Terms
• Coding – classifying data and assigning a
representation for that data
• Clinical coding – coding diagnoses and
procedures
• Nomenclature – systematic listing of
proper names
• Classification – grouping together of
similar items
Other systems
• Diagnostic and Statistical Manual of Mental Disorders – DSM
• ICD-O
• Systemized Nomenclature of Human and Veterinary Medicine
International – SNOMED
– Topography; morphology; function; living organisms; chemicals, drugs,
and biological products; physical agents, activities, and forces;
occupation; social context; disease/diagnosis; procedures; general
• Read codes (specifically for use in computerized formats)
• LOINC (Logical Observation Identifier Names and Codes) – for
laboraory (mapped to SNOMED)
• Case Mix and Severity of Illness
– DRGs, RUGs, Atlas
Cooperating Parties for ICD-9-CM
Organization
Responsibilities
National Center for Health Statistics
• Maintains the disease classification
• Approves official coding guidelines
Health Care Financing
Administration
• Maintains the procedure classification
• Approves official coding guidelines
American Hospital Association
• Maintains Central Office on ICD-9-CM
• Approves official coding guidelines
• Publishes Coding Clinic
American Health Information
Management Association
• Certifies coders
• Provides coding education
• Sponsors Council on Coding and
Classification and the Society for Clinical
Coding
• Approves official coding guidelines
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Coding Process
• Review of medical record
• Selection of diagnoses and procedures to
code
• Assignment of code numbers
• Sequencing codes (esp. inpatients)
• Entry of coded data into database
(abstracting)
• Generation of indexes and Entry of codes
on patient’s bill
DRG’s
Notice to Physicians: Medicare payment to
hospitals is based in part on each patient’s
principal and secondary diagnoses and the
major procedures performed on the patient, as
attested to by the patient’s attending physician
by virtue of his or her signature in the medical
record. Anyone who misrepresents, falsifies, or
conceals essential information required for
payment of Federal funds, may be subject to
fine, imprisonment, or civil penalty under
applicable federal laws.
Encoder
• Logic – asks questions
• Automated codebooks
Ethical coding
• http://www.ahima.org/infocenter/guidelines
/standards.cfm
Quality of Coding
• National Correct Coding Intitiative (NCCI)
– Fiscal intermediaries
– Medicare Code editor
• Peer review organizations – now Quality
Improvement Organization (QIO)
– South Dakota Foundation For Medical Care
http://www.sdfmc.org
• Fraud and Abuse – compliance plans
Quality of Coding
• Reliability – get same results
– Same coder is intrareliability
– Different coders is interreliability
• Validity – accurately reflect
diagnosis/procedure
• Completeness –
• Timeliness –
Cause of Errors
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Failure to review entire record
Selection of incorrect principal diagnosis
Selection of incorrect code
Coding dx/proc not validated in record
Errors in data entry
Improve Quality
• Coding policies
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Instructions on what to do about conflicting documentation
Instructions on what to do when a code cannot be found
Directions for reviewing the record
Use of optional codes (e.g., outcome of delivery, M codes)
List of UHDDS definitions
Directions for keeping books updated
Use of reference materials (e.g., Coding Clinic)
Requirements for abstracting
• Quality improvement studies
• Documentation guidelines
Hiring Coders
Coding time per record x number of discharges
and/or visits for period
___________________________________
Number of paid hours worked per coder for the
time period
30 minutes x 10,000 discharges/year = 300,000 minutes or 5000 hours
______________________________________________________
1800 hours/year (2080 is full time, figure for time off, breaks, etc.)
5000/1800 = 2.78 coders needed
Other Issues
• Retention of coders
– Incentive system
– CE opportunities
– Benefits (work setting, flex time)
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Resources
Contract coding and review services
Concurrent/Retrospective coding
Specialization