Merchant transactions usually entail a few steps: Purchase stock for the operating business at wholesale prices; set a retail price that covers operating costs, plus profit; sell the product and receive debit or credit payment if paid immediately upon purchase; if not, bill the customer if that is part of the business model; keep track of inventory to replenish stock when needed; repeat.
Pretty straight forward.
Not so in the Health Information Management (HIM) Department at Box Butte General Hospital, which is vital in processing all the charts, charges and patient health information requests made each month. This article will focus on just the coding manual coders go by and the steps they use to make sure all criteria are met for payment by individuals and insurers, be they private (e.g. Blue Cross/Blue Shield) or public (e.g. Medicare, Medicaid). Hold on to the proverbial hat.
The coding manual currently in use by the health care industry is something called the International Classification of Diseases, Version 9, or ICD-9 for short. The coding manual (with its attending ICD Clinical Modification section [ICD-9-CM] used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization) is almost three inches thick. It contains approximately 81,000 codes describing everything from an injured index finger treated in the ER to the x-ray ordered to determine the extent of the injury. Add to that codes used to determine how the break occurred, where it occurred (e.g. at home or at work), how it was treated, drugs (if any) used to treat the injury and a multitude of other modifiers often required to complete the charge process, and readers may get a glimmer of an idea about the complexities involved to get a bill out the door to clients using hospital services. Code it right, and payment may be received in weeks from third party insurers. Code it wrong, and payment is often delayed months.
The Health Information Management (HIM) coder depends on the team work of a multitude of staff (from admission staff, nurses and medical providers to rehab, lab and radiology technicians) to accurately chart diagnosis, treatment and ancillary services rendered. Each and every one has to correctly document each encounter with a patient in a timely manner. One delay in reporting or incorrect data input can create a snarl that adds days to the billing process.
Coder Ann Weishaar gave a step by step demonstration of how she would code a simple Emergency Room encounter involving an imaginary patient who had fallen, lacerating the back of the head requiring only an adhesive strip, some pain medication, and a trip to radiology for a CT scan to make sure there was no neurological damage or neck injury incurred from the fall. For this sample case, the patient was not admitted to the hospital and was discharged within a few hours of being transported to the ER via ambulance.
Patient charts are audited by another HIM staff member prior to coding to insure all charges are correctly entered based on the documentation. The coder is the one who determines the accurate coding based on the documentation, her knowledge and use of references. “First we review the charts and notes provided by the attending nurse, medical provider and any ancillary department involved,” Ms. Weishaar said. “Once it is determined there are no glaring omissions and everything looks in order, I start our 3M Encoder software, which provides a step by step process for coding the encounter.” Around 12 popup windows later and after reviewing a summary window at the end that highlights any inputs that may need further modifying codes, she saves the information she’s entered.
That was just for a simple ER encounter. “It takes me around five minutes to process a chart from the ER,” Ms. Weishaar said. “For an inpatient encounter, that can take as long as 30 minutes because of all the treatment and ancillary services that can entail. Outpatient encounters aren’t as lengthy, taking about 3-5 minutes each.”
BBGH HIM Manager Claudia Olafson, CCS, reports HIM processes anywhere from 65 to 85 inpatients a month. Outpatients processed averages around 1,955 per month. “So every minute counts when processing that many clients each month,” she said. Her department has four coders on staff.
This is where it gets even more complicated: Pity the poor coder when October 1, 2014 arrives. That’s the date ICD-10-CM comes on line, with those 81,000 codes ballooning to approximately 168,000. For example, where only10 codes were needed for the fingers of each hand under ICD-9, there will be 27 codes under ICD-10.
“It’s going to be a challenge to be fully trained on the go live date, but we’ll meet it,” said Ms. Olafson, who is also an AHIMA approved ICD-10 Trainer. “I have four HIM employees scheduled to train for 300 man-hours each from now until the October 1, 2014 implementation date. That’s a lot of training.” Most of that is due to the complexity of the coding itself, including: going from a five digit numerical code to a seven digit alphanumerical code structure; some chapters being rearranged, some titles changed and conditions being regrouped; ICD-10 having more than twice as many categories as ICD-9; and finally, some fairly minor changes made in the coding rules for mortality.
The United States is the last industrialized nation to adopt the ICD-10 coding matrix. “ICD-9 is over 30 years old, uses outdated terms, and is inconsistent with what the other industrialized nations use (ICD-10),” Ms. Olafson said. “Discussion began in 1999 to change to the internationalized ICD-10 coding, and it’s taken this long to get it reviewed, discussed, amended and finally acted on.” She added the rest of the world is scheduled to start using ICD-11 in 2014. “So we’re a bit behind the curve, but going from ICD-9 to ICD-10 was the real challenge. I don’t think transitioning to ICD-11 is going to be nearly as hard.”
What is the bottom line on how important the HIM department is at BBGH? Well … it’s the bottom line, literally. “Over the past two weeks, we’ve processed 523 charts, including all outpatients and inpatients of the various departments, totaling $629,511.92,” Ms. Olafson said. “For us to receive that money in a timely manner, our department has to be sure each and every code is proper and complies with what insurers need to process claims in a timely manner. Is that process completely flawless? No. There are just too many human factors involved. But we continually strive to make it as flawless as it can be considering the complexities of the job.”