Overuse of Unspecified Diagnosis Codes

Coding Notes
ImprovingDiagnosisBy Jacquie zegan, CCS, wC

Specificity in ICD-IO Coding

VALID ICD-IO-CM/PCS (ICD-IO) codes have been required for claims reporting since October 1, 2015. But ICD-IO diagnosis coding to the correct level of specificity—a more recent requirement—continues to be a problem for many in the healthcare industry. While diagnosis code specificity has always been the goal, providers were granted a reprieve in order to facilitate implementation of ICD-IO. For the first 12 months of ICD-IO use, the Centers for Medicare and Medicaid Services (CMS) promised that Medicare review contractors would not deny claims “based solely on the specificity of the ICD-IO diagnosis code as long as the physician/practitioner used a valid code from the right family.”l Commonly referred to as the “grace period,” this flexibility was intended to help providers implement the ICD-IO-CM code set and was never intended to continue on in perpetuity. In fact, this CMS-granted grace period expired on October 1, 2016.2

   Unfortunately, nonspecific documentation and coding persists. This is an ongoing problem, even though the official guidelines for coding and reporting require coding to the highest degree of specificity. Third-party payers are making payment determinations based on the specificity of reported codes, and payment reform efforts are formulating policies based on coded data. The significance of overreporting unspecified diagnosis codes cannot be understated. In the short term, it will increase claim denials, and in the long term it may adversely impact emerging payment models.3•4 Calculating and monitoring unspecified diagnosis code rates is critical to successfully leverage specificity

44/Journal of AHIMA April 18

in the ICD-IO-CM code set.

An ICD-IO-CM code is considered unspecified if either of the terms “unspecified” or “NOS” are used in the code description. The unspecified diagnosis code rate is calculated by dividing the number of unspecified diagnosis codes by the total number of diagnosis codes assigned. Health information management (HIM) professionals should be tracking and trending unspecified diagnosis code rates across the continuum of care.5

Acceptable use of Unspecified Diagnosis Codes Unspecified diagnosis codes have acceptable, even necessary, uses. The unspecified code rate is not an error rate, but rather an indicator of the quality of clinical documentation and a qualitative measure of coder performance and coding results. Even CMS explicitly recognizes that unspecified codes are sometimes necessary. “When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code.”6 It’s also important that coding professionals use good judgment to avoid unnecessary queries for clarification of unspecified diagnoses. The official coding guidelines provide explicit guidance for appropriate uses of unspecific diagnosis codes.7

Overuse of Unspecified Diagnosis Codes

Coding NotesConditions Commonly Reported with Unspecified Diagnosis CodesAlcohol and drug use, abuse, and dependence· Alzheimer’s diseaseArthritis· Asthma· Atrial fibrillation· Atrial flutter· CardiomyopathyCerebral palsy· Congestive heart failure (CHF) DepressionEpilepsy· Intestinal obstruction MigrainesNeoplasmsNon-pressure ulcers· PneumoniaPressure ulcers· Respiratory failureSepsis· Strokes· Traumatic injuries

Overuse of unspecified diagnosis codes is a problematic trend. Use of unspecified ICD-IO-CM codes, ignored during the first year following implementation of the code set, is not improving. In this author’s experience, unspecified diagnosis code rates can range anywhere from 20 percent, on the low end, to over 40 percent. A diagnosis code rate over 30 percent requires investigation and appropriate corrective actions.

Widespread use of unspecified codes should be the exception, not the rule. 8 High unspecified diagnosis code rates may be due to either clinical documentation or coding practices. One strategy to ensure unspecified codes are used appropriately is to monitor unspecified code rates and address any upward trends or outliers. HIM professionals should spot check the most commonly reported unspecified codes. Review the clinical documentation on a targeted sample to confirm that the reported codes align with the degree of specificity in the health record. Examples of some conditions most commonly reported with unspecified diagnosis codes are listed in the sidebar above.

HIM professionals should identify the most commonly reported unspecified diagnosis codes in their facility and review a sample of related encounters to confirm that unspecified codes were used appropriately. When overuse of unspecified codes is identified, solutions may involve improvements in the specificity of clinical documentation or process improvement to ensure coding professionals are coding to the highest degree of specificity that is available.

Specificity in Physician Documentation

                       Coding specificity is a shared responsibility between the provider and the coding professional to create a clear clinical picture of the encounter. Providers have an obligation to document conditions to the full extent oftheir clinical knowledge of the patient’s health. Toward this aim, providers may need assistance—in the form of provider education or clinical queries—to recognize relevant clinical details that may impact the specificity of code assignment. Inpatient and outpatient clinical documentation improvement (CDI) efforts should address documentation specificity to leverage the details available in ICD-10-CM.

Coding to the Highest Degree of Specificity

While physicians are expected to document the most specific clinical diagnosis, it is equally important that coding professionals assign diagnosis codes to the highest degree of specificity documented. There is a disturbing amount of unspecified diagnosis code reporting when more specific diagnoses are documented in the health record. Cod ing professionals must continually train their “coder eye” to look for specificity in provider documentation. A finely tuned “coder eye” and attention to the level of specificity available in the ICD-IO-CM code set will ensure the highest degree of specificity of the codes assigned and reported.

As a final step in the coding process, coding professionals should perform a final review of the diagnosis codes on an encounter. Diagnosis codes ending in the numbers zero or nine are often indications that an unspecified diagnosis code was assigned. A quick second review of the clinical documentation associated with these codes may reveal clinical details needed to derive a more specific diagnosis code. Supporting documentation, particularly imaging reports, may be used to code to the highest degree of specificity when the physician has already documented a condition. AHA Coding Clinic for ICD-IO-CM and ICD10-PCS, from the American Hospital Association, provides guidance for using documentation from imaging reports when a physician has already documented a condition, such as a fracture, stroke, or pain. 9′ 10′ 11 The following coding examples demonstrate appropriate coding to the highest degree of specificity.

Coding Example A

For this example, the documentation in the outpatient setting is as follows: the emergency department provider

Journal of AHIMA April 18/45

Coding Notes

A finely tuned “coder eye” and attention to the level of specificity available in the ICD-IO-CM code set will ensure the highest degree of specificity of the codes assigned and reported.

documents a “non-displaced right talus fracture.” The right the-July-6-2015-CMS-AMA-Joint-Announcement.pdf.
ankle X-ray documents a “non-displaced avulsion fracture 3. Eramo, Lisa A. “Don’t Deny the Denials: Experts Recom-
of the right talus.” mend Implementing a Strong Claims Denial Strategy to
The code S92.101A, Unspecified fracture of right talus, was Offset ICD-10-based Coder Productivity Loss.” Journal of
initially assigned. After a final review, the code S92.154A, Non- Al-IIMA 85, no. 6 (June 2014): 30-33.
displaced avulsion fracture of right talus, is assigned based on 4. Fernandez, Valerie. “Ins and Outs of HCCs.” Journal of
the greater specificity found in the imaging report. AHIMA 88, no. 6 (June 2017):54-56.
5. Stanfill, Mary H. “Call for Additional Coding Metrics.”
Coding Example B Journal ofAHIMA 86, no. 4 (April 2015):56-57.
For this example, the documentation in the inpatient setting 6. Department of Health and Human Services. “Infor-
is as follows: the history and physical and discharge summa- mation and Resources for Submitting Correct ICD-IO
ry document that the patient suffered an “embolic cerebral Codes to Medicare.” MLN Matters. 2014. www.cms.gov/
infarction with residuals.” The brain CAT scan report docu- Outreach-and-Education/Medicare-Learning-Network-
ments a “large embolus in the right middle cerebral artery MLN/MLNMattersArticIes/Downloads/SE1518.pdf.
(MCA) territory.” 7. Department of Health and Human Services. “ICD-IO-CM
The code 163.40, Embolic cerebral infarction of unspecified Official Guidelines for Coding and Reporting FY 2017.” wvvw.
artery, was initially assigned. After a final review, 163.411, Ce- cdc.gov/nchs/data/icd/
rebral infarction due to embolism of right middle cerebral ar- 8. Lee, Christine. “Nothing Lasts Forever: How Physicians
tery, should be assigned based on greater specificity found in Can Prepare for the End of the One-year Amnesty from
the brain CT report. Post Payment Reviews Due to Unspecified Codes.” ICDTEN. May 2016. http://bok.ahima.org/doc?oid=301570.
Addressing Nonspecific Documentation and Coding 9. American Hospital Association. “Using the X-ray Report
Despite the importance of specific documentation and di- for Specificity.” AHA Coding Clinic for ICD-IO-CM and
agnosis code reporting, nonspecific documentation and ICD-IO-PCS (First Quarter 2013). Chicago, IL: AHA cen-
coding persists. The solution lies in addressing both im- tral Office, 2013: 28.
provements in the specificity of clinical documentation 10. American Hospital Association. “Use of Imaging Reports
and process improvement to ensure medical coding profes- for Greater Specificity.” AHA Coding Clinicfor ICD-IO-CM
sionals are coding to the highest degree of specificity that is and ICD-IO-PCS (Third Quarter 2014). Chicago, IL: AHA
available. The challenge for medical coders is to achieve a Central Office, 2014:5.
balance in productivity and quality to ensure that reported 11. American Hospital Association. “Use of X-ray to Deter-
codes align with clinical documentation. The goal is to re- mine Site of Pain.” AHA Coding Clinic for ICD-IO-CM
port specific diagnosis codes when they are supported by and ICD-IO-PCS (Fourth Quarter 2016). Chicago, IL: AHA
the available medical record documentation and clinical Central Office, 2016: 143.

                        knowledge of the patient’s health condition—and use unspecified codes only when they are the best choice to accurately reflect the healthcare encounter. O


1. Centers for Medicare and Medicaid Services. “CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-IO Frequently Asked Questions.” www.cms.gov/ Medicare/Coding/ICDIO/Downloads/ICD-IO-guidance.pdf.

2. Centers for Medicare and Medicaid Services. “Clarifying Questions and Answers Related to the July 6, 2015, CMS/ AMA Joint Announcement and Guidance Regarding ICD-IO Flexibilities.” www.cms.gov/Medicare/Coding/


46/Journal of AHIMA April 18

Tough Cases: How tb

Critical Tlinking and

Coding Notes
TacklingEmpower TemperBy Sarah Htmbert,

Productivity Goals



BY THE YEAR 2020, new technological advancemenc are predicted to occur evety 30 seconds.I This explosion of technology includes the healthcare industry—and with it, clinical coding.

The healthcare industry is already witnessing rapid development ofcutüng-edge medical procedures using disruptive technologies and processes. Most common in academic medical centers, experimental surgical procedures raise ICD-IO-CM/ PCS-related questions for coding professionals and their management teams. Coding professionals often are foced to choose between fully researching complex cases or cutting comers to meet productivity

ICD-IO affords the flexibility to code diese complec cases, but it also requires that coding professionals apply cridcal thinking skills and that coding managers adjust producdvity ecpectations.

The Critical Thinking Mindset

According to the World Economic Forum’s report entitled “Tie Future of Jobs,” critical üiinking is listed as die number two top SEII required in all areas by2020. Encouragng codingprofessionals to engage their critical thinking skills is pammountwhen coding complex cases or newexperimentalprocedures. Accordingto Critical Thinking Web, a website maintained by Joe Izu, PhD, of tie philosophy department at the University ofHong Kong:

VA üiinker is able to deduce consequences fromwhat he knows, and hehows howto use ofinformadontosolve problems, and to seek relevant sources of information to inform himselE„ Critical thinking help us acquireknowledge, improve our theories, and strenghen arguments. We can use criücal thinkng to enhancework processes andimprove social institutions.”2

56/Journal AHIMAJanuary 18

For coding professionals, critical thinking skills must be coupled widl a solid punding in anatomy/physiolow and pharmacology. This foundadon ensures coding pmfessionals understand the enäre clinical picture painted through ancillary and clinical documentation.

Coding professionals also benefit from having an investigator menulity and the ability to think outside the box when performing research. For example, instead ofrelying only on “typical” codEng resources, a critical thinker may use to find a YouTube video ofa new procedure and go to the manumcturers website br anyrecommended codß sucested for the device or procedue

Empowering Critical Thinkers

How can a coding manager identify coding professionals who possess critical thinking skills and encourage their development? Tie best way is to use a different coding exam—one that includes several new procedures not already explained in the coding book Coders who aren’t afraid to ask for clarificadon are usually the best candidates, especially if they seek input via dioughtful and referenced questions.

Generallyspeakng codingandidateswho don’t dar&don tend to be more focused on producti%ity rather ülan aczuraw. They tend to forego die drne needed to perform research or quBtionsWhile the lack ofquestions maybe an attnptto appar knowledgeable, it does notsucætastrongaitiæl tfrlkingmin&et Consider the following strategies to encourage a critical thinking mindset among coding teams:

· Foster an environmentofcuriosity, leaming and sharing. Staff should feel comfortable asking quætions with impunity.

· Routinely share knowledge of new experimental procedures, ideally once per week

· Create a queue for secondary review holds that coding professionals can use when they have questions.

· Reach out to a coding outsourcing company for guidance on diffcult cases or new procedures.

· Post questions on AHIMA message boards, or even groups on social media.

It is better for coding professionals to take time, conduct research, ask questions, and code complex cases right the first time versus repeating efforts when a claim is denied or rejected by the payer. A few extra minutes on the front end saves time and money on the back end. This is especially true for new experimental procedures. However, coding managers must factor in the additional time needed for these cases.

Resetting Productivity Expectations

Again, it is important for coding professionals working in organizations with progressive technology to have the skill set required to research the best way to code a new procedure. If professional coders are taking time to research cutting-edge medicine, how can coding managers balance productivity expectations with accuracy—while also maintaining discharged-not-final-coded goals?

A proven strategy is to flex productivity benchmarks for com-

Coding Notes

plex cases. Here are three tactics to consider:

1. Base coding productivity goals for complex cases on length of stay (LOS), allotting more time for records with a higher LOS.

2. Factor in total charges to accommodate for new, high-complexity surgical procedures that may have a much lower LOS than anticipated.

3. Use a combination of LOS and total charges to account for complexity in coding productivity standards.

As medical technology continues to advance, coding professionals will be pushed to code complex, new, and experimental cases. The critical thinking mindset, combined with flexibility in productivity expectations, ensures coding professionals and managers collaborate to tackle new horizons and learn new skills that advance the coding profession. O


l. Emerging Future. “Disruptive Technology Riding the Emerging Wave of the Future.” www.theemergingfuture. com/disruptive-technology.htm.

2. Lau, Joe. “[COII What is critical thinking?” Critical Thinking Web. http://philosophy.hku.hk/think/critical/ct.php.

Sarah Humbert (shumbert@kiwi-tek.com) is corporate coding and compliance manager at Kiwi-Tek.

STEPHENSF.Commitment to the industry· Focus on affordability· Preliminary degree plans personalized for youExplore programs, ask questions or complete our easy online application now at:online@stephens.edu stephens.edu(800) 876-7207dream up.C O L L E G

Journal Of AHIMAJanuary 18/57

Coding Notes
[CD-IOA DynamicBy Lau MIA CCS

and Quality Measures: fo


hot ant tek the in

inl of:thisic su
CODING PROFESSIONALS ARE the guardians of the pa- of the metrics associated with quality measures. Coding
tient’s story; they translate the language of medicine into portrays the severity level of the patient and is used in part it)
coded data. The accuracy of this translation is essential for to assess quality ofcare and patient outcomes. The dangers wi
many reasons beyond today’s reimbursement. Coded data of poor documentation and coding include an inaccurate (G
is used for clinical decision making, healthcare policy, pub- representation of the severity of the patient and care ren- th
lic health tracking, research, and quality initiatives. Coded dered to a patient as well as skewed quality data. Accurate
data helps shape the public’s perception of healthcare pro- and complete coding is also necessary for survival in to-
viders and institutions through ready access to a plethora day’s climate of value-based models with flnancial incen- in
of public data and rankings for physicians, hospitals, and tives tied to quality of care and ramifications of accurate
healthcare providers. Coded data contributes significantly hospital-acquired condition (HAC) and patient safety indi- a!
to the US healthcare system’s ranking and position on the cator (PSI) reporting. dc
world stage. A coding professional’s daily work has global The patient’s story is linked to a wide variety ofinitiatives
significance. This article will explore the far-reaching effects related to healthcare quality, effective patient care, health- by
ofcoding through the dynamic relationship between ICD-IO care economics, policy, and reform. It is important to take
and quality measures. full advantage of the specificity that ICD-IO provides in or-
The Centers for Medicare and Medicaid Services (CMS) der to capture robust data that is used in assessing patient a
“implements quality initiatives to [enlsure quality health severity, the quality of care received, and patient outcomes.
care for Medicare Beneficiaries through accountability and The continued evolution of ICD-IO will necessitate the u
public disclosure. CMS uses quality measures in its vari- growth and development of quality measures.
ous quality initiatives that include quality improvement, c
pay for reporting, and public reporting. Quality measures Sepsis Mortality Study
are tools that help us measure or quantify healthcare pro• A recent study by the Ohio Hospital Association (OHA) il-
cesses, outcomes, patient perceptions, and organizational lustrates the effect coding has on quality outcomes. Ace s

structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.”‘

Accurate and complete coding is a foundational element

70/Journal October 17

cording to the Centers for Disease Control and Prevention, sepsis is responsible for roughly 258,000 deaths in the United States each year and represents 6.2 percent of all hospital costs across the nation. The federal government’s Healthcare Cost and Utilization Project identified sepsis as the costliest condition in the nation’s healthcare sys-

Coding Notes

ICD-10 and quality measures are inseparable, which places coding professionals at the center of the healthcare quality conversation. Coding professionals must ask if provider documentation and codes reported for an encounter are wholly reflective of the patient at that place in time.




tem. Mike Abrams, OHA president and CEO, says Ohio’s hospitals in 2015 decided to “confront the brutal truths” and begin a campaign to reduce sepsis encounters and related deaths by 30 percent by 2018. Nine months into the initiative, OHA reported an eight percent reduction in mortality with 353 lives saved. The study asserts that “ICD-IO has improved the ability to accurately report the infections, especially upon admission, which is where 80% of sepsis cases are traced.•a

Ultimately, Abrams says OHA “wants to do for sepsis what we did for ventilator-associated pneumonia: Make them rare.”3 Clean data, which is derived from accurate provider documentation, coding, and present on admission reporting, is foundational to life-saving initiatives such as this one.

‘CD-IO Interwoven with Quality Measures

ICD-IO and quality measures are inseparable, which places coding professionals at the center of the healthcare qualtrt ity conversation. CMS predicts that US healthcare spending will account for 19.9 percent of the gross domestic product te (GDP) by 2025, due in part to the aging of a large portion of the population. And yet a recent report from the Commonte wealth Fund revealed •the United States ranks last in health  care system performance among the Il countries included n- in the study. The U.S. ranks last in Access, Equity, and Health te Care Outcomes, and next to last in Administrative Effciency, as reported by patients and providers. Only in Care Process does the US. perform better, ranking fifth among the Il es countries.D4 In light ofthe fact that quality ofcare is measured h- by outcomes that are reflected by documentation and codke ing, this ranking begs the question: Was the data correct?

Coding professionals must continue to think strategically nt and globally about their role in better healthcare for our population. Coding professionals must ask if provider documentation and codes reported for an encounter are wholly reflective of the patient at that place in time. Consistent coding reviews, performed through the dual lens of reimbursement and quality, will help ensure that coded data is reliable for the purpose of quality measures. The APR-DRG C- system offers a sophisticated method ofassessing both codn, ing quality and reimbursement simultaneously.

Grace Whiting Myers, the founder of AHIMA, wrote her autobiography in 1948 and shared her professional credo: “Give ofyour best to anything you attempt to do.” Her words inspire is and inform today’s health information management and cods- ing professionals as they work to ensure quality documentation and coding with 10-10. O


l. CentersforMedicare and MedicaidServices. “QualltyMeasures.” CMS.gov. www.cms.gov/Medicare/Quality-Iniäatives-Patient-Assessment-lnstrumenc/QualiWMeasures/ index.html?redirect=/quaIitymeasures/05_ehrincentiveprogramappeals.asp.

2. Commins, John. “Sepsis: Ohio Provides Hospitals with a Battle Plan.” HealthLeaders Media. June 26, 2017. www. healthleadersmedia.com/technology/sepsis-ohio-provides-hospitals-battle-plan.

3. Ibid.

4. Schneider, Eric C. et al. “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better US. Health Care.’ The Commonwealth Fund. www.commonwealü1fund.org/imetactives/2017/july/mirror-mirror/.


Advisory Board. “CMS: US health care spending to reach nearly 20% ofGDP by 2025.” February 16, 2017. www.advisory.com/ daily-briefing/2017102/ 16/spending-growüi.

Centers for Medicare and Medicaid Services. “ICD-IO and Quality Measures.’ CMS.gov. www.cms.gov/Medicare/ Quality-initiatives-Patient-Assessment-Instruments/ QualityMeasures/ICD-lO-and-Quality-Measures.htmI.

Giannangelo, Kathy and Linda A. Hyde. ØICD-IO’s Impact on Quality Measures.” Joumal ofAHIMA 83, no. 4 (April 2012): 46-47.

Leon-Chisen, Nelly. “Coding and Quality Reporting: Resolving the Discrepancies, Finding Opportunities.” Journal ofAHIMA 78, no. 7 (July

Potyraj, Julie. “The Quality of US Healthcare Compared With the World.” AJMC.com. February Il, 2016. www.ajmc. com/contributor/julie-potyraj/2016/02/the-quaIity-of-us• healthcare-compared-with-the-world/.

Rangachari, Pavani. “Coding for Quality Measurement; the Relationship between Hospital Structural Characterisäcs and Coding Accuracy from the Perspective of Quality Measurement.” Perspectivß in Health Information Managernent4, no. 3 (Spring2007). http://perspecäves.ahima. org/coding-for-quality-measurement-the-relationshipbetween-hospital-structural-characteristics-and-codingaccuracy-from-the-perspective-of-quality-measurement/.

Daniel Land (dland@mdpartnershinmm) ts director ofcompliance reviewservicßatMedPartners

Journal October 17/71

Coding Notes
Data of CodedBy Felicia A. Thomas, RHIT, CCS, CPC,

Analytics: The Power Data

CIC, CPC-I, CCDS, and Wahiyda Harding, MSA, RHIA, CCS

TO UNDERSTAND THE power of coded data, let’s first take a look at its definition. Data analytics is the science of examining raw data with the purpose of drawing conclusions about that information. Data analytics is used in many industries to allow companies and organizations to make better business decisions and in the sciences to verify or disprove existing models or theories.l The purpose of analytics is to take existing data collected from either a single source or multiple sources and use it to arrive at the optimal decision. Essentially, analytics can be best defined as a science of analysis. This is most commonly used in situations where realistic judgements are necessary.2

Healthcare analytics is a term used to describe healthcare analysis activities that can be undertaken as a result of data collected from four areas within healthcare:

· Claims and cost data

· Pharmaceutical and research and development (R&D) data

· Clinical data (collected from electronic health records (EHRs))

· Patient behavior and sentiment data (patient behaviors and preferences)

    In health information management (HIM)—and in coding, specifically—the health information professional must understand the importance of their role in interpreting and abstracting this data to be collected and analyzed. While this data is used primarily in reimbursement and claims activities, it also plays a much larger role in clini-

48/Journal October 18

cal data analysis performed in facilities for quality of care reporting, disease management, and best care practices. Let’s take a brief look at the power of coded data in each of these areas.

Reimbursement and Claims

The reimbursement models in the United States are very complex, but the underlying constant is the coded data abstracted from the health record. Coding and clinical documentation professionals play a pivotal role in the abstracting and reporting of this information. “Iheir understanding of the disease process, the Official Guidelines for Coding and Reporting, and any official guidance from the American Hospital Association’s Coding Clinic for ICD-IO-CM and ICD-IO-PCS publication helps ensure the accuracy of the abstracted data. The data needs to represent the true clinical picture of that encounter; it has to tell the story.

For example, consider a scenario where a 28-year-old man presents to the emergency department with an open fracture to his left thumb. He was returning from the break room to his area in the warehouse when several large boxes fell off of the conveyor belt. He held up his hands to block the boxes from striking his head and sustained an open fracture to his left thumb. How this encounter is coded and abstracted can not only impact the reimbursement made to the facility, but also plays a part in how this employee can recover from his injuries.

Coding NotesThe power of coded data transcends far beyond the doors of the health information management department.

It is important that not only the place of occurrence is reported correctly, but what this employee was doing at the time of injury as well. ICD-IO-CM Chapter 20: External Causes of Morbidity codes play an important role in telling this story. The code used could literally be the difference between whether this employee receives workers’ compensation or not.

Quality Care Reporting

A 37-year-old female with Crohn’s disease presents to the facility with intense abdominal pain. After work-up it is determined that she is experiencing a flare-up of her Crohn’s disease and will require a partial large bowel resection due to the extensive damage to the lining of her colon. During her recovery in the hospital she starts experiencing abdominal pain and is taken to radiology. It is determined that she is experiencing a post-procedural ileus.

How these types of encounters are coded and abstracted can have an impact on the quality of care scores for a facility. If these types of cases are coded as complications of care without confirmation from the provider, it can and will negatively impact the complication rates of the facility through the Potentially Preventable Complications (PPCs) data reported. There are many post-procedural occurrences that are all but expected after certain surgical procedures due to the inherent nature of the disease process.

In another example, a 59-year-old partially bedbound functional quadriplegic is admitted to a facility due to lethargy and altered mental status. It is determined that this patient has a severe urinary tract infection and will require several days of hospitalization before they are stable enough to go back to their nursing home. After 10 days the patient is discharged and this encounter is sent down to coding and is billed out to the payer. Upon auditor review it is discovered that this encounter went out with Present on Admission (POA) indicators of “N” on a stage 3 pressure ulcer that was documented by the nursing staff and reported on the history and physical by the attending provider. This type of error in abstracting can again negatively impact the quality scores of a facility. HIM professionals must pay close attention to the data they report and recognize the implications their errors may have.

Disease Surveillance and Monitoring

       According to the Centers for Medicare and Medicaid Services’ Official Guidelines for Coding and Reporting, there are certain conditions that may not be abstracted and reported without confirmation by the provider. HIV/AIDS and the Zika virus are the two exceptions to the Section Il. H. guideline for inpatient encounters for uncertain diagnoses. These two conditions must be confirmed by the provider.

With this guideline in place, the Centers for Disease Control and Prevention (CDC) can track and monitor these outbreaks via the coded data.

Through the CDC’s National Vital Statistics System, states collect and disseminate statistics on births and deaths. In this manner, the public and healthcare professionals are able to learn more about tuberculosis, HIV, influenza, and hospital infections.3

HIM professionals need to understand how erroneously coded data can have far-reaching implications throughout the healthcare continuum. Facilities need to have policies and protocols in place to ensure the accuracy of coded data involved in data mining activities. The power of coded data transcends far bevond the doors of the HIM department. O


1. Rouse, Margaret. “data analytics (DA).” TechTarget. December 2016. https://searchdatamanagement.techtarget.com/definition/data-analytics.

2. wiseGEEK. “What is Data Analytics?” www.wisegeek. com/what-is-data-analvtics.htm.

3. Centers for Disease Control and Prevention. “Disease Surveillance and Monitoring.” 2016. www.cdc.gov/ about/facts/cdcfastfactsßurveillance.html.


Centers for Disease Control and Prevention. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-IO-CM). www.cdc.gov/nchs/icd/ icdl()cm.htm.

Centers for Medicare and Medicaid Services. ICD-IO web page. www.cms.gov/Medicare/Coding/ICDIO/index.html.

Felicia A. Thomas (felicia.thomas@accds.com) is inpatient quality auditor and Wahiyda A. Harding (tcahiyda.harding@accds.com) is DRG team coach atAccuity Delivery Systems, LLC.

‘JoumaIöfAHlM4ContiNJing EducatidnQuit

Quiz ID: Q1838909 1 EXPIRATION DATE: OCTOBER 1, 2019

HIM Domain Area: Clinical Data Management

Article—”Data Analytics: The Power of Coded Data”

Review Quiz Questions and Take the Quiz Online at https://my.ahima.org/store

Note: AHIMA CE quizzes have moved to an online-only format.

Journal October 18/49

Coding Notes
Effectively CodingBy Clark Chaffin, MBA, RHIA, CCS

Managing a Growing Workforce

HEALTH INFORMATION MANAGEMENT (HIM) departments across the United States, whether small or large, are experiencing a multitude of challenges and growing pains in todays healthcare landscape. As more experienced members of the worldorce are retiring, an increasing number of workforce members are training for expanded areas of HIM not focused solely on coding. And HIM professionals are also navigating constant demands of lowering current discharged not final billed (DNFB) with simultaneous scrutiny aimed at achieving and maintaining high quality coding despite incomplete documentation. This article will discuss how the HIM department at one healthcare organization—CoxHealth, a six-hospital system in the Midwest region of the US—has approached the task of managing a growing coding workforce while meeting all organization expectations for the department.

In the past five years, the coding department at CoxHealth in Springfield, MO has almost doubled its staffing due to the addition of new hospitals, increased inpatient volumes, and growth in outpatient markets. To successfully manage the demands of this changing environment, the deparment developed a coding project plan to address all aspects ofcoding, including DNFB, to manage not only employee retention but also recruitment, coding productivity, and internal/external coding audits.

 Healthcare is a business and just like other successful businesses there must be a project plan in place in order to achieve goals and successes. As such, it is important for HIM departments to have goals in place as well, and the implementation of a clearly defined coding project plan has proven key to CoxHealth’s HIM department achieving success.

48/Journal February 19

What Should the Coding Project Plan Address?

The coding project plan should address all areas that affect the management of coding-related activities. eme coding project plan at CoxHeaIth addresses the following:

· Coding education (How often should it be done? What topics should be covered?)

· Coding productivity (How is it measured for inpatient and outpatient?)

· Coding quality (How often is it checked? What are steps for improvement?)

· Coding recruitment/retention (What is the best way to attract and retain coding staff?)

· Coding training programs (What is being covered in training? What professional organization will provide the best foundation to train future coders?)

‘lhe following sections of this article take a closer look at each of these elements.

Coding Education

The type of education approach that works best can vary widely for individual employees. Keeping this in mind, CoxHealth provides coding education in various forms, including quarterly coding audits/training meetings, online training tools, webinars, email communications like the “Monthly Coder Notes” newsletter, and a monthly department-wide newsletter.

Coding Productivity

Although there are coding productivity standards in the industry, the set coding productivity measures should be based on the systems/functionality of the electronic health record (EHR) within each health system. assessment of coding productivity at 10 different hospitals would yield widely varied results.

CoxHealth conducted extensive measurements ofwhat codes are captured, how the EHR is set up, and clinical documentation in order to set the standards across the system. Using available industry standards as a foundation, CoxHealth customized their standards based on coding productivity studies conducted at the organization after ICD-IO-CM implementation. Consistent monitoring of coding productivity is necessary for all organizations in order to maintain adequate staffing and meet goals, such as those related to DNFB directives.

Coding Quality

Ihe CoxHealth standard for coding quality is greater than 95 percent accuracy, which is the common industry standard. Primary focus on coding quality should be emphasized over coding productivity. The accuracy of coding is a top priority and affects reimbursement, quality outcomes for patients, and hierarchical

condition category coding on the physician’s side.

Coding Recruitment/Retention

As the “Baby Boomer” generation gets older, hospital coding departments are seeing their seasoned coding professionals either retiring or nearing retirement. It is important to plan ahead now and craft succession plans for those coding professionals exiting the field. Ihe HIM profession should be utilizing these seasoned coders to provide the training for new incoming coding professionals. They are the best source ofknowledge ofwhat it takes for a solid foundation in the complexities ofcoding. This is an emerging issue that must be on the radar of any coding project plan in order to avoid the necessity of using additional coding resources to aid with the potential staffing shortage.

Thinking outside the box is fundamental for the most effective recruitment techniques to attract new coding professionals to an organization. Coders working remotelywant autonomywith their work schedules, less traveling to the office for meetings, and the ability to advance within the coding department. Coding professionals want the opportunity to learn everything very quickly, and keeping up with that demand means leveraging experienced/ seasoned coders to become auditors or trainers to aid in successfully moving the next generation of coders into the workforce.

CoxHealth decided to undertake recruitment efforts beyond the usual tactics in order to find and recruit new coders. For example, internally, document imaging and discharge analysis assistants were sent to online and in-person training on outpatient coding to get a foundation on the basics of such concepts as coding guidelines, how to use code books, and code assignment. CoxHealth invested in this group of clerical staff in order to grow the outpatient coding program internally.

Retention of current coders is also constantlv on the radar in the coding project plan. It is costly for any organization to effectively train coders in-house. Organizations must have outside-the-box coder retention tools. For example, coder retention bonuses that are separate from the employees’ annual salary is one way to re

                              Coding Notes


ward coders. Quality bonuses are a great incentive to reward coders for their quality of coding and meeting established standards. Providing ongoing continuing education opportunities is a must in today’s coding environmentto ensure coders are staying abreast of current coding trends. Lastly, look at the current workforce and see what it is that makes sense for your particular market. Not every worker is incentivized solely by monetary measures.

Coding Training Programs

CoxHealth currently has two training programs in place—an inpatient and outpatient coding training program. The inpatient training program was put in place prior to the implementation of ICD-IO-CM/PCS and started in January 2015. It was set up to internally train more inpatient coders to reduce the need for

long-term contract coding. Ihere was a growing need to bring some of that coding back in-house and internally move coders from outpatient coding to inpatient coding to achieve proper coverage of inpatient coding needs.

The inpatient coding program began with Ovo inpatient coding auditors and nine inpatient coder trainees. The program started

with dividing those nine inpatient coder trainees into medical service line training so they were learning at different levels and distributing the worldoad out evenly amongst the nine trainees and five seasoned inpatient coders. The goal of the program is to graduate inpatient coders within a two-year period so that all medical service lines are covered. New inpatient coders start in January each year with the goal to complete the training period within two years. There was a delay with ICD- 10-CM implementation, which prolonged the first group of graduates. Additionally, an inpatient coding auditor/trainer was added during this process to assist with further training.

The outpatient coding program began in spring 2017. Online/ in-person training for new coders with no hands-on experience taught basic skills and then moved to teaching outpatient coding at a designated coding level, such as ancillary and/or emergency department coding, to build a strong foundation of coding a variety of different types of cases. Under the direction of the coding auditor/trainer, the coder is assigned cases to code and coding is reviewed for a period of time and then released when the coding meets 95 percent accuracy or greater. Ihe coder progresses to monthly quality review by the assigned coding auditor. O

Clark Chaffin (Clark.Chafin@coxhealth.com) is system director, coding and health information management at CoxHeaIth.






Quiz ID: 01939002 l EXPIRATION DATE: FEBRUARY 1,2020 HIM Domain Area: ClinicalData Management

Article—”EffectiveIy Managinga Growing Coding Workforce”



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