Medical Coding - Aditi Bhat Ref: Coding HS, Coding is not just for reimbusement

Numerical representation of diseases and treatment provided What is Coding Numerical representation of diseases and treatment provided Assignment of codes based on care and services received Collection, storage and sharing of data and statistics .

Why Coding In order to count, sort and analyse text fields, it is necessary to convert text fields into a standardized format by assigning codes. Text items that are generally coded include below modules: Adverse Events Concomitant Medications Medical history Surgical History Death

History of Coding John Graunt began the statistical study of disease in the early 17th century 1837 William Farr wanted adoption of a uniform classification of causes of death In 1893 Jacques Bertillon developed the Bertillon classification of Causes of Death and the U.S. began using that system around 1898 The name was changed in 1938 to International classification of Diseases (ICD) In 1978, the ninth edition of the classification system was published and included “Clinical Modification” (CM) to its title. The new name International Classification of diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the one still used today – although transition is beginning for the 10th (ICD-10-CM) edition now

History of Coding (Contd..) Originally it was a 3-volume set, established by the WHO in 1977, but has now been condensed into 1 book that contains either two or three of the volumes giving offices the choice of buying one book containing the volume specific to its need

Compliance In the beginning, physicians were only required to give simple descriptive phrases or 1st 3-digits of the diagnosis, but today, Federal agencies and most payers require correct diagnosis coding and reimbursement which are directly impacted on those codes. Now, 5-6 digits are required for more specific diagnosis’ & treatments

Types of Dictonaries MedDRA –Medical Dictionary for Regulatory Activities WHO-ART –World Health Organization Adverse Reaction Terminology WHO-DD–World Health Organization Drug Dictionary COSTART –FDA’s Coding Symbols for Thesaurus of Adverse Reaction Terms SNOMED –Systemized Nomenclature of Medicine

Coding Process Flow Setup Coding Tool Assign Coder Perform Coding Provide on going Quality Create queries to resolve discrepancies File Documentation

Coding Process Flow Discreption Assign a Coder: The coder is a Clinical Data Manager or Clinical Safety Associate qualified to perform medical coding activities Setup Coding Tool: This is performed by the database programmer and the coder using the Annotated Case Report Form and Dictionary Coding conventions Perform Coding: This is done by the Coder and may be performed manually or automatically. Codes are assigned as closely as possible to the original verbatim unless otherwise specified by the client.

Coding Process Flow Discreption (Contd…) Create queries to resolve discrepancies: Queries are generated by the coder to resolve discrepancies for questionable and/or ambiguous data. All coding queries must be resolved at the time of database freeze Provide ongoing quality control: This is performed by the coder or may be performed by a second coder, medical director or designated physician. Quality control is performed to ensure accuracy and consistency.

Coding Process Flow Discreption (Contd…) File Documentation: The medical record is the major source document for coding and reporting of diagnoses and procedures Coding and documentation should be integrated into the process of providing care Seek clarification from providers for questions regarding documentation Responsibility for the capture of accurate diagnoses and procedures lies with the provider, not the coder Teamwork is essential between providers and coders Quality care is a principal measure

Coding Process Flow Discreption (Contd…) Remember” “Not documented, Not coded” The coder files the following, at minimum, to the Trial Master file for each clinical database: A list of any unique coded terms A list of split terms A list of blank terms Documentation of quality control review activities

Coding Types Manual Coding It may take place prior to data entry as part of the initial monitoring procedure or carried out as a separate activity. This process is generally used for studies with a small subject population. Auto Coding It may take place after data entry using a coding tool built into the system. This method permits greater consistency and efficiency since each term is programmatically assigned a code once rather than for each instance.

Selection of Diagnosis and Procedure Code Code Assign Patient Encounter Review Medical Record Selection of Diagnosis and Procedure Code Assign Code Number Sequencing of Code

Confirmed as (Not a problem) Resolution Types Resolved Confirmed as (Not a problem) Can’t be Resolved Data Management Edit Acceptable Discrepancy

Diagnosis Principal diagnosis: “The diagnosis established after study to be chiefly responsible for occasioning the patient's episode of care in hospital (or attendance at the health care facility)" Secondary Diagnosis: “A condition or complaint either coexisting with the principal diagnosis or arising during the episode of care or attendance at a heath care facility"

Documentation and Coding The medical record is the source document for coding Coders rely on the documentation in the record to determine what codes to assign for services provided Responsibility for capturing accurate diagnosis and procedures, in particular, principal diagnosis, lies with the provider, not the coder A joint effort between providers and coders is essential to achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures

Documentation and Coding (Contd..) Coders should seek clarification from providers for questions regarding documentation Resolved issues should be documented within the medical record Communication between the coding staff, providers, and other individuals involved in the coding process is vital to ensuring the accuracy of coding

Coded Data Coded data is: compiled and analyzed to reveal public health patterns and identify ways to better use resources and cut healthcare costs Used on hospital and physician reimbursement claims to describe diagnoses, services, and procedures provided Coded data serves several important functions within healthcare to include: Hospital payments and physician reimbursement Quality review Collection of general medical statistical data Clinical

Coded Data (Contd..) Functions of coded data within healthcare Epidemiology Population health Business Research Used for statistical analysis Coded data is used internally by institutions for Quality management Case-mix management Planning Marketing Other administrative and research activities

Documentation Error Inconsistent documentation Incomplete progress notes Undocumented care Missing test results Historical diagnosis documented as current Chronic conditions not documented Post-op complications not listed Documentation not completed on time

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