Category Archives: Coding Best Practices

Improving coding accuracy; complete and accurate coding; computer-assisted coding; CAC; remote coding; web-based coding; APR-DRGs; DRGs; diagnosis related groups

Alphabet Soup: Acronyms and E&M Coding

As healthcare professionals, we have a lot of acronyms to keep straight, don’t we? Feels like alphabet soup in my head some days. I’m reminded of a scene in the movie, Good Morning Vietnam, where Robin Williams’ character has an entire conversation using acronyms, making fun of the military jargon. We could do the same in healthcare, especially in E&M coding.

Today, let’s think a bit about HPI, not to be confused with PHI. If you have a translator in your head the way I do, these two don’t even sound the same, but for those outside the realm of coding, these acronyms can get confusing. PHI is Protected Health Information. HPI, or History of Present Illness, is the portion of the E&M (Evaluation and Management) visit during which the patient describes why they are seeing the physician. Continue reading

OPPS Proposed Rule for 2015

July 4th has come and gone, but we can still look for fireworks in next year’s OPPS proposed rule, which is now available on the CMS website.

CMS plans to continue expanding the packaging they began in 2014 by implementing comprehensive APCs and packaging of ancillary services.

Continue reading

The Real Impact of DRGs: Meaningful Data that Changed Hospital Management

A recent blog by François de Brantes, executive director of HCI3, titled “Letting the Facts Get in the Way of So-called Truths,” is highly critical of the DRG based Medicare inpatient prospective payment system (PPS). He urges readers to discover the facts about DRGs, a system he describes as endorsed by “agents of the status quo” that produces “meaningless comparisons” of patient data, with hospitals “being hurt more than helped by false truths.” As a member of the research team that developed Diagnosis Related Groups in the late 1970s, I want to respond to his assertions. Mr. de Brantes’ blog is rife with errors and distortions of fact; any valid points are lost in a barrage of misinformation. Continue reading

Oh what a tangled web we weave…The impact of CDI and Coding part II

I previously discussed how selection of principal diagnosis may impact quality. This ripple effect (like a pebble on a pond) may occur when one works in a silo, ignoring other departments such as quality. If only the ripple effect was the lone “offender” in which CDI and coding may impact quality outcomes. Consider a spider web: intricately designed and seeming impervious. However, as strands get broken, the web collapses.

In review, CDI professionals and coders are tasked with obtaining and capturing a complete picture of the patient’s encounter for appropriate reimbursement, accurate reflection of severity of illness (SOI) and risk of mortality (ROM) and outcomes of care. Historical models of CDI programs and coding processes focused predominately on the first two tasks, without acknowledgement of how this may affect quality outcomes (potentially fracturing the spider web). Continue reading

E&M Coding: Handling Two Sets of Guidelines

Evaluation and Management (E&M) coding has a lot of ins and outs. It’s the most commonly billed service, so as 3M’s first blogger in the realm of Professional coding, I think E&M coding is the best place to start this blog series. The first thing a coder or provider needs to decide is which set of guidelines to use. On the facility side of things, there aren’t any CMS guidelines to follow, but on the professional side, we have two sets: the 1995 guidelines and the 1997 guidelines. Why do we have two sets? Well, that’s a good question. Way back in the dark ages, when I was a production coder, we had one set, the 1995 guidelines. They had their problems, primarily for the specialists.   The exam of the 1995 guidelines was body part and/or organ system based. This meant that a specialist had to do a head to toe exam of a patient to qualify for the higher levels of care. For many providers, this wasn’t an issue, but for some it was. A head to toe exam isn’t really necessary for a complex ophthalmology patient. But, we all knew the body parts (arms, legs, head, neck, etc) and organ systems. We also knew how to total them up to select the level of exam documented. In short, that’s the good and bad of the 1995 exam. Continue reading

Coders and Computers, People and Machines

The bi-annual public meeting at CMS headquarters of the Coordination and Maintenance Committee is where interested parties come to propose changes to the U.S. version of the International Classification of Disease. Until the most recent meeting on September 18 and 19 this meant ICD-9, —now all proposals are exclusively for future updates of ICD-10-CM/PCS.

Discussion during these meetings centers on whether a proposed change would be useful to coders, whether additional instruction needs to be added for coders, and whether a distinction would be clear or confusing to coders. The reason for this is obvious: If new codes or coding instruction (which includes index entries, instructional notes in the codebook, and the official coding guidelines themselves) are incorrect or inconsistent, the resulting coded data is useless. Continue reading

Under the Streetlight

Towards midnight, a cop comes upon a guy crawling around on his hands and knees under a streetlight. The cop asks, “What are you doing?” “Looking for my car keys.” The cop thinks maybe he can help, so he asks, “Exactly where were you when you dropped them?” The guy looks up, considers and points into the dark, halfway down the block. “Somewhere there.” The cop asks, “Then why are you looking here?” Answer: “The light is better here.”

We’ve developed a tool that lets a payer or provider input the number of claims they submitted or processed under MS-DRGs or APR-DRGs in one year. The tool then computes estimates of the changes in reimbursement that might occur if those claims were coded in ICD-10. It also provides a table by DRG of all estimated shifts to other DRGs under ICD-10, their probability of occurrence, and projected reimbursement change. For some of those shifts, we provide a clinical explanation of the coding reason behind the shift and, when possible, improved ICD-10 coding practices that would avoid the shift. Continue reading

HIMagine That! Coding Variance from ICD-9 to ICD-10

Donna: Sue, I have been reviewing data files with ICD-9 codes translated to ICD-10 to determine if there are DRG changes between the two coding systems.

Sue: Well, Donna, what have you found?

Donna: As you would suspect, there are some variances from the MS-DRG assigned using ICD-9 codes to the MS-DRG assigned using the ICD-10 codes. But that is not the most interesting finding in my review. The issues I have come across are some strange pairings of ICD-9 codes that do not translate well into ICD-10.

Sue: I have heard that there are some variances in a small number of cases. I think one of the most common is when there is an anemia caused by a malignancy. This causes the MS-DRG to change from the anemia MS-DRG to the malignancy MS-DRG. Almost everyone has heard of this change, though, so describe what other things you are finding. Continue reading

Highlights from the CMS July APC Update

The July APC update is out, and I’m sure many of you have already installed it and find the changes 3M made valuable for you.

With this update out, we now get to look ahead to 2014. This week CMS published the proposed rules for the Hospital Outpatient Prospective Payment for next year. There seem to be a number of notable changes coming up for hospitals in 2014. I would like to highlight a couple of them. Continue reading

Coding All-Stars, Step Right Up!

This week, Julia Palmer, Project Manager with the Consulting Services Business Unit of 3M HIS joins HIMagine That’s Sue Belley to introduce the 3M Coding Challenge.

Things are really kicking into high gear in the world of healthcare information management. Inpatient and outpatient coders, CDI specialists, and professional staff are ramping up their preparations for the ICD-10 transition by doing everything from engaging ICD-10 through dual coding to measuring the financial and productivity impact of ICD-10.

In response to this, 3M is launching an ICD-10 coding challenge. We will post ICD-10 scenarios each month. Those entering correct answers will be entered in a drawing for prizes. Then we’ll report back each month and talk about what we’ve learned from the response. This is a chance for you to dig in, roll up your sleeves, and test your skill at solving ICD-10 scenarios.  Take a look below for an idea of what the scenarios, answers, and commentary will look like. Continue reading