed from incomplete to a satisfactory grade in the SC4 records. The purpose for this policy is to ensure student success. As the HIT core courses are foundational in nature (meaning they build upon one another), students receiving an incomplete grade in a course will not be sufficiently prepared to enter the course HIT core courses in the following semester.

The following guidelines have been established to provide students at St. Clair County Community College with a process for resolving concerns related to the academic environment and/or support services. When a concern arises that is covered by college policy, including sexual harassment, racial or sex discrimination, or those arising under the Americans with Disabilities Act, the issue should be referred to the Office of Human Resources. All others will be handled in the following manner:

1. The student will meet with the faculty or staff member involved to attempt to resolve the concern.
2. If a satisfactory resolution has not been reached, the student has the option to consult with the appropriate academic lead or supervisor.
3. If the issue has not been satisfactorily resolved with the academic lead or supervisor, the student has the option to meet with the next appropriate supervisor for final resolution. Academic environment matters should be addressed to the Vice President of Academic Services and other matters to the Dean of Instruction.
4. The student must provide specific documentation of the resolution efforts and to support issues and concerns related to the complaint.

The SC4 HIT program may accept credit from HIT accredited programs at other institutions. Students are to submit a copy of transcripts, which will be evaluated along with course descriptions, by HIT administration. The criteria used will be:

1. Course description
2. Grade received (must be no less than a 2.0 or ‘C’
3. Course(s) completed within the last five (5) years

Review of credit from other colleges is not a guarantee of acceptance at SC4, and additional assessment may be required. An example of additional assessment is completing a final for the course in question, completing a laboratory project or requiring the student to audit the class.

Background Check

The State of Michigan Public Acts 26, 27, 28 and 29 of 2006 mandates the obtainment of criminal background information, of all individuals who seek employment, independent contractor relationships, students training over 40 hours in total or clinical privileges in positions that provide “direct access” to the consumers served at healthcare facilities. “Direct Access” is defined under Public Acts 26, 27, 28 and 29 of 2006 as access to a patient or resident or to a patient or resident’s property, financial information, medical records, treatment information or any other identifying information. Due to this mandate, all HIT students will be required to submit to a criminal background check at the cost of the student.

Background checks must be completed and submitted to the HIT administration office prior to the beginning of the student’s first fall semester. Background checks will be honored for the duration of the HIT program, unless there is a break in enrollment of one or more semester(s). However, it is the responsibility of the student to immediately notify the HIT administration of any changes in criminal history. Failure to do so will result in immediate dismissal from the HIT program. To that end, students should be aware that PPE sites often run their own criminal background checks as a part of the PPE validation process.

Students must be aware, although having a criminal history does not legally preclude one from becoming an HIT professional, it may make placing a student in a PPE, or securing employment following graduation significantly more difficult.

The Health Insurance Portability and Accountability Act requires all protected health information to be kept confidential and secure by all people responsible who handle or have access to said information. Throughout the education process, HIT students will have access to protected health information, both real and fictional. As the HIT program is providing ‘true-to-life’ scenarios for learning, students are to treat all protected health information as real, maintain the confidentiality and conduct themselves in a professional manner related to dissemination of the information. Students are required to sign a confidentiality agreement at the beginning of the HIT program. Failure to adhere to this agreement may result in dismissal from the HIT program.

Students must complete the HIPAA training course which is located at http://www.hipaaexams.com/, at a nominal cost to the student. When this has been completed, a certificate is to be printed and turned in to the HIT administration offices no later than two (2) weeks prior to the start of the PPE. Failure to complete this training will result in delay of PPE start, which may delay graduation for the student.

Inclement Weather

1. If the college closes because of severe weather, announcements will be made as early as possible.
2. The Port Huron campus may close for day classes only, night classes only, or for both day and night classes. Day classes are defined as classes that begin between 8 a.m. and 5:30 p.m., Night classes are defined as classes that begin between 6 and 10 p.m. (Note:  If the college is closed for day classes, but open for night classes, the Achievement Center, College Bookstore, Library and Student Support Services offices will remain closed for the evening.)
3. The Port Huron campus also may close early at any point in the day or evening.
4. Off-campus centers make independent decisions about closing. Whether they are open or closed is not related to if the Port Huron campus is open or closed.
5. To ensure you are getting accurate information, check the front page of the college website (www.sc4.edu), listen to the voicemail message on the college’s main switchboard at (810) 984-3881 or the class cancellation hotline at (810) 989-5770, or login from home and check your SC4 email account. Please note:  Cancelations by the instructor for individual classes will be reported only on the class cancelation hotline at (810) 989-5770, at
6. on the student portal home page and through other methods the instructor chooses.
6. Text alert messages available:  You may sign up to get text alert messages about closings delivered to your cellular phone or other wireless device. Sign up on your student Portal homepage:  Click on “SC4 Alerts” under the “My Bookmarks” heading, follow the prompts to sign up or edit an existing account. Alerts will arrive labeled from “SC4 alerts.”
7. While details about closings also will be reported by local newspapers, radio and television stations, and their websites, the only information the college can guarantee the accuracy of for SC4 closings will be on the college website, switchboard, class cancellation hotline, and email and text alert messages.
8. Specifically, for early closings:  If the Port Huron campus closes early at any point in the day or evening, Campus Patrol will notify classes in session about the closing. Because of the possibility of closing early, students should monitor the various communications listed above throughout the day.
9. Because SC4 is not in a busing situation, the college’s decision on closing is not related to decisions to close by any K-12 school districts.
10. If the college must close for severe weather during finals week, special announcements will be made regarding final exams.

It is recommended students sign up for Text Message Alerts, as outlined in number (6) above.

Immunizations

Although HIT professionals do not have patient contact equivalent to that of nurses, facilities are still required to prove certain immunizations have been received by all individuals. Therefore, all HIT students are required to provide proof of immunity for the following:

1. Measles, Mumps, Rubella (MMR) – Proof of 2 doses OR Titer showing immunity
2. Varicella – Proof of 2 doses OR Titer showing immunity
3. Hepatitis B series – Proof of 3 doses OR Titer showing antibody response Schedule first dose before PPE begins; second dose 4-weeks after the first; third dose 5-months after the second. Submit proof after each shot. Get titer drawn 1-2 months after last dose for proof of antibody.
4. Tetanus, diphtheria, a-cellular pertussis (Tdap) – Proof of vaccine within past 10 years (must contain all of the above; not just tetanus). Td (Tetanus, diphtheria) is recommended thereafter, every ten years.
5. Flu vaccine – Bring proof to the Allied Health office. Must be done yearly by October 15.
6. TB test – Must be done prior to the start of PPE and renewed annually. If you have a chest x-ray instead of Intradermal test, it is good for 5 years.

Each student must pass a physical examination taken at his/her own expense not more than three (3) months before entering his/her first PPE in the program.

Physical examination forms will be provided by the PPE Instructor. All required lab work, 10 panel drug screen (urine), a chest x-ray or TB skin test must be completed and verification submitted to the HIT department two (2) weeks prior to the start of the first HIT PPE. The drug screen must be no earlier than six (6) weeks prior to the start of the first HIT PPE. Failure to submit any required health forms will result in the inability to attend the PPE, and may delay the student’s program completion.

Professional Liability Insurance

Each student enrolled in the HIT program must carry professional liability insurance. This can be purchased through SC4 for a nominal fee. Students will be required to produce proof of coverage prior to beginning the first PPE. Any student not producing proof of coverage will not be permitted to begin his/her PPE, which may delay graduation.

All students are required to complete training in Universal Precautions and Bloodborne Pathogen training at their own cost. This must be completed online at the cost of the student utilizing the following website:

www.hipaaexams.com/compliance-training-courses/OSHA-Bloodborne-Pathogens-training

When this has been completed, a certificate is to be printed and turned in to the HIT administration offices no later than two (2) weeks prior to the start of the PPE. Failure to complete this training will result in delay of PPE start, which may delay graduation for the student.

Students are expected to attend all PPE sessions, and are expected to be on time. Only in an extreme emergency (as outlined in HIT policies) would missing a PPE session be acceptable. Lack of childcare, lack of transportation, etc., are not acceptable reasons for missing a PPE session.

Any missed PPE time must be made up, and must be done so at the convenience of the PPE site. Failure to make up PPE time will result in course failure to incomplete, and will delay or prevent the student from graduating.

Additionally, no call/no show to a PPE session may result in removal from the PPE site. As PPE sites are difficult to obtain, it may be challenging to place a student a second time, which may result in an inability to graduate from the program on time. (Please refer to the ‘Attendance’ section of this handbook).

Students of the SC4 HIT program will have access to protected health information that is, by law, the property of the patient. Students are expected to adhere to HIPAA regulations, and to maintain complete confidentiality of all patient information, real or fictional, at all times during the HIT program. Failure to comply may result in dismissal from the HIT program.

Faculty of SC4 and the HIT department have academic, legal and ethical responsibilities to protect members of the public and of the healthcare community from unsafe or unprofessional practices. HIT students, while representing SC4 at any PPE site, must conduct themselves in an ethical, professional, and safe manner. Students are expected to assume responsibility for their actions and will be held accountable for them. Students will adhere to SC4 and PPE site policies during each PPE. Failure to comply with program, SC4 or PPE site policies may result in dismissal from the HIT program.

Students are expected to adhere to the AHIMA Code of Ethics at all times during the HIT program. Failure to comply may result in dismissal from the HIT program.

Service Work

SC4 HIT students are not allowed to operate in place of qualified staff during PPEs. Once a student has been successfully evaluated concerning particular procedures, then s/he may perform those procedures under supervision of qualified staff only.

No one will be placed for his/her PPE at their current place of employment. This represents a conflict of interest due to potential service work issues.

Once a site has been assigned, there will be no changes. The HIT program administration will do it’s best to place students at desired locations, however this may not always be possible. If, when sites are assigned, a student is unhappy with his/her placement, s/he must notify the PPE instructor within five (5) business days. At that time, HIT program administration will take the request for change under consideration. After the five (5) business day time period is up, there will be no changes made to PPE site assignments unless the student is experiencing some type of on-going, document harassment at the site.

SC4 HIT students are expected to observe all universal precautions while at PPE sites.

HIT students are encouraged to take advantage of the many resources SC4 offers to ensure student success. These resources include, but are not limited to:

• Educational planning
• Academic advising
• Personal crisis services
• Student Success seminars
• The Library
• Computer in the Library and Achievement Center
• Tutoring
• Disability Services
• English as a second language assistance
• Writing Center
• Math Center

Further information concerning these and other services, and where to obtain them, can be found in the SC4 catalog.

What we offer:

• One search to find it all! Research @ SC4 library box searches:  hundreds of thousands of Books & eBooks, Reference, Articles, Journals, Magazines, Newspapers, Streaming Videos & more.
• 24/7 Live Chat support, Ask the library, email, text, walk-in research and reference assistance, information literacy programs, research guides.
• Computer workstations, group study rooms, printing, study space, interlibrary loan, course reserves, citation management tool.
• Off campus access to all online resources using Student ID# & Skippers One Card barcode (on back of card)

Why use the library?

Librarians can assist in guiding you through the research process, from selecting sources to formatting citations. The amount of available information can be daunting, and librarians help select reliable, current, and comprehensive sources.

Starting a search

Start at the library homepage http://esearch.sc4.edu. The Research @ SC4 search box finds books, reference, journal articles, images, videos, and searches the library catalog and all library databases.

• Find your topic – If you have trouble coming up with a topic, browse some of the library’s Health & Science databases or browse reputable industry websites for ideas to start with and build upon.
• Search strategies – For information on search strategies visit:
• Keywords – Keep track of terms you search. Try different combinations of synonyms, etc. Use terms that those writing about the topic would use. This may require some background research to come up with good terms.
• Use the library and the internet too! – Don’t limit yourself to one or the other.
• Get Help! – Talk to a librarian, tutor, and watch tutorials at http://esearch.sc4.edu/pqrc for guidance through the research process.

Evaluating the quality of sources

To consider when choosing a source:

• Publication – What site, journal or publisher has chosen to publish this work? Did it go through an editorial process? Is it self-published?
• Authorship – Qualifications, affiliations, body of work
• Sources and quotes – To what other sources does the author refer? Do they seem credible? Are they correctly citing their sources?
• Bias or interest – Does the author express a strong point of view? Are they dismissing one side of the argument?
• Currency – Does the information provide topic background? When was it published? Have more recent developments or advancements been made?
• Relevancy to topic – Does the source cover your topic, or does it just mention it in passing?

When reading a source consider:

• What is the author trying to accomplish in their writing?
• Do they reference other research or authors on the topic?
• Who is the intended audience?
• Is this fact, opinion, or propaganda? Is the author being objective?
• Is the information presented accurate?
• Is the argument one-sided? Does the author make generalizations or back up opinion with facts?
• If required to use evidence based practice, does this source integrate research with clinical & patient values and expertise?

Citing your sources & plagiarism

It is always important to give credit whenever you are using a direct quote, paraphrasing, or otherwise referring to an idea, statistic, or passage created by someone other than yourself, aside from those that are considered common knowledge.

Refer to:

SC4 Library Research Guide on APA Style & Academic Integrity – http://esearch.sc4.edu/apa

SC4 Library Research Guide on Preventing Plagiarism – http://esearch.sc4.edu/AntiPlagiarism

Purdue OWL – http://owl.english.purdue.edu/

Flow citation management – http://flow.proquest.com (sign up for a free account)

Where to find help

SC4 Library – College Center A100 (810) 989-5640 library@sc4.edu

Achievement Center Tutors – College Center B100 (810) 989-5759 ac@sc4.edu

TRIO Student Support Services – College Center B100 (810) 989-5801 trio@sc4.edu

Writing Center – Main Building 313 (810) 984-3381 ext. 6223 wc@sc4.edu (Open Fall & Winter Semesters Only)

Math Center – Clara E. McKenzie Building 104 (810) 989-5701 (Open Fall & Winter Semesters Only)

• https://owl.english.purdue.edu/owl/resource/553/1/

Writing Tutorial Services (Indiana University)

The following table is a listing of resources which may assist students throughout their educational career. Note:This is not an exhaustive list.

 

CAHIIM	Commission on Accreditation for Health Informatics and Information Management Education	www.cahiim.org
AHIMA	American Health Information Management Association	www.ahima.org
MHIMA	Michigan Health Information Management Association	www.mhima.org
SEMHIMA	South Eastern Michigan Health Information Management Association	www.semhima.org
AAPC	American Academy of Professional Coders	www.aapc.com
		www.hicareers.com
For the Record		www.fortherecord.com
Coding Edge		www.thecodingedge.com
Just Coding		www.justcoding.com
Advance for Health Information Professionals		www.advanceweb.com
NCRA	National Cancer Registrars Association	www.ncra-usa.org
HIMSS	Healthcare Information and Management Society	www.himss.org

The AHIMA VLab will be utilized for the SC4 HIT program. This virtual environment consists of software applications commonly used in the day to day operations of an HIM department. These applications are:

• Dr. Chronos – An electronic medical record for student use.
• 3M Encoder – Coding software with references
• Quadra Med MPI Suite – Registration software
• Solcom EDMS – Read-only electronic document management system for imaged documents
• Health Port eSmartLog Release of Information – Release of Information and correspondence tracking software
• Tableau – Data visioning and analysis software and practice data sets
• Find-A-Code

These applications will be available via a web portal. Students must maintain access to the AHIMA VLab for the entirety of the HIT program. Access cards to the AHIMA VLab must be purchased once per calendar year. These cards are available through the SC4 Bookstore. Each student will then be registered as an authorized AHIMA VLab user by HIT Administration, and will receive his/her own login IDs and passwords.

Notice to all Prospective Health Information Technology Students

All prospective Health Information Technology (HIT) students should be aware that success in the HIT program will be directly dependent upon each student’s access to a computer. Greater than 90% of the homework assignments will be completed electronically; therefore, a student taking 14 credits in a semester will have 28 hours of homework AT A MINIMUM. In this scenario, at least 25 hours a week would require use of a computer. All computers must meet the following system requirements (please note these minimum requirements are subject to change due to updates by portal and software providers, and every effort will be made to notify students of changes in a timely fashion):

Software – Minimum requirements

• ONLY Microsoft Windows Vista or Windows 7 are supported. Mac OSX is not supported.
  • Broadband High Speed Internet Access:  Cable or DSL
• Internet Explorer 8
• Microsoft Word 2010
• Microsoft Excel 2010
• Microsoft PowerPoint 2010

Hardware – Minimum requirements

• 1Ghz Intel or AMD processor (minimum)
• 2 GB of RAM (minimum)
• Screen resolution capable of 1024 x 768
• CD-ROM
• USB Ports
• Built in sound card
• Headphone jack and/or USB port for speakers and/or headphones

The ethical obligations of the health information management (HIM) professional include the safeguarding of privacy and security of health information; disclosure of health information; development, use, and maintenance of health information systems and health information; and ensuring the accessibility and integrity of health information.

Healthcare consumers are increasingly concerned about security and the potential loss of privacy and the inability to control how their personal health information is used and disclosed. Core health information issues include what information should be collected; how the information should be handled, who should have access to the information, under what conditions the information should be disclosed, how the information is retained and when it is no longer needed, and how is it disposed of in a confidential manner. All of the core health information issues are performed in compliance with state and federal regulations, and employer policies and procedures.

Ethical obligations are central to the professional’s responsibility, regardless of the employment site or the method of collection, storage, and security of health information. In addition, sensitive information (e.g., genetic, adoption, drug, alcohol, sexual, health, and behavioral information) requires special attention to prevent misuse. In the world of business and interactions with consumers, expertise in the protection of the information is required. Purpose of the American Health Information Management Association Code of Ethics. The HIM professional has an obligation to demonstrate actions that reflect values, ethical principles, and ethical guidelines. The American Health Information Management Association (AHIMA) Code of Ethics sets forth these values and principles to guide conduct. The code is relevant to all AHIMA members and CCHIIM credentialed HIM professionals [hereafter referred to as certificants], regardless of their professional functions, the settings in which they work, or the populations they serve. These purposes strengthen the HIM professional’s efforts to improve overall quality of healthcare.

The AHIMA Code of Ethics serves seven purposes:

• Promotes high standards of HIM practice.
• Identifies core values on which the HIM mission is based.
• Summarizes broad ethical principles that reflect the profession’s core values.
• Establishes a set of ethical principles to be used to guide decision-making and actions.
• Establishes a framework for professional behavior and responsibilities when professional obligations conflict or ethical uncertainties arise.
• Provides ethical principles by which the general public can hold the HIM professional accountable.
• Mentors practitioners new to the field to HIM’s mission, values, and ethical principles.

The code includes principles and guidelines that are both enforceable and aspirational. The extent to which each principle is enforceable is a matter of professional judgment to be exercised by those responsible for reviewing alleged violations of ethical principles.

The following ethical principles are based on the core values of AHIMA and apply to all AHIMA members and certificants. Guidelines included for each ethical principle are a non-inclusive list of behaviors and situations that can help to clarify the principle. They are not meant to be a comprehensive list of all situations that can occur.

I. Advocate, uphold, and defend the individual’s right to privacy and the doctrine of confidentiality in the use and disclosure of information.

A health information management professional shall:

1.1. Safeguard all confidential patient information to include, but not limited to, personal, health, financial, genetic, and outcome information.

1.2. Engage in social and political action that supports the protection of privacy and confidentiality, and be aware of the impact of the political arena on the health information issues for the health care industry.

1.3. Advocate for changes in policy and legislation to ensure protection of privacy and confidentiality, compliance, and other issues that surface as advocacy issues and facilitate informed participation by the public on these issues.

1.4. Protect the confidentiality of all information obtained in the course of professional service. Disclose only information that is directly relevant or necessary to achieve the purpose of disclosure. Release information only with valid authorization from a patient or as authorized by federal or state regulations. The minimum necessary standard is essential when releasing health information for disclosure activities.

1.5. Promote the obligation to respect privacy by respecting confidential information shared among colleagues, while responding to requests from the legal profession, the media, or other non-healthcare related individuals, during presentations or teaching and in situations that could cause harm to persons.

1.6. Respond promptly and appropriately to patient requests to exercise their privacy rights (e.g., access, amendments, restriction, confidential communication, etc.). Answer truthfully all patients’ questions concerning their rights to review and annotate their personal biomedical data and seek to facilitate patients’ legitimate right to exercise those rights.

II. Put service and the health and welfare of persons before self-interest and conduct oneself in the practice of the profession so as to bring honor to oneself, peers, and to the health information management profession.

A health information management professional shall:

2.1. Act with integrity, behave in a trustworthy manner, elevate service to others above self-interest, and promote high standards of practice in every setting.

2.2. Be aware of the profession’s mission, values, and ethical principles, and practice in a manner consistent with them by acting honestly and responsibly.

2.3. Anticipate, clarify, and avoid any conflict of interest, to all parties concerned, when dealing with consumers, consulting with competitors, in providing series requiring potentially conflicting roles (for example, finding out information about one facility that would help a competitor), or serving the Association in a volunteer capacity. The conflicting roles or responsibilities must be clarified and appropriate action taken to minimize any conflict of interest.

2.4. Ensure that the working environment is consistent and encourages compliance with the AHIMA Code of Ethics, taking reasonable steps to eliminate any conditions in their organizations that violate, interfere with, or discourage compliance with the code.

2.5. Take responsibility and credit, including authorship credit, only for work they actually perform or to which they contribute. Honestly acknowledge the work of and the contributions made by others verbally or written, such as in publication.

A health information management professional shall not:

2.6. Permit one’s private conduct to interfere with the ability to fulfill one’s professional responsibilities.

2.7. Take unfair advantage of any professional relationship or exploit others to further one’s own personal, religious, political, or business interests.

III. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regards health information and other information of a confidential nature obtained in an official capacity, taking into account the applicable statues and regulations.

A health information management professional shall:

3.1. Safeguard the privacy and security of written and electronic health information and other sensitive information. Take reasonable steps to ensure that health information is stored securely and that patients’ data is not available to others who are not authorized to have access. Prevent inappropriate disclosure of individually identifiable information.

3.2 Take precautions to ensure and maintain the confidentiality of information transmitted, transferred, or disposed of in the event of termination, incapacitation, or death of a healthcare provider to other parties through the use of any media.

3.3 Inform recipients of the limitations, and risks associated with providing services via electronic or social media (e.g., computer, telephone, fax, radio, and television).

IV. Refuse participate in or conceal unethical practices or procedures and report such practices.

A health information professional shall:

4.1. Act in a professional and ethical manner at all times.

4.2. Take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues. If needed, utilize the Professional Ethics Committee Policies and Procedures for potential ethics complaints.

4.3. Be knowledgeable about established policies and procedures for handling concerns about colleagues’ unethical behavior. These include policies and procedures created by AHIMA, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations.

4.4. Seek resolution if there is a belief that a colleague has acted unethically or if there is a belief of incompetence or impairment by discussing one’s concerns with the colleague when feasible and when such discussion is likely to be productive.

4.5. Consult with a colleague when feasible and assist the colleague in taking remedial action when there is direct knowledge of a health information management colleague’s incompetence or impairment.

4.6. Take action through appropriate formal channels, such as contacting an accreditation or regulatory body and/or the AHIMA Professional Ethics Committee if needed.

4.7. Cooperate with lawful authorities as appropriate.

A health information professional shall not:

4.8. Participate in, condone, or be associated with dishonesty, fraud and abuse, or deception. A non-inclusive list of examples includes:

• Allowing patterns of optimizing or minimizing documentation and/or coding to impact payment
• Assigning codes without physician documentation
• Coding when documentation does not justify the diagnoses or procedures that have been billed
• Coding an inappropriate level of service
• Miscoding to avoid conflict with others
• Engaging in negligent coding practices
• Hiding or ignoring review outcomes, such as performance data
• Failing to report licensure status for a physician through the appropriate channels
• Recording inaccurate data for accreditation purposes
• Allowing inappropriate access to genetic, adoption, health, or behavioral health information
• Violating the privacy of individuals

4.9 Engage in any relationships with a patient where there is a risk of exploitation or potential harm to the patient.

V. Advance health information management knowledge and practice through continuing education, research, publications, and presentations.

A health information professional shall:

5.1. Develop and enhance continually professional expertise, knowledge, and skills (including appropriate education, research, training, consultation, and supervision). Contribute to the knowledge base of health information management and share one’s knowledge related to practice, research, and ethics.

5.2. Base practice decisions on recognized knowledge, including empirically based knowledge relevant to health information management and health information management ethics.

5.3. Contribute time and professional expertise to activities that promote respect for the value, integrity, and competence of the health information management profession. These activities may include teaching, research, consultation, service, legislative testimony, advocacy, presentations in the community, and participation in professional organizations.

5.4. Engage in evaluation and research that ensures the confidentiality of participants and of the data obtained from them by following guidelines developed for the participants in consultation with appropriate institutional review boards.

5.5. Report evaluation and research findings accurately and take steps to correct any errors later found in published data using standard publication methods.

5.6. Design or conduct evaluation or research that is in conformance with applicable federal or state laws.

5.7. Take reasonable steps to provide or arrange for continuing education and staff development, addressing current knowledge and emerging developments related to health information management practice and ethics.

VI. Recruit and mentor students, staff, peers, and colleagues to develop and strengthen professional workforce.

A health information management professional shall:

6.1. Provide directed practice opportunities for students.

6.2. Be a mentor for students, peers, and a new health information management professional to develop and strengthen skills.

6.3. Be responsible for setting clear, appropriate, and culturally sensitive boundaries for students, staff, peers, colleagues, and members within professional organizations.

6.4. Evaluate students’ performance in a manner that is fair and respectful when functioning as educators or clinical internship supervisors.

6.5. Evaluate staff’s performance in a manner that is fair and respectful when functioning in a supervisory capacity.

6.6. Serve an active role in developing HIM faculty or actively recruiting HIM professionals.

A health information management professional shall not:

6.7. Engage in any relationships with a person (e.g., students, staff, peers, or colleagues) where there is a risk of exploitation or potential harm to that other person.

VII. Represent the profession to the public in a positive manner.

A health information management professional shall:

7.1. Be an advocate for the profession in all settings and participate in activities that promote and explain the mission, values, and principles of the profession to the public.

VIII. Perform honorably health information management association responsibilities, either appointed or elected, and preserve the confidentiality of any privileged information made known in any official capacity.

A health information management professional shall:

8.1. Perform responsibly all duties as assigned by the professional association operating within the bylaws and policies and procedures of the association and any pertinent laws.

8.2. Uphold the decisions made by the association.

8.3. Speak on behalf of the health information management profession and association, only while serving in the role, accurately representing the official and authorized positions of the association.

8.4. Disclose any real or perceived conflicts of interest.

8.5. Relinquish association information upon ending appointed or elected responsibilities.

8.6. Resign from an association position if unable to perform the assigned responsibilities with competence.

8.7. Avoid lending the prestige of the association to advance or appear to advance the private interest of others by endorsing any product or service in return for remuneration. Avoid endorsing products or services of a third party, for-profit entity that competes with AHIMA products and services. Care should also be exercised in endorsing any other products and services.

IX. State truthfully and accurately one’s credentials, professional education, and experiences.

          A health information management professional shall:

9.1 Make clear distinctions between statements made and actions engaged in as a private individual and as a representative of the health information management profession, a professional health information association, or one’s employer.

9.2 Claim and ensure that representation to patients, agencies, and the public of professional qualification, credentials, education, competence, affiliations, services provided, training, certification, consultation received, supervised experience, and other relevant professional experience are accurate.

9.3 Claim only those relevant professional credentials actually possessed and correct any inaccuracies occurring regarding credentials.

9. 4 Report only those continuing education units actually earned for the recertification cycle and correct any inaccuracies occurring regarding CEUs.

X. Facilitate interdisciplinary collaboration in situations supporting health information practice.

A health information management professional shall:

10.1 Participate in and contribute to decisions that affect the well-being of patients by drawing on the perspectives, values, and experiences of those involved in decisions related to patients.

10.2 Facilitate interdisciplinary collaboration in situations supporting health information practice.

10.3. Establish clearly professional and ethical obligations of the interdisciplinary team as a whole and of its individual members.

10.4. Foster trust among group members and adjust behavior in order to establish relationships with teams.

XI.Respect the inherent dignity and worth of every person.

A health information management professional shall:

11.1. Treat each person in a respectful fashion, being mindful of individual differences and cultural and ethnic diversity.

11.2. Promote the value of self-determination for each individual.

11.3. Value all kinds and classes of people equitable, deal effectively with all races, cultures, disabilities, ages and genders.

11.4. Ensure all voices are listened to and respected.

Violation of principles in this code does not automatically imply legal liability or violation of the law. Such determination can only be made in the context of legal and judicial proceeding. Alleged violations of the code would be subject to a peer review process. Such processes are generally separate from legal or administrative procedures and insulated from legal review or proceedings to allow the profession to counsel and discipline its own members although in some situations, violations of the code would constitute unlawful conduct subject to legal process.

Guidelines for ethical and unethical behavior are provided in this code. The terms ‘shall and shall not’ are used as a basis for setting high standards for behavior. This does not imply that everyone ‘shall or shall not’ do everything that is listed. This concept is true for the entire code. If someone does the stated activities, ethical behavior is the standard. The guidelines are not a comprehensive list. For example, the statement ‘safeguard all confidential patient information to include, but not limited to, personal, health, financial, genetic and outcome information’ can also be interpreted as ‘shall not fail to safeguard all confidential patient information to include personal, health, financial, genetic, and outcome information.

A code of ethics cannot guarantee ethical behavior. Moreover, a code of ethics cannot resolve all ethical issues or disputes or capture the richness and complexity involved in striving to make responsible choices within a moral community. Rather, a code of ethics sets forth values and ethical principles, and offers ethical guidelines to which a HIM professional can aspire and by which actions can be judged. Ethical behaviors result from a personal commitment to engage in ethical practice.

Professional responsibilities often require an individual to move beyond personal values. For example, an individual might demonstrate behaviors that are based on the values of honesty, providing service to others, or demonstrating loyalty. In addition to these, professional values might require promoting confidentiality, facilitating interdisciplinary collaboration, and refusing to participate or conceal unethical practices. Professional values could require a more comprehensive set of values than what an individual needs to be an ethical agent in one’s own personal life.

The AHIMA Code of Ethics is to be used by AHIMA members and certificants, consumers, agencies, organizations, and bodies (such as licensing and regulatory boards, insurance providers, courts of law, government agencies, and other professional groups) that choose to adopt it or use it as a frame of reference. The AHIMA Code of Ethics reflects the commitment of all to uphold the profession’s values and to act ethically. Individuals of good character who discern moral questions and, in good faith, seek to make reliable ethical judgments, must apply ethical principles.

The code does not provide a set of rules that prescribe how to act in all situations. Specific applications of the code must take into account the context in which it is being considered and the possibility of conflicts among the code’s values, principles, and guidelines. Ethical responsibilities flow from all human relationships, from the personal and familial to the social and professional. Further, the AHIMA Code of Ethics does not specify which values, principles, and guidelines are the most important and ought to outweigh others in instances when they conflict.

Copyright ©2012 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduces, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.

The Standards of Ethical Coding are based on the American Health Information Management Association’s (AHIMA’s) Code of Ethics. Both sets of principles reflect expectations of professional conduct for coding professionals involved in diagnostic and/or procedural coding or other health record data abstraction.

A Code of Ethics sets forth professional values and ethical principles and offers guidelines to which professionals aspire and by which their actions can be judged. Health information management (HIM) professionals are expected to demonstrate professional values by their actions to patients, employers, members of the healthcare team, the public, and the many stakeholders they serve. A Code of Ethics is important in helping to guide the decision-making process and can be referenced by individuals, agencies, organizations, and bodies (such as licensing and regulatory boards, insurance providers, courts of law, government agencies, and other professional groups).

The AHIMA Code of Ethics (available on the AHIMA website) is relevant to all AHIMA members and credentialed HIM professionals and students, regardless of their professional functions, and due to the complex regulatory requirements affecting the health information coding process, coding professionals are frequently faced with ethical challenges. The AHIMA Standards of Ethical Coding are intended to assist coding professionals and managers in decision-making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate coding professionals’ commitment to integrity during the coding process, regardless of the purpose for which the codes are being reported. They are relevant to all coding professionals and those who manage the coding function, regardless of the healthcare setting in which they work or whether they are AHIMA members or nonmembers.

These Standards of Ethical Coding have been revised to reflect the current healthcare environment and modern coding practices. The previous revision was published in 1999.

Coding professionals should:

1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.
2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in conventions, rules, and guidelines.
3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.
4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator).
5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.
6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.
7. Facilitate interdisciplinary collaboration in situations supporting prior coding practices.
8. Advance coding knowledge and practice through continuing education.
9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.
10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).
11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Revised and approved by the House of Delegates 09/08

The following ethical principles are based on the core values of the American Health Information Management Association and the AHIMA Code of Ethics and apply to all coding professionals. Guidelines for each ethical principle include examples of behaviors and situations that can help to clarify the principle. They are not meant as a comprehensive list of all situations that can occur.

1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.

                   Coding professionals and those who manage coded data shall:

1.1. Support selection of appropriate diagnostic, procedure and other types of health service related codes (e.g. present on admission indicator, discharge status).

Example:
Policies and procedures are developed and used as a framework for the work process, and education and training is provided on their use.

1.2. Develop and comply with comprehensive internal coding policies and procedures that are consistent with official coding rules and guidelines, reimbursement regulations and policies and prohibit coding practices that misrepresent the patient’s medical conditions and treatment provided or are not supported by the health record documentation.

Example:
Code assignment resulting in misrepresentation of facts carries significant consequences.

1.3. Participate in the development of institutional coding policies and ensure that coding policies complement, and do not conflict with, official coding rules and guidelines.

1.4. Foster an environment that supports honest and ethical coding practices resulting in accurate and reliable data.

Coding professionals shall not:

1.5. Participate in improper preparation, alteration, or suppression of coded information.

Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, public data reporting, quality and patient safety measurement, research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.

Coding professionals shall:

2.1. Adhere to the ICD coding conventions, official coding guidelines approved by the cooperating Parties, the CPT rule established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets.

Example:
Appropriate resource tool that assist coding professionals with proper sequencing and reporting to stay in compliance with existing reporting requirements are available and used.

2.2. Select and sequence diagnosis and procedure codes in accordance with the definitions of required data sets for applicable healthcare settings.

2.3. Comply with AHIMA’s standards governing data reporting practices, including health record documentation and clinician query standards.

3. Assign and report only the codes that are clearly and consistently supported by health record documentation in accordance with applicable code set conventions, rules, and guidelines.

Coding professionals shall:

3.1 Apply skills, knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances equipment, supplies, or other items used in the provision of healthcare services).

 

Example: Failure to research or confirm the appropriate code for a clinical condition not indexed in the classification, or reporting a code for the sake of convenience or to affect reporting for a desired effect on the results, is considered unethical.

Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator)

Coding professionals shall:

4.1. Participate in the development of query policies that support documentation improvement and meet regulatory, legal, and ethical standards for coding and reporting.

4.2. Query the provider for clarification when documentation in the health record that improvement and meet regulatory, legal, and ethical standards for coding and reporting.

4.3. Use queries as a communication tool to improve the accuracy of code assignment and the quality of health record documentation, not to inappropriately increase reimbursement or misrepresent quality of care.

Coding professionals shall not:

4.4. Query the provider when there is no clinical information in the health record prompting the need for a query.

Example:
Query the provider regarding the presence of gram-negative pneumonia on very pneumonia case, regardless of whether there are any clinical indications of gram-negative pneumonia documented in the record.

5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.

Coding professionals shall not:

5.1 Change the description for a diagnosis or procedure code or other reported data element so that it does not accurately reflect the official definition of the code.

Example:
The description of a code is altered in the encoding software, resulting in incorrect reporting of this code.

6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.

Coding professionals shall:

6.1. Select and sequence the codes such that the organization receives the optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to increase payment by means that contradict regulatory guidelines.

6.2. Misrepresent the patient’s clinical picture through intentional incorrect coding or Omission of diagnosis or procedure codes unsupported by health record documentation, to inappropriately increase reimbursement, justify medical necessity, improve, publicity reported data, or qualify for insurance policy coverage benefits.

Example:
A patient has a health plan that excludes reimbursement for reproductive management or contraception; so rather than report the correct code for admission for tubal ligation, it is reported as a medically necessary condition with performance of a salpingectomy. The narrative descriptions of both the diagnosis and procedures reflect an admission for tubal ligation and the procedure (tubal ligation) is displayed on the record.

A code is changed at the patient’s request so that the service will be covered by the patient’s insurance.

Coding professional shall not:

6.3. In appropriately exclude diagnosis or procedure codes in order to misrepresent the quality of care provided.

Example:
Following a surgical procedure, a patient acquired an infection due to a break in sterile procedure; the appropriate code for the surgical complication is omitted from the claims submission to avoid any adverse outcome to the institution.

Quality outcomes are reported inaccurately in order to improve a healthcare organization’s quality profile or pay-for-performance results.

7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.

Coding professionals shall:

7.1. Assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, and re-sequence or include diagnoses or procedures when needed to more accurately reflect the acuity, severity, and the occurrence of events.

Example:
Failure to advocate for ethical practices that seek to represent the truth in events as expressed by associated code sets when needed in considered an intentional disregard of these standards.

8. Advance coding knowledge and practice through continuing education.

Coding professionals shall:

8.1. Maintain and continually enhance coding competency (e.g. through participation in educational programs, reading official coding publications such as the Coding Clinic for ICD-9-CM, and maintaining professional certifications) in order to stay abreast of changes in codes, coding guidelines, and regulatory and other requirements.

9. Refuse to participate in or conceal unethical coding practices or procedures.

Coding professionals shall:

9.1. Act in a professional and ethical manner at all times.

9.2. Take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues.

9.3. Be knowledgeable about established policies and procedures for handling concerns about colleagues’ unethical behavior. These include policies and procedures created by AHIMA, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations.

9.4. Seek resolution if there is a belief that a colleague has acted unethically or if there is a belief of incompetence or impairment by discussing their concerns with the colleague when feasible and when such discussion is likely to be productive. Take action through appropriate formal channels, such as contacting an accreditation or regulatory body and/or the AHIMA Professional Ethics Committee.

9.5. Consult with a colleague when feasible and assist the colleague in taking remedial action when there is direct knowledge of a health information management colleague’s incompetence or impairment.

Coding professionals shall not:

9.6. Participate in, condone, or be associated with dishonesty, fraud and abuse, or deception. A non-exhaustive list of examples includes:

• Allowing inappropriate patterns of retrospective documentation to avoid suspension or increase reimbursement.
• Assisting codes without supporting provider (physician or other qualified healthcare practitioner) documentation.
• Coding when documentation does not justify the diagnoses and/or procedures that have been billed.
• Coding an inappropriate level of service.
• Miscoding to avoid conflict with others.
• Adding, deleting, and altering health record documentation.
• Copying and pasting another clinician’s documentation without identification of the original author and date.
• Knowingly reporting incorrect present on admission indicator
• Knowingly reporting incorrect patient discharge status code.
• Engaging in negligent coding practices.

10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).

Coding professionals shall:

10.1. Protect all confidential information obtained in the course of professional service, including personal health, health, financial, genetic, and outcome information.

10.2. Access only that information necessary to perform their duties.

11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Coding professionals shall:

11.1. Act in an honest manner and bring honor to self, peers, and the   profession.

11.2.Truthfully and accurately represent their credentials, professional     education, and experience.

11.3. Demonstrate ethical principles and professional’s values in their actions to patients, employers, other members of the healthcare team, consumers, and other stakeholders served by the   healthcare data they collect and report.

Copyright ©2012 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.