Friday, July 22, 2011

DNFB, AR, Bill Hold and Other Things You Need to Know Before You Interview at a Hospital

I've interviewed my share of individuals who come in with a padded resume who discredit themselves in about 5 minutes. It has nothing to do with a coding test, education, or certifications. They don't know what the DNFB is. And that is tell tale sign that they have never worked in a hospital coding department before. I can deal with inexperience and honesty. I have trouble accepting lying and deceit.

And while I can't give you all experience, I can let you in on some important coding lingo and explain why it's so important. DNFB stands for "discharged, not final billed." It means - every account held for billing for some reason. Some hospitals refer to it as AR (accounts receivable) or simply "the unbilled." The reasons for unbilled accounts are generally categorized into 3 major buckets:
  • Accounts within suspense (also known as the bill hold) is a facility-defined number of days in which an account will be held from billing so charges can be entered after the patient is discharged from the hospital. Any charges added after the suspense period, which typically ranges from 3-5 days, are considered late.
  • Accounts outside of suspense and not coded - charts awaiting coding before bill drop.
  • Accounts outside of suspense and not billed - charts that have been coded but are being held by billing until issues are resolved (e.g., awaiting late charges)
The concept is simple - the patient receives services, charges are entered, the record is coded and billed. The execution is complicated and the process can hit a number of hiccups before the bill gets out the door.

An informed coding manager can tell you any given day where the facility's DNFB is sitting, particularly those that fall outside suspense and have not been coded. An effective coding manager reports the DNFB to his/her coding staff on a daily basis, keeps the unbilled accounts at a dollar figure the CFO can live with, and can tell you why accounts haven't been coded.

In my experiences with DNFB cleanup as a consultant, I can tell you, it's often not a shortage of coding staff that leads to a high unbilled report. At one client, I was given unlimited coding resources, but as I looked outside my office at the empty shelves that were supposed to be filled with paper records (this was about 10 years ago), I remember telling my boss not to send me more coders but to send me people who could find charts instead. This began a major search in the hospital for medical records that never came down from the floors. Today as we pave the way for electronic health records, there are still a lot of facilities using paper that is then scanned into an electronic format, so tracking down this paper is still an issue for some.

In short, DNFB is not just every coding manager's responsibility, it's every coder's responsibility. You should be prepared to react to fluctuations in the DNFB - when it's high, you may be asked for overtime, denied time off, or taken off other projects that don't contribute to dropping bills (e.g., going to educational seminars). If you're being trained in a new area of coding but are proficient in another, you may be asked to revert to your level of experience before continuing your training.

Thursday, July 21, 2011

Evolution of the Coder Coach

I recently looked over my past blog postings to see what material I haven't covered. Well, there's a lot. And I realize my last few posts have been very heavy on ICD-10 - mainly because that's what I'm working on most of the time. It got me thinking, though - have I strayed from the initial intent of this blog? Who is my audience - current coders or future coders?

I have a friend and avid blogger (who's blog I am sorely behind in reading!) whom I consulted before I started the Coder Coach blog and I asked her, "What do I blog about?" She said, "Whatever you want!" Perfect! Because if I can't write about something I truly want to write about, what's the point of having a blog?! And today it really hit home - my audience has expanded.

I started the Coder Coach group and blog about 2 years ago because I identified an alarming trend. Schools are turning out coding professionals by the dozens and many of them are becoming certified. They spend a lot of time, money, and effort to get the training they will need to land them in a lucrative career only to have the doors of employers slammed in their faces because they lack experience. I've talked to my peers and we're all under regulatory pressures that make it difficult for us to train new employees. But can we ever really expect to hire someone who can truly hit the ground running without any training?

The Coder Coach isn't just this blog, it's also a Facebook group (where I post links to this blog and others) and it's a group of curious individuals in the Denver area who get together every couple of months to learn something about coding from a pro (not always me!) that goes above and beyond classroom learning. In my mind, the Coder Coach is helping to fill that big gap between school and experience.

But as I mentioned, my audience is growing. The unknown isn't just limited to coding students and new grads right now. The coding field is about to undergo a monster transition and at the same time, health information management (HIM) professionals are struggling with implementation of electronic health records (EHRs), health information exchanges (HIEs), and meaningful use standards. As an HIM professional and coder, I see and talk to many people who are paving the way for the future of these professions. My mother is a retired RHIT who was before her time - she retired about 10 years ago and before her retirement was really excited about the future of EHRs. When I tell her about what's going on in the field right now, she is in awe - we are just starting to realize what she had a vision for 15 years ago.

And as I've toured the state of Colorado, conducting outreach through our ICD-10 Task Force, I've had many HIM practitioners asking me questions that coding students ask me. Should they consider a change from the operational side of HIM to coding and what's the best way to do it? So I will try to give a good balance in my blog postings of basic things I think anyone interested in a coding career should know now along with what everyone seems to need - a little insight into what it will be like as an ICD-10 coder.

Happy evolving to all of us!

Wednesday, July 20, 2011

31 Flavors of Ice Cream, 31 Root Operations in ICD-10-PCS

Sunday I decided to give up ice cream. Not forever, just for a few weeks or so while I try to kick what has become a rather troublesome sugar addiction. It turns out Sunday was not a good day to give up ice cream because that was National Ice Cream Day. How that very important holiday was omitted from my Outlook calendar when I imported all the US holidays, I'll never know, so I will have to be more watchful next year. I am proud, albeit unsatisfied, to tell you I stuck to my guns and didn't celebrate National Ice Cream Day this year. There's always 2012!

You might be laughing right now, but ice cream is a very serious matter to me. When asked what my favorite ice cream is, I will inevitably ask you "from where?" and then launch into a tirade about how the manufacturer is key in determining what flavor to eat and continue with a discussion about proper chocolate-to-ice-cream ratio that would make Sally Allbright from When Harry Met Sally proud. I consider myself a bit if a connoisseur, which my mother tells me goes all the way back to that first ice cream cone I "shared" with her. The words "death grip" come to mind when I think of her telling the story. In short, she didn't get any ice cream that day and so began my love affair with the creamy treat.

Monday morning, ice cream ban still in full swing, and ready to start another work week, I shuffled into ICD-10 Central (aka, my office), where it's quite obvious there is some serious ICD-10 work going on: the two large flipchart posters on the wall listing the root operations, stacks of ICD-10 books from current and past years, and a hot pink post-it stuck to my July (national ice cream month!) calendar stating quite simply: "31 Flavors of ice cream - 31 Root Operations."

The ice cream post-it is the only way I can remember how many root operations there are in ICD-10-PCS. I heard a speaker once tell the audience to take a root operation a month and study it in preparation for ICD-10-PCS and then she said there weren't enough months before implementation. And sure enough, here we are in July 2011 and the October 1, 2013 deadline is looming ever closer - only a couple years away.

When I tried to relay that story to one of my audiences, I decided it was pathetic I couldn't tell anyone off the top of my head how many root operations there were. So thank you, Baskin Robbins, for helping me out with this one and loaning me your 31 Flavors terminology. Even though at last count there were more than 31 flavors behind your counter. And even though, in my mind, there is only one flavor of Baskin Robbins ice cream (accolades for proper chocolate-to-ice-cream ratio!).

So there you have it. There are 31 root operations in ICD-10-PCS that hospital inpatient coders must become familiar with. It will be quite impossible to code without knowing the root operations. For ease of use as I have sat down with medical records and began coding my little ICD-10 heart out, I posted the wall charts right in front of my desk, arranged in categories I wish I could take credit for creating:

Root operations that take out some or all of a body part:
  • Excision
  • Resection
  • Detachment
  • Destruction
  • Extraction
Root operations that take out solids, fluids, or gases:
  • Drainage
  • Extirpation
  • Fragmentation
Root operations that involve cutting or separation:
  • Division
  • Release
Root operations that involve putting in or putting back or moving some or all of a body part:
  • Transplantation
  • Reattachment
  • Transfer
  • Reposition
Root operations that alter the diameter or route of a tubular body part:
  • Restriction
  • Occlusion
  • Dilation
  • Bypass
Root operations that always involve devices:
  • Insertion
  • Replacement
  • Supplement
  • Change
  • Removal
  • Revision
Root operations that involve examination only:
  • Inspection
  • Map
Root operations that involve other repairs:
  • Control
  • Repair
Root operations with other objectives:
  • Fusion
  • Alteration
  • Creation
Some root operations have very limited use: mapping is used only for cardiac electrophysiology mapping; the root operation creation has only two possible uses - gender reassignment from male to female or vice versa. Some are more commonplace: excision is removal of part of a body part while resection is removal of the entire body part. That contradicts the way we code today where excision is a complete removal.

But don't worry - this alien new coding system comes with its own set of guidelines that define these root operations and tell you when to code out separate components of a procedure. For example, there is a hierarchy for spinal fusions that utilize bone graft, internal fixation, and cages so you only end up with a single code. On the other hand, placement of a completely embedded vascular infusion device requires two codes: one for catheterizing the vessel, and one for placement of a subcutaneous port.

If you're wondering how to get a leg up on ICD-10, don't bother learning to code it right now. We've all heard that, right? You will forget it unless you use it every day. But you can and should start reading the coding guidelines and become familiar with the table format of ICD-10-PCS. It's different for everyone who codes now (that was spy code for all you novices looking for a level playing field!). ICD-10-PCS coding will identify a whole new population of coders with the skill to properly categorize root operations. It will mean knowing not only the name of the procedure, but what that procedure is trying to accomplish and how it's performed. So brushing up on surgical procedures is a great way to bide your time until it is time to get moving with hands-on training.

So are you ready to test out those 31 flavors of root operations? I will start posting some teasers for you and you can test your ability to name that root operation. If you would like to download the latest version (2012) of ICD-10-PCS, the files are free at CMS' website - guidelines included! Check it out here at: While you start reading, I am going to go hide my car keys and my Ben and Jerry's pint cozy. I suddenly have a craving for ice cream. Weird.

Wednesday, July 13, 2011

Evolution of the Coder

When I started the HIM program at the local community college in... ahem, a few years ago (sly smile), I split my time working as a file clerk in a doctor's office and a catch-all clerk in a physician's billing office. The doctor's office was a family practice managed by the owner of the billing office, which was located just next door. I remember my coworkers asking me why I was going to school to learn about medical records because I was already a file clerk. I also remember hearing one of the billers grumble about an insurance company denying claims for a male patient with pelvic pain and "can't men have pelvic pain?!"

Well, it didn't take me long to realize that the HIM field was more than filing - especially these days as hospitals and physicians move to electronic health records. And it didn't take me long to learn that, at least in the eyes of ICD-9-CM, men can't have pelvic pain - at least not the kind classified to code 625.9, Unspecified symptom associated with female genital organs (as evidenced by the word "female" in the code description and the little female symbol next to the code).

That was a long time ago and a lot has changed in the coding (and HIM) field since then. As a consultant, I work with hospitals to identify areas for coding education and then develop a curriculum and deliver training. It used to be as simple as telling my client to have all their coders at the training at a specific time and date. But not anymore. You see, the coders in a hospital aren't just sitting in the coding unit (physical or virtual) anymore. There could be coders all across a hospital. There could be people coding who don't even know they're coding. There could be nurses working with doctors to improve their documentation to ensure proper code-based reimbursement. There could be clinic coders coding the professional side for physicians working in hospital-based clinics. Finding coders in a facility is a challenge!

In short, coding has evolved.

And this is a great thing - this means that if you have the skill to be a coder - and it is a skill - there are many directions your career path can take you. So what's your passion? Do you relate to transactional work? Are you production oriented? Do you like the clinical puzzle involved in coding and secretly harbor fantasies of being Dr. Gregory House and solving the diagnostic dilemma in front of you? Do you like finance? Are you a data hound? Do you love to do research? If you answered yes to any of the above, there's a niche for you in coding.

The Transactional/Production Coder
I'll be honest. As a coder, my production, in general, stinks. At least it did the last time I did it. Some days I could concentrate very well and knock out a bunch of records. Some days it was like ADD kicked in and I just couldn't concentrate on the documentation in front of me. But there is a group of very special people who are production-based and enjoy transactional work. These are the people who are a coding manager's dream. They come to work, know how many accounts they need to code for the day, and they get it done. I have a lot of respect for those people. I wish that was me!

The Dr. House Coder
I use the TV show, House, a lot in my training sessions and blogs. I watch it and see if I can diagnose the patient before Dr. House. Usually not. But it's fun to try! Physicians and nurses alike are often surprised when they talk to coders to learn how much coders know about clinical practice and disease process. If you read enough medical records in your lifetime and see the treatment plans, it starts to rub off! If you love the clinical stuff like me, there's a lot of opportunity. Clinical documentation improvement (CDI) programs are popping up all over hospitals. The point: get the physician to document as specific as possible to ensure proper reimbursement for the hospital. Clinical documentation specialist (CDSs) are on the floor, looking at charts while the patient is in-house and talking directly with physicians. This is a job that can be done by a nurse or a coder who has been given proper clinical training. Some hospitals employ both coders and nurses as CDSs for a collaborative effort. I don't really have a desire to go back to working for a hospital, but if I did, I think I would like to be a CDS.

The Code-Based Reimbursement Coder
More and more I see coders being placed in the billing departments of hospitals. Or certified coders being given the role of charge description master (CDM) analyst. As Medicare and other code-based payers get really sticky with their billing requirements, it gets more difficult to get a clean claim out the door. Coders working on the revenue side are typically ensuring hospital systems that incorporate the use of codes are updated and interfacing/functioning properly.

A CDM analyst maintains the hospitals list of charges. If you're looking for a picture of what a CDM looks like, it's a massive spreadsheet for each department in the hospital with a line item for everything they could possibly charge for along with prices for those services and supplies. And some of those line items are attached to codes. CDM analysts work with clinical department heads to make sure charges are set up for all their services and supplies. They also make sure CPT and HCPCS codes in the CDM are updated according to regulatory standards. They might be called into a clinical department to assist in training personnel who are responsible for charging.

For lack of a better title, the code-based reimbursement analyst (an aptly named title I borrowed from a former employer where I was responsible for training code-based reimbursement analysts), is a catch-all before a claim goes out the door. Or someone who audits claims and makes corrections. This person may be responsible for working NCCI edits to get claims through the hospital scrubber and may also work closely with the coders, educating them on the latest Medicare reimbursement changes.

Code-based reimbursement analysts may also be placed in departments prone to frequent coding and charging errors, like interventional radiology, wound care, or injections and infusions. These specialty coders often work not only with documentation, but also with nurses entering charges and physicians regarding their documentation. They may also have a link to billing so they can see how their coding is translating to claim denials and errors.

If you like the revenue and compliance side of coding, there are lots of opportunities for you. Students and recent grads interested in this area often ask me where they can get training or certification for this type of job. Well, there really isn't a specific type of training for it. The best thing you can do is try to get your foot in the door and learn on the job. The coding piece of this is probably the hardest - the rest you learn from your employer. Revenue cycle is part of what I do as a consultant and I like it. I particularly like trying to figure out the complex changes Medicare has put into effect and walking that tightrope between ensuring the provider is getting paid as much as possible while maintaining revenue compliance. Let's just call this code-based coder the "Goldilocks" coder - don't code too much, don't code too little, code just right!

The Data Coder
Maybe you like analyzing data. I for one, find it dull after about 15 minutes. But I've had the joy of working with people who love doing that so we can leverage our skills for the greater good. There are many opportunities for the data-oriented coder. Of course, we should all be concerned about data integrity and coding what was done. But there are positions for people who want to slice and dice and interpret coded data. Registry programs (e.g., cancer, trauma, cardiac) often incorporate the use of codes and then some. The plus to being a registrar is that you usually become an expert in one particular area. For example, I know a cancer registrar who has been to enough tumor board meetings where cancer cases are discussed among physicians, she can effectively diagnose skin cancers most of the time (of course, the real diagnosis comes from a physician!).

Coded data is used by many - health departments, clearinghouses, universities, state hospital associations - and the list goes on. As the government becomes more concerned about outcomes of care and pay-for-performance in hospitals, there is a heavier reliance on accurate coded data. Independent companies like HealthGrades rely on coded data to compare the quality of healthcare among providers and report it to consumers. Someone is behind that data ensuring it's accuracy and interpreting it's impact and meaning. That could be you!

The "Why" Coder
I saved the best for last - well, in my opinion anyway. The "why" coder is the one who loves research and wants to know why. Why will Medicare not pay for a biopsy and an excision of a lesion done at the same time? Why does Medicare pay less for certain patients who have been discharged to a nursing home rather than home? What's the difference between two codes that at first glance appear to have identical code descriptions? Why can't men have pelvic pain?! And this is why I have trouble being a production coder. It's hard to produce when you keep asking why. Luckily, I am able to put my investigative skills to work and do research to build training materials for other coders - like production coders - so they can do their jobs efficiently. The best thing about the "why" coder is that it's free. You can learn just about anything you ever wanted to know about Medicare and their why's and not pay a cent. Of course, the price for accessing public domain information is the sheer amount of information you need to paw through to answer a single question - it can be several hundred pages.

So what's your passion? What kind of coder will you be? The opportunities are endless and we need all kinds!