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

2. 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 .

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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.

10. 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.

11. 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

12. 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

13. 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.

14. 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

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

16. 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"

17. 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

18. 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

19. 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

20. 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

21. 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

22. Questions

23. Thanks