Tuesday, February 16, 2010
When I was taking coding classes on Thursday evenings in the mid-90s, everyone in my class – including the instructor – had the same dilemma. There was a great new show on TV called “ER.” And it was on during coding class. Bearing mind that DVR didn’t exist at the time, sometimes we were able to talk our instructor into letting us go early and she would joke with us and tell us she’d give us extra credit if we went home and coded “ER,” that is, translate the conditions of the patients of the week into codes. I don’t know if anyone actually did. I certainly didn’t because I was just trying to understand the clinical lingo and decide what was important and what wasn’t. So now it’s your turn – how would you code this hospital inpatient scenario?
“CC: Pt adm w/ c/o CP, SOB, fever, weakness. PMH: CHF, HTN, DM type 2. Findings: Temp 102. BP: 100/65. CXR w/ infiltrates. Labs: WBC 40,000, sputum (-), BC (-). Assessment: sepsis, pna. Plan: IV abx, IVF, repeat BC.”
Statements such as these are a reality and before you can look up a code in a book, you first have to know what to look up. It often reminds me of my elementary school teachers telling me if I didn’t know how to spell a word to look it up in the dictionary. I remember thinking, “How do I look it up in the dictionary if I can’t spell it?!” Of course, we all learned to sound out the word and attempt to look it up in the dictionary. But coding is a little trickier because physician short hand is difficult to decipher if you don’t have any clinical knowledge. And before you can translate a clinical statement into codes, you first have to translate it into English!
Have you figured out the scenario above? Here’s the answer:
-038.9 Unspecified septicemia
-486 Pneumonia, organism unspecified
-428.0 Congestive heart failure, unspecified
-401.9 Unspecified essential hypertension
-250.00 Diabetes mellitus, without mention of complication, Type II or unspecified
But how do you get there? That’s the question. So I will break down the coder’s thought process as he/she reads the statement and determines what to code.
Step 1: Translate the clinical shorthand into English.
The statement above, if written out long hand, would read as follows: “Chief complaint: patient admitted with complaints of chest pain, shortness of breath, fever, and weakness. Past medical history: congestive heart failure, hypertension, type 2 diabetes mellitus. Findings: Temperature 102 degrees. Blood pressure: 100/65. Chest x-ray with infiltrates. Labs: white blood count 40,000, negative sputum culture, negative blood cultures. Assessment: sepsis, pneumonia. Plan: intravenous antibiotics, intravenous fluids, repeat blood cultures.”
Step 2: Determine what brought the patient to the hospital and the underlying cause of that problem.
The patient had several complaints: chest pain (CP), shortness of breath (SOB), fever, and weakness. The patient’s fever was high and blood pressure was low. Tests showed infiltrates on chest x-ray, which is indicative of pneumonia and labs showed a high white blood cell (WBC) count, which is indicative of infection and blood and sputum (respiratory secretions) cultures did not grow any bacteria – but if the patient was on antibiotics before the cultures were taken, they may not grow any bacteria. The final assessment was sepsis and pneumonia. Symptoms of sepsis are weakness, fever, hypotension (low blood pressure), and high WBC count. Symptoms of pneumonia are chest pain, shortness of breath, fever, high WBC count, and weakness.
Step 3: Assign codes for the reason that brought the patient to the hospital.
Knowing that we don’t code symptoms when an established associated condition is present, we can narrow the final coding down to the sepsis and pneumonia. Coding rules tell us that coding for sepsis requires two codes: 038.9 and 995.91 and pneumonia without further specification is coded to 486. Of course, if this were a real hospital, we hopefully would have more specific documentation telling us the causative organism of both the sepsis and the pneumonia. That would require more digging through the record.
Step 4: Determine if there are other conditions that should also be reported.
In this case, the patient has a past medical history of congestive heart failure (CHF), hypertension, and type 2 diabetes mellitus. All of these are chronic conditions that impact the care of the patient and should therefore be coded. We can then add codes 428.0, 401.9, and 250.00. We can’t assume a cause and effect relationship between the CHF and hypertension because it’s not documented by the physician and we would want to look for documentation of a specific type of congestive heart failure (e.g., acute on chronic diastolic heart failure) and any diabetic complications.
So coding is just looking up a code in a book. At least that’s the tangible part of it. The rest of it is the thought process that goes behind it and explains why, if you watch coders work, you will see them spend most of their time staring at a computer screen or flipping through a medical record. I often compare coding to doing a word search: you have to sort through all the gobbledygook (i.e., pages of clinical mumbo jumbo) to find the right word to look up in the codebook.
You either found this explanation horribly boring or oddly fascinating. If you belong in the latter category, welcome to the wonderful world of coding. You're going to love it.
Tuesday, February 9, 2010
ICD-9-CM vs. ICD-10?
First, let's get straight what exactly we're talking about. Currently, we use the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to report diagnoses and hospital inpatient procedures. ICD-9-CM is divided into three volumes:
- Volume 1 - Tabular list of diagnosis codes (lists all codes with their descriptions)
- Volume 2 - Index of diseases
- Volume 3 - Tabular list and index of procedures
It seems logical, then, that ICD-10-CM will replace ICD-9-CM, but it's only partially true. The diagnosis portion of ICD-10 is part of the clinical modification (ICD-10-CM) and the procedure portion is part of ICD-10-PCS (Procedure Coding System). In order to simplify, some articles will refer to the system collectively as ICD-10 or ICD-10-CM/PCS. When it comes time for training, though, you want to make sure you are getting trained in both CM and PCS if you plan to work as a hospital inpatient coder.
I've often been asked if it's such a big deal to switch why we don't just stick with ICD-9-CM. There are many reasons for making the switch to ICD-10, but here are the main reasons:
- ICD-10-CM/PCS offers better specificity in reporting diagnoses and procedures
- The US is the only G7 nation that does not use a version of ICD-10, which makes comparing data worldwide difficult
- The structure of Volume 3 ICD-9-CM codes does not allow for proper expansion of the code set in order to report new technologies
When the proposed rule announcing implementation of ICD-10 was released, there was a lengthy discussion about the possibility of replacing CPT with ICD-10-PCS. Researchers determined, however, that the two coding systems were developed for different purposes, which did not make them interchangeable. CPT was developed originally to report physician services while ICD-10-PCS was developed for hospitals. The use of CPT will not be impacted by implementation of ICD-10-PCS and it will still be required for reporting on physician and outpatient hospital claims.
How Different is ICD-10?
While the general format and look of the ICD-10-CM tabular section doesn't look too different from ICD-9-CM, the codes themselves do. Existing ICD-9-CM code format is 3-5 numeric digits, except in the case of V and E codes. ICD-10-CM codes have 3-7 alphanumeric characters. To me, the codes look more like license plate numbers! The method of looking up a code is similar to ICD-9-CM - you locate the main term in the index, consult the secondary entries, and then consult the tabular listing to confirm code assignment.
ICD-10-PCS codes are very different from ICD-9-CM procedure codes. Coding in ICD-10-PCS understands a great understanding of the procedure performed, as the main index term is the root operation rather than the eponym or name of the procedure. For example, there is no term in the ICD-10-PCS index for "Whipple procedure." The coder must know which of the major root operations this falls under and code appropriately. Once the procedure is located in the index, the coder will find only the first 3-4 of the total 7 character code listed. Those first characters will lead the coder to tables, not a tabular list, that allows for building the rest of the code.
Who Will be Affected Most?
There is much debate about who will be most affected by implementation of ICD-10. For physician offices, although physicians and their coders will not need to learn ICD-10-PCS, they will need to learn ICD-10-CM. If the physician uses a superbill (a list of commonly used codes for that practice), it will need to be redesigned - and expanded - to include the ICD-10-CM codes. Some physician practices may find it tedious to continue to code using a superbill as it goes from a dual-sided to a multi-page document. Practices that do not currently use superbills and rely on coders to assign ICD-9-CM codes will need training in ICD-10-CM.
Hospitals, although only required to report ICD-10-PCS codes on inpatient claims, may choose to collect ICD-10-PCS data on all patients (including outpatients) in order to compare data internally. It is common practice currently for hospitals to collect ICD-9-CM procedure codes on all patient, even though they are "scrubbed" from the bill. As such, hospital coders will need to learn both ICD-10-CM and ICD-10-PCS. Of the two coding systems, ICD-10-PCS is expected to require more education as the structure is completely different from ICD-9-CM procedures. In addition, the clinical knowledge required to assign an ICD-10-PCS code is much greater than that needed to assign an ICD-9-CM code. I think coders with CPT coding experience will find the transition easier because of the level of detail needed to report those codes.
Right now AHIMA and the AAPC are training future ICD-10 trainers in preparation for training the masses. Software companies that utilize ICD-9-CM codes are currently applying the General Equivalency Mappings (GEMs) to map between ICD-9 and ICD-10 codes and beta testing the new code sets to ensure they work accurately. As an industry, experts aren't recommending that front line coders get trained prior to 2012, however, it is recommended that employers conduct a gap analysis to see what training their coders need and provide medical terminology, anatomy and physiology, and pathophysiology training starting now.
If you are a coding student, AHIMA recommends that your educational institution begin ICD-10 training in 2011 for associate and baccalaureate degree programs and in 2012 for coding certificate programs. If you plan to code prior to October 1, 2013, you will still need to learn ICD-9-CM coding and if you plan to graduate in 2012, it is likely you will learn both systems. For those considering enrolling in a coding program, determining the ICD-10 education schedule of the school will tell you a lot about the institution. Beware of the school with no plan.
The best part of the transition is that this is a great time for new coders to enter the field. This is a do-over, only it's the experienced coders doing to do-over and they will struggle with it just like new coders. It's going to be a level playing field for anyone interested in being a coder. So if you've ever considered it, now is the time!
Thursday, February 4, 2010
- Fourth Tuesday of each month – Coder Coach presentation (presenter and/or facilitator), Denver, CO
- April 13 – “Taking the Shock out of Electrophysiology (EP) Coding” – Local AAPC Chapter, Denver, CO
- April 23 – “Soft-Hard Cath Lab Coding in an EMR Environment” - AAMAS Annual Meeting, Orlando, FL
- May 5 – “Cardiac Catheterization: Beyond the Basics” - CHIMA/WyHIMA Annual Meeting, Golden, CO
- June 17 – “Cardiac Catheterization Coding” and “The Importance of Networking in Coding” – Local AAPC Chapter, Colorado Springs, CO
- September 2 – “FY 2011 CMS IPPS Update” – AHIMA Audio Conference
If you have any questions about specific events, please feel free to email me at firstname.lastname@example.org.
Monday, February 1, 2010
When I enrolled in HIM school, I never envisioned my career would end up the way it has. For those of you keeping score at home, let me briefly outline how it has turned out. I am a senior consultant - and the only coding professional - for a small consulting firm that specializes in hospital revenue cycle management and electronic medical record conversions. I do project-based work that involves improving coding and charging accuracy with our clients. Right now that means working closely with cardiac catheterization and interventional radiology coders and auditors. In the coming months and years it means hours of developing ICD-10 training materials and helping the coding workforce get ready for the switch in 2013.
Well obviously as a child I didn't think "I want to grow up to be a coding professional" but even once I selected an area of study and was taking classes, I was having trouble visualizing what my days would be like - which is pretty sad considering my mother had been in the business for about 20 years and all my stuffed animals had medical records when I was a kid. I knew about the HIM field, but I didn't really know about it. I guess I imagined that some day I would go to work as a manager in an HIM department like my mom, but I couldn't really figure out how to get there or if it was right for me.
"I Don't Want to be a Coder"
When I took my first coding class I hated it! I didn't understand it and the statements the instructor gave us to code were confusing. I constantly arrived at the wrong code and sometimes didn't even know what to look for. And unfortunately at that time, I never wanted to ask questions because I didn't want to feel stupid. When they handed me an inpatient medical record for the first time I wanted to cry. How was I supposed to put it all together and come up with the right codes - the ones everyone else in the class seemed to have no trouble getting? I vowed that I would never be a coder and rebelled by not renewing my free updates for codebooks for the coming year. And then I decided I would follow my mom's path and go into the operations side of HIM, focused on legal health information issues, completion of medical records, and the general management of health information.
And then it happened. Enlightenment. Divine intervention. My aha moment. Or whatever you want to call it. I went to do an internship at a local hospital and they started me out on emergency room records. All of a sudden it started to make sense. Practical application of coding was something I excelled at. Instead of being given statements to code, I was given (small and manageable) medical records that represented real people with real problems and it was my job to translate those problems into a set of codes. That excited me.
Don't get me wrong. I coded a lot of things wrong in the beginning and that initial feeling of looking at an operative report and wanting to cry didn't go away quickly. When I was assigned a senior coder to check my work, I was amazed that I could get so many wrong and she still thought I had potential. And now, nearly 15 years later and with substantial experience in the training and education of coders, I understand what she saw. I was only there three weeks, but I learned so much and by the end of the internship I knew I was meant to be a coder. My internship supervisor thought so too. Within a month of graduation, she had another coding position approved and I had my first job as an outpatient coder.
Why Don't Employers Want to Train Inexperienced Coders?
It's a long road from learning coding in school and applying it in the real world. I receive emails from wanna-be coders across the country asking me why it's so hard to get a job as a coder and this last week I had another epiphany as I presented an intro to diagnosis related groups (DRGs) to a group of coding students at one of my Coder Coach events. It was the first time I had deconstructed a complex topic like DRGs and presented it in an "introductory" format to coding students. And as I listened to their questions and watched the look of awe on their faces as the complexity of code-based reimbursement started to sink in, I was reminded how much I've learned and how hard it is to explain that coding isn't just looking up a code in a book.
The long and the short of it is this: health care providers are being scrutinized from every angle and the best way to prevent increased scrutiny is to decrease risk. The best way to decrease risk is to ensure that staff is well educated and experienced. Unfortunately, our industry isn't doing a very good job of replenishing the ranks as coders move on to advanced coding-related jobs in other departments or with other companies. There are coding jobs to be had, but trying to get one as an inexperienced coder is really tough. So what you have to know how to do is convince your future employer that you are the right choice.
What Your Future Employer Needs to Know About You
As health care dollars become tighter and patient premiums rise, provider budgets are being slashed. The first thing to typically be cut from any budget is education dollars. Ten years ago it was much more common to find an employer willing to pay to maintain dues for professional organizations or to send employees to regular educational seminars or classes than it is today. So the first thing your employer needs to know is that you are so committed to this profession that you will pay for your own education.
But here's the best part - so much of what's out there to learn is free. It just takes time to acquire it. If you want to be a coder so bad you can taste it, this will be a labor of love for you. If you are reading this now thinking I'm nuts ("how dare she suggest my employer not pay!"), then maybe coding isn't for you. Like any career profession, what you get out of coding will be relative to what you decide to commit to it. So if you want to be an inpatient hospital coder, now is the time to start learning about DRGs. At least learn the lingo. If you go into an interview for an inpatient coding position and they are asking you about CCs and MCCs and decreasing case mix and you have no idea what they are talking about, your chances of getting the job aren't good. So let your employer know what you will do for them to expedite the training process.
What You Need to Know About Your Future Employer
I've worked with a lot of coding students over the years and there have been some stars and there have been some duds - and it doesn't take long to spot the difference. The stars haven't always been perfect, but they have an enthusiasm and skill that can't be taught in a classroom. Some of the duds just didn't have the skill. And if you don't have the skill to be a coder, trying to force your way into it is like trying to fit a square peg in a round hole.
Are you wondering if you have the skill and if it's recognizable? If so, work on getting that interview and once you get the interview, ask to take a coding test for the employer. A good coding test, even if "failed" as far as percentages go, can show a prospective employer if you have the skill to be a great coder once trained.
Of course, many people wonder why someone would hire an inexperienced coder when they could have an experienced one. That was what I wondered when I graduated and here is what my mentor/first employer told me: experienced coders have picked up bad habits along the way; hiring someone with the skill to be a good coder means the employer can train them the way they want. There are no bad habits to erase.
Use Your Employer - and Let Them Use You
Okay, that sounds less than appealing, but I mean it in the most positive way. The best jobs I've had have been the ones where there has been "mutual using" of each other. The employer takes advantage of the employee's strengths and willingness to learn and in return, the employee gets the most wanted commodity: experience. No matter how mundane a project may seem, there is probably a wealth of experience to be gained by taking the project. You won't really know how much you've learned until people start coming to you for advice or you find yourself knowing exactly how to handle a situation because of your previous work. This might mean sitting on an inter-departmental committee, working claim denials, or reading up on a Medicare memorandum about how they will (and won't) pay for certain services based on documentation and coding.
Keep an Open Mind
Whatever you decide to do or wherever you work, remember to keep an open mind. My career sure didn't turn out the way I thought it would - it turned out better than I ever imagined! If you put yourself into a boxed category you will stifle your growth, but if you believe in limitless possibilities, you just might soar! So be bold and good luck!