Greetings! My name is Deanne Hicks and I have worked in the Health Information Technology field as a certified coder for the past ten years. So, what is coding? The greatest analogy I can use to describe coding is to compare it to learning a new language. Essentially, it is the art of storytelling. A coder abstracts information from the patient's medical chart and translates that medical information into alpha or numeric codes that are up to five characters in length. There are several uses for codes, with the most common usage to drive reimbursement for providers. The other uses are for statistic collection, vital records for cause of death, public safety for communicable disease reporting, epidemic/pandemic reporting from hospital records in certain geographic areas and a host of other topics.
You may wonder how someone becomes a coder. For me, I needed a life change and decided to go back to school. Having just gone through a fairly difficult pregnancy, undergoing several encounters with a myriad of different providers over a course of almost two years, medical terminology and anatomy became fascinating to me. I wanted to learn more! I signed up for a diploma program as a medical office assistant and away I went, on a journey from which I have never turned back. I learned more about the human anatomy than I ever thought possible. When I took my medical terminology course, I was completely hooked! Once I got to the medical billing and coding portion of my program, I was on cloud nine. Although medical billing an insurance didn't interest me, I still persevered onward, patiently awaiting this thing called medical coding. Once I learned how to code, it was as if I had found my passion. For the first time in my life I knew what I wanted to be when I grew up...a Coder.
Earlier, I mentioned that coding is first and foremost, utilized in order to get the provider paid. As young medical students who dream of becoming a physician someday, wouldn't you eventually like to get paid for your time? I realize you will most likely have a hefty student loan to repay, so I suspect you will appreciate getting maximum reimbursement for services rendered. Yes, your practice will have a coder to assist you in this effort, but what you need to keep in mind is this; coders code from the medical record so the more complete and specific the documentation is, the more specific the code choice will be. In turn, the higher the reimbursement might be!
Here is a great example, hypertension. In the coding manual, hypertension is divided into three types, those being malignant hypertension, benign hypertension and unspecified hypertension. Malignant hypertension (ICD-9 code 401.0) is defined as very high blood pressure that comes on suddenly and quickly, with the diastolic reading above 130mmHg. With malignant hypertension, complications could arise with kidneys, blindness or an increased risk of stroke or myocardial infarction. If a patient exhibits symptoms such as blurred vision, confusion, anxiety, chest pain, nausea, vomiting, shortness of breath, or weakness in the limbs with a high diastolic reading, malignant hypertension needs to be considered. However, more often than not, the treating physician will simply enter the abbreviation of "HTN" on the encounter form. Because coders code from the medical documentation given, the only code choice would be unspecified hypertension (ICD-9 code 401.9). Also, benign hypertension's (ICD-9 code 401.1) definition describes this type of hypertension as slightly elevated blood pressure which, if left untreated, could cause cardiovascular and central nervous system complications.
If a physician were to document and diagnose the specific type of hypertension, this would open up the opportunity to allow a deeper evaluation of the patient with blood work, ECG if warranted, additional body systems to examine and evaluate as well. In order to code the encounter in the outpatient setting, the more body systems examined and the more test results to review on subsequent visits, the higher the level of coding for the physician's cognitive skills. All things considered, the reimbursement level for the provider will increase over a period of time, which will certainly help to make the practice thrive and in turn give the patient a higher level of care.
Everyone is a winner! Here is the successful chain of events:
- Medical students learn to give greater detail in medical documentation in preparation for future billing
- Coders and billers can code more specifically from detailed documentation
- Greater reimbursement can be obtained
- Patient's, doctors and coders are happy
Deanne works with Lincoln Group of Schools, a group of career training schools. She is a medical billing and coding training instructor, which is one of the various Lincoln programs available.
Question of the Week
While attending the cardiology clinic, the staff nurse measures the blood pressure of a 61 year-old man and finds that it is 182/100 mmHg sitting and 190/104 standing. He has a heart rate of 82/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackles on chest examination. Which of the following pathological findings is most likely to be present?
A. Left ventricular hypertrophy
B. Left atrial myxoma
C. Occlusive coronary atherosclerosis
D. Cor pulmonale
E. Mitral regurgitation
Answer & Explanation