Coding, Classification & Reimbursement

Coding

  • 1.  Coding

    Posted 16 days ago
    ​I would like to know, is coding still a part of the HIM profession or is it changing to a finance thing?  All these years
    that I have been in the profession, it has always been HIM.  Just wanted to ask.

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    Cheryl Ervin, RHIT
    Coordinator, Health Information Management
    Community Hospital of Bremen
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  • 2.  RE: Coding

    Posted 15 days ago
    Cheryl,
    Thanks for sharing your thoughts....we are often thinking that our function here is not necessarily "HIM" but that we have suddenly become a financial department as well. I have been in the profession a lot of years and it sure has changed. We really can't be "record keepers" anymore because of financial reports, statistics, medical necessity, working rejections and on and on.....not sure it's a good thing either.
    Anyone else have thoughts?

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    Utona Hamby
    Director of Health Information
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  • 3.  RE: Coding

    Posted 14 days ago

    Ok, you have hit a  sore spot for me.  I have also been in the profession for a long time and currently work as a quality data analyst.  We need to remember our roots.  Even though finance has crept into our profession over the years, the coded data lives far beyond the claim getting paid.  And don't get me wrong, I completely understand that claims need to get out and get paid, however, when analyzing coded data for research, planning, quality, etc., it needs to be consistent regardless of payer.  Hence, is why we have coding guidelines.  Now that being said, our coding team still resides in HIM and we have built payer specific rules in our billing system.  The department also has a position called billing editor with HIM credentials that reviews rejections, denials etc.  If there is a clear mistake in the coding, then that gets fixed in the coding/abstracting system.   If it is a payer specific requirement, then the claim will get updated in the claims system (i.e. they want one code before another code).   HIM professionals are in the spotlight with conflicting priorities in this area but have the skills to navigate this opportunity. 

     

     

     






  • 4.  RE: Coding

    Posted 10 days ago
    I am interested in hearing about the reasons for coding, and I hope that people will share examples of how the codes are used within their hospitals (for example, quality measures, credentialing/appointment process, statistics, policy/procedures, resource allocation, etc.). Here is another way to look at it.  If diagnosis and procedure coding was not required for reimbursement, would we still have a need for diagnosis and procedure codes?  Absolutely yes!  I do realize that reimbursement has elevated this function to a more prominent level, but there is a need for classification systems that aggregate data for other reasons, too.  ICD-10-CM and ICD-10-PCS are not just used for reimbursement.  DRGs were in use prior to reimbursement to evaluate resources used.  Susan Ouellette shared that she is a quality data analyst.  I bet many HIM professionals who work in quality/performance improvement recognize how important coding is for reasons other than just reimbursement.  The importance of reliable, accurate, timely coded data became very clear to me when I was a quality assessment coordinator and reinforced further when I was a risk manager in a hospital.  Those who work in coding play an important role.  It is important to follow coding conventions, rules, and guidelines, and not focus solely on the role that ICD-10-CM and ICD-10-PCS play in revenue cycle. It is not just about reimbursement.  it is important to keep in mind that we really do not know how the coded data that we report might be used in the future, so it is best to keep in mind that coding is not just about reimbursement.

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    Judy Bielby
    Consultant and educator
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  • 5.  RE: Coding

    Posted 10 days ago
    Hi Judy,
    I completely agree with you, unfortunately most hospitals are looking at coding as a money making business only.
    I worked at a place where I was told to only capture codes that have an impact on the DRG. Don't query unless it has an impact on the DRG. It takes too much time to capture all services. I think that not too many places are worried about the use of codes for any reason except reimbursement.

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    Rivona Wasserman
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  • 6.  RE: Coding

    Posted 8 days ago
    It is important for those of us who truly recognize the impact of coding to educate others.  If someone were to tell me that I should only capture codes that have an impact on the DRG, I would first ask - which type of DRG system are we talking about?  MS-DRGs? APR-DRGs? IR-DRGs? Some other DRG system? I would ask this question in order to make the point that MS-DRGs are not the only system around.  Payers might reimburse based on one DRG system but that does not prevent them from performing analysis using a different DRG system and making decisions that impact reimbursement in the future.  If I were a payer and I noticed that one hospital's patients had fewer comorbid conditions (based on the ICD-10-CM codes reported) but required more resources than other hospitals that had sicker patients, I would want to look into that further.  Payers do not throw away the claims data that providers/facilities submit to them after the claim has been paid.  They use that data for other purposes.  Policy makers make the presumption that coding professionals are following the coding conventions, rules, and guidelines when they make policies.  We do not even know how all this data that have been provided to various entities will be used for future decisions, and some of those decisions will impact the bottom line in the future.  The best course of action is to keep in mind that there are many uses for coded data. It is important to adhere to coding rules, conventions, and guidelines - even when it does not have an impact on the immediate reimbursement of a claim.  Sometimes those other activities can also impact hospitals and providers financially.

    Only reporting codes that have an impact on immediate reimbursement and omitting other codes that meet criteria for reporting is a bad idea.  If you find yourself in such a situation, know that AHIMA has a resource that might help you - Standards of Ethical Coding.  If your facility includes in their compliance plan that you will adhere to the AHIMA Standards of Ethical Coding even better.  Even if your facility does not include such a statement, you (and the person who is trying to require improper coding) are still expected to adhere to these standards.  Sometimes it is just a matter of educating the other person and that is how I approach this when I find myself in situations like this.  I make the presumption that the other person does not want to do things that could get that person in trouble - they just do not know.

    http://bok.ahima.org/CodingStandards


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    Judy Bielby
    Consultant and educator
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