Thursday, November 10, 2011

I Bet You're Wondering What I've Been Up To...

Oh wow, has this been a crazy fall! Up until this year, "Rocktober" was a term we used in Colorado whenever our beloved Colorado Rockies made it to the playoffs. This year Rocktober took on a whole new meaning for me. And while it was a great month, I am so happy to say it's over and now I can concentrate on the less busy holiday season. Yes, October was that busy!

As you saw from some of my blog postings, I kicked off October in true coder fashion by attending the AHIMA Convention and Exhibit in Salt Lake City. What a great opportunity to learn the newest, latest, and greatest from some of the nation's best HIM and coding minds and get in some serious networking as well. This year was particularly busy at convention as I was honored with an AHIMA Triumph Award for mentoring, mainly due to my efforts with the Coder Coach blog and some of the networking and educational events I've hosted over the last couple of years. It was an incredible honor and to help commemorate the occasion, I took my personal and professional mentor - my mom (pictured here with me) - along with me. It's hard to tell who was more excited about my award!

This was also the first year that I was chosen to speak at the national level. I presented an outpatient track at the coding meeting on the overlap between coding and charging in the cardiac cath lab. As if that wasn't enough, I just couldn't say no when another Triumph Award recipient and fellow Coloradan, Dee Johnson, asked me to be a part of the Student Academy. Dee is a student at Arapahoe Community College, my alma mater here in Colorado, and was a key planner in this year's Student Academy. The academy is a free event for students in AHIMA programs at the convention each year. I was a part of the mentor lightning rounds where several established professionals spent a few minutes with each group of students to share our experience and answer questions. All of that and Apolo Anton Ohno too! The Olympic athlete and Dancing with the Stars champion was our closing keynote speaker and he had an inspiring message about giving it your all.

Once I was back at home, there was no rest for the weary as I delved into not one, not two, but FIVE client trainings. For those who aren't aware, training sessions take about 4-5 times as long to prepare as they do to present but the work is always well worth it when I get to training. That is my favorite part of my job because it combines two of my great talents: coding and talking! My last week of training involved three training sessions, work-related road travel, a snow storm, and, of course, that inevitable sinus infection as a result of a crazy month. I would love to tell you that following that last training on October 28 I headed out for happy hour with my friends, but truth be told, I had a nice evening vegging out on the sofa and catching up on all my DVR'd shows!

So here we are in November and I'm trying to wrap a few things up before the holidays. Last weekend I met with a fantastic group of super coder geeks (birds of a feather!) who were so amazing to not only spend their own time coding some records in ICD-10, but to also give up a Saturday to come together and talk about the results. This is a project that the Colorado Health Information Management Association's (CHIMA) ICD-10 Task Force has undertaken to assess documentation readiness for ICD-10. I have had a great year chairing this task force and working with an enthusiastic group who is making great strides as a clearinghouse for ICD-10 information in the state of Colorado.

Last week I was interviewed by ICD-10 Watch, a terrific resource for anyone interested in ICD-10. We specifically chatted about the fantastic opportunities that await coders as we transition to ICD-10. The interview is recounted in the blog posting How ICD-10 can create opportunities for medical coders.

Whew, I think I need to take a nap now that I've recounted the previous month's events! I plan to get back to the ICD-10-PCS series in another week or two, but bear with me - November's calendar is starting to fill up, so it might be 2012 before I can give the series the attention it deserves. In the meantime, I hope everyone has a terrific holiday season.

Tuesday, October 4, 2011

ICD-11 is Coming...

That was a key message this morning in a presentation by Dr. T.B. Ustun from the World Health Organization (WHO) at the AHIMA convention general session. Yes we are still on track for implementing ICD-10 in the US on October 1, 2013 (just under 2 years for those of you keeping score at home) but while the US works to catch up with the rest of the industrialized countries who have been using ICD-10 for several years, the WHO is already looking at ICD-11. Does that worry you as a current or future coding professional?

I know a few current students are concerned about learning ICD-9 in school and then trying to get a position as a coder using ICD-10. Should they go ahead and start working now using ICD-9 or wait until 2013 and use ICD-10? Well, from my perspective, the critical thinking skills that make a coder a good coder will not change even though the codes themselves do. And yes, ICD-10 - especially from the procedure perspective (ICD-10-PCS) requires more anatomy and physiology, medical terminology, and procedural knowledge but you can learn that over the next couple of years as you code in ICD-9-CM. Plus, most employers have plans for training their workforce and getting a coding position now gives you a starting point for learning ICD-10.

So go ahead and go for that open coding position now. Do whatever you can to position yourself for the transition and get ready for a career of continuing education. Not only will you need to book continuing education units to maintain any coding credentials you have, the codes change at least annually, so change is constant. And be ready to adopt ICD-11....

Monday, October 3, 2011

From the Green Room at AHIMA

Today is a big day as the AHIMA conference General Session kicks off. At the moment, I'm hanging out in the green room backstage with the Triumph Award recipients. I am very honored this year to have been awarded one of the Triumph Awards for mentoring for my work with the Coder Coach. This is a new experience for me - to be backstage and a part of the presentation. And I'm very excited to have one of my mentors (and favorite people in general) with me to celebrate - my mother, who is also a retired RHIT. I will post more pictures later, but here's a super secret green room photo!

Sunday, October 2, 2011

Networking at the AHIMA Student Academy

Today I spent a couple of hours at the AHIMA Student Academy as a mentor for their lightning rounds. AHIMA's Student Academy is a one day free event for students in AHIMA based programs. Several mentors including myself were asked to spend time giving advice on certification, career planning, volunteering, and networking - you know, a lot of the things I blog about through the Coder Coach!

It was great to network with the future of our profession and see so many people excited about their future careers.

So here's a little recap from the mentors' advice to students today:
-Follow your bliss - if a particular area interests you, pursue it, even if the pay isn't great. If you go for a job that you're passionate about, the money will follow.
-Certification is a must if you want to be taken seriously and want to excel.
-Network, network, network. Communicating and networking with current pros is key.
-Volunteer. You would be amazed at the doors that will open for you when you volunteer either with coding/HIM departments or with your local coding/HIM associations.
-Stay positive and avoid being defensive. People pick up on attitude quickly. If you are looking for a job and have been for a long time it's easy to let bitterness creep into your conversations. So be careful to keep positive and hopeful.

More from AHIMA in Salt Lake City coming soon!

Saturday, October 1, 2011

Live from AHIMA Salt Lake City!

Today marks the first day of AHIMA's Coding Community meeting, which kicks off the annual convention. This year we're meeting in Salt Lake City and as usual, I am like a little kid in a candy store here. Every year AHIMA is a bigger deal to me since it's a chance to reconnect with former coworkers and meet new professional contacts. And since this year my focus is heavily on workforce development, I thought it would be fun to send out reports from my experiences through my blog and maybe you can join me at AHIMA next year.

So here goes...

This afternoon I will be presenting on coding and charging in the cardiac cath lab and I'm sure my audience will find it the best presentation at this conference (tongue in cheek!). But for me, my favorite presentation happened this morning with the national coding update. Every year we have the coding gurus from AHIMA, the American Hospital Association and the AMA talking about upcoming coding changes for ICD-9-CM and CPT. I love getting that firsthand information and feel a little like I'm getting some super secret information - along with the other 500 people in the room.

More for SLC as the conference progresses... Stay tuned!

Monday, August 15, 2011

Spotlight on Certification: The Certified Coding Associate (CCA)

I get a lot of questions from interested individuals about coding certifications. Like it or not, employers are looking more and more to credentialed coders to staff the workforce. It's almost impossible to get hired without a coding certification -but which one is right for you? What do the different certifications say about your qualifications? And what will you have to do to maintain your certifications?

I thought I would help out by spotlighting different coding credentials. There are two main organizations I will focus on and there are a lot of certifications. So be patient - I will get to all of the AHIMA and AAPC credentials eventually! And remember - I hold certifications with both organizations, so I'm not here to sell you on any single credential. If you plan to work in hospitals, AHIMA credentials are more widely recognized whereas physician offices usually require AAPC certifications. Before you decide which organization to join, do your homework and find out what credentials they require where you want to work.

I'd like to start with the newest AHIMA credential, the Certified Coding Associate (CCA).

I've never taken the CCA exam because when it came out, I was already certified as a Certified Coding Specialist (CCS). And while many aspire to be a CCS, AHIMA doesn't recommend taking that exam until one has at least 2-3 years of experience as a hospital inpatient and outpatient coder. But what about those people who have taken coding classes and want to prove they know a thing or two so they can land an entry-level coding position? Enter, the CCA credential.

AHIMA created the CCA credential to demonstrate one's "coding competency in any setting, including both hospitals and physician practices." In essence, it lets your future employer know you've taken the core coding and HIM classes. When I talk to people who are trying to begin coding careers, I often hear them say something along the lines of, "Why should I waste my time with an introductory credential?" or, "It's a waste of money."

Well, from my perspective, if you have taken the time and effort to take the CCA exam, it tells me one big thing: you're serious about coding as a career because you took the initiative to study for an exam. And if I were hiring, that is something I would definitely take into account. Coding certifications cost money - it's an occupational hazard. But being without a coding credential most likely means not having a career as a coder. Which do you want more?

CCA Specs
The CCA credential, as mentioned, is available through AHIMA. It costs $199 for AHIMA members to take the test. If you aren't a member of AHIMA and plan to work as a hospital-based coder, I highly recommend joining. Again, another cost that is important to your career if you're serious about working as a coder. If you aren't a member of AHIMA, the cost is $299. The CCA credential is the only HIM credential worldwide that is accredited by the National Commission for Certifying Agencies (NCCA), although I've heard AHIMA is seeking the same approval for other credentials.

As for content, it's not just coding. And I think this surprises a lot of people who take the test. It also tests for HIM-related competencies. That's something to keep in mind when you're studying for it. There are six domains that make up the CCA test:
  1. Health Records and Data Content (20%)
  2. Health Information Requirements and Standards (14%)
  3. Clinical Classification Systems (36%)
  4. Reimbursement Methodologies (10%)
  5. Information and Communication Technologies (6%)
  6. Privacy, Confidentiality, Legal, and Ethical Issues (14%)
The tasks for each domain are outlined on AHIMA's website along with FAQs and other important exam information. If you plan to take the CCA exam, I recommend spending a lot of time on the CCA page.

CCA Jobs
The CCA credential is still relatively new for those of us who have been around for a decade or so. And I admit, as a profession, we're a little slow to accept new ideas sometimes. Job postings may not state the CCA credential as one that is accepted. My general rule is, if the job calls for a CCS and you have the CCA, apply for it. The employer may not get enough job applications from qualified individuals. And if it was me, I would certainly look at a CCA with more interest than someone without any certification. The credential is catching on, though, and I'm starting to see it in job postings. So, do I think it's a credential worth getting? If you don't have any other certifications, then yes. Absolutely!

Curious about whether or not to take the CCA if you have an RHIT? If so, check out this past blog of mine on the HICareers website: "Should There be a CCA After RHIT in Your Title?"

Monday, August 1, 2011

I Love ICD-9-CM - What if I Don't Feel the Same Way About ICD-10?

I think there are a lot of students out there learning ICD-9-CM right now who are feeling a certain apprehension about the ICD-10 implementation. It's a tricky time to be educated in coding right now - you may decide you love ICD-9-CM only to have it ripped from your grip in 2013 and replaced by something that doesn't closely resemble your new found love. So maybe you've been reconsidering a field in coding.

Well, let's not overreact! First of all, let's look at what it is you like about coding, what will be changing, and then decide if it's time to overreact!

First of all, ICD-9-CM, Volumes 1 and 2 (the diagnosis codes) are being replaced by ICD-10-CM. And although there are some tricky areas and all of the code numbers are different, the overall feel and use of ICD-10-CM is not that dissimilar to what we're used to today. Yes, it will be more difficult to roll codes off the top of our heads like many of us can now with ICD-9-CM, but it will not be impossible (after a week coding in ICD-10, I found it was not difficult to memorize frequently used codes. The major changes? We have extensions now to indicate the episode of care for patients with injuries and we have codes for underdosing of medications - something that's completely foreign. And although in ICD-10 there are two types of excludes notes instead of one (not coded here vs. not coded in addition), that's a nice change that most coders are happy about.

ICD-10-PCS on the other hand, is very different from Volume 3 of ICD-9-CM, which includes procedures. In fact, ICD-10-PCS is very different from anything we've ever used for coding. The fact that there are no inclusion and exclusion notes - no tabular listing, in fact - only pages of tables, makes it seem daunting. This will be a huge impact, no doubt.

But should you worry about it? Remember - ICD-10-PCS has limited application. It is only required for billing on hospital inpatient claims. So if you work for a physician - or plan to - you will not have to learn ICD-10-PCS. If you code outpatients in a hospital, the jury is still out. Many hospitals still collect ICD-9-CM procedure codes for outpatients so they can use the data internally (remember - coding is about data collection too, not just billing). There is much discussion in the industry on the productivity impact of having coders code in both ICD-10-PCS and CPT for hospital outpatient services.

CPT is not at all affected by ICD-10 implementation. If you code for a physician, you will continue to use CPT to code and bill for his services and procedures.

Of course, if you find you have an affinity for ICD-10-PCS, perhaps this will help you determine your career path and you can look for opportunities to code in a hospital. Inpatient coding is usually a higher level coding position, so it may take time to get promoted up, but if you have the skill for ICD-10-PCS, it's my belief that you will be in demand. I think some current inpatient coders may decide they don't care for ICD-10-PCS at all and make some changes in their career paths.

Friday, July 22, 2011

DNFB, AR, Bill Hold and Other Things You Need to Know Before You Interview at a Hospital

I've interviewed my share of individuals who come in with a padded resume who discredit themselves in about 5 minutes. It has nothing to do with a coding test, education, or certifications. They don't know what the DNFB is. And that is tell tale sign that they have never worked in a hospital coding department before. I can deal with inexperience and honesty. I have trouble accepting lying and deceit.

And while I can't give you all experience, I can let you in on some important coding lingo and explain why it's so important. DNFB stands for "discharged, not final billed." It means - every account held for billing for some reason. Some hospitals refer to it as AR (accounts receivable) or simply "the unbilled." The reasons for unbilled accounts are generally categorized into 3 major buckets:
  • Accounts within suspense (also known as the bill hold) is a facility-defined number of days in which an account will be held from billing so charges can be entered after the patient is discharged from the hospital. Any charges added after the suspense period, which typically ranges from 3-5 days, are considered late.
  • Accounts outside of suspense and not coded - charts awaiting coding before bill drop.
  • Accounts outside of suspense and not billed - charts that have been coded but are being held by billing until issues are resolved (e.g., awaiting late charges)
The concept is simple - the patient receives services, charges are entered, the record is coded and billed. The execution is complicated and the process can hit a number of hiccups before the bill gets out the door.

An informed coding manager can tell you any given day where the facility's DNFB is sitting, particularly those that fall outside suspense and have not been coded. An effective coding manager reports the DNFB to his/her coding staff on a daily basis, keeps the unbilled accounts at a dollar figure the CFO can live with, and can tell you why accounts haven't been coded.

In my experiences with DNFB cleanup as a consultant, I can tell you, it's often not a shortage of coding staff that leads to a high unbilled report. At one client, I was given unlimited coding resources, but as I looked outside my office at the empty shelves that were supposed to be filled with paper records (this was about 10 years ago), I remember telling my boss not to send me more coders but to send me people who could find charts instead. This began a major search in the hospital for medical records that never came down from the floors. Today as we pave the way for electronic health records, there are still a lot of facilities using paper that is then scanned into an electronic format, so tracking down this paper is still an issue for some.

In short, DNFB is not just every coding manager's responsibility, it's every coder's responsibility. You should be prepared to react to fluctuations in the DNFB - when it's high, you may be asked for overtime, denied time off, or taken off other projects that don't contribute to dropping bills (e.g., going to educational seminars). If you're being trained in a new area of coding but are proficient in another, you may be asked to revert to your level of experience before continuing your training.

Thursday, July 21, 2011

Evolution of the Coder Coach

I recently looked over my past blog postings to see what material I haven't covered. Well, there's a lot. And I realize my last few posts have been very heavy on ICD-10 - mainly because that's what I'm working on most of the time. It got me thinking, though - have I strayed from the initial intent of this blog? Who is my audience - current coders or future coders?

I have a friend and avid blogger (who's blog I am sorely behind in reading!) whom I consulted before I started the Coder Coach blog and I asked her, "What do I blog about?" She said, "Whatever you want!" Perfect! Because if I can't write about something I truly want to write about, what's the point of having a blog?! And today it really hit home - my audience has expanded.

I started the Coder Coach group and blog about 2 years ago because I identified an alarming trend. Schools are turning out coding professionals by the dozens and many of them are becoming certified. They spend a lot of time, money, and effort to get the training they will need to land them in a lucrative career only to have the doors of employers slammed in their faces because they lack experience. I've talked to my peers and we're all under regulatory pressures that make it difficult for us to train new employees. But can we ever really expect to hire someone who can truly hit the ground running without any training?

The Coder Coach isn't just this blog, it's also a Facebook group (where I post links to this blog and others) and it's a group of curious individuals in the Denver area who get together every couple of months to learn something about coding from a pro (not always me!) that goes above and beyond classroom learning. In my mind, the Coder Coach is helping to fill that big gap between school and experience.

But as I mentioned, my audience is growing. The unknown isn't just limited to coding students and new grads right now. The coding field is about to undergo a monster transition and at the same time, health information management (HIM) professionals are struggling with implementation of electronic health records (EHRs), health information exchanges (HIEs), and meaningful use standards. As an HIM professional and coder, I see and talk to many people who are paving the way for the future of these professions. My mother is a retired RHIT who was before her time - she retired about 10 years ago and before her retirement was really excited about the future of EHRs. When I tell her about what's going on in the field right now, she is in awe - we are just starting to realize what she had a vision for 15 years ago.

And as I've toured the state of Colorado, conducting outreach through our ICD-10 Task Force, I've had many HIM practitioners asking me questions that coding students ask me. Should they consider a change from the operational side of HIM to coding and what's the best way to do it? So I will try to give a good balance in my blog postings of basic things I think anyone interested in a coding career should know now along with what everyone seems to need - a little insight into what it will be like as an ICD-10 coder.

Happy evolving to all of us!

Wednesday, July 20, 2011

31 Flavors of Ice Cream, 31 Root Operations in ICD-10-PCS

Sunday I decided to give up ice cream. Not forever, just for a few weeks or so while I try to kick what has become a rather troublesome sugar addiction. It turns out Sunday was not a good day to give up ice cream because that was National Ice Cream Day. How that very important holiday was omitted from my Outlook calendar when I imported all the US holidays, I'll never know, so I will have to be more watchful next year. I am proud, albeit unsatisfied, to tell you I stuck to my guns and didn't celebrate National Ice Cream Day this year. There's always 2012!

You might be laughing right now, but ice cream is a very serious matter to me. When asked what my favorite ice cream is, I will inevitably ask you "from where?" and then launch into a tirade about how the manufacturer is key in determining what flavor to eat and continue with a discussion about proper chocolate-to-ice-cream ratio that would make Sally Allbright from When Harry Met Sally proud. I consider myself a bit if a connoisseur, which my mother tells me goes all the way back to that first ice cream cone I "shared" with her. The words "death grip" come to mind when I think of her telling the story. In short, she didn't get any ice cream that day and so began my love affair with the creamy treat.

Monday morning, ice cream ban still in full swing, and ready to start another work week, I shuffled into ICD-10 Central (aka, my office), where it's quite obvious there is some serious ICD-10 work going on: the two large flipchart posters on the wall listing the root operations, stacks of ICD-10 books from current and past years, and a hot pink post-it stuck to my July (national ice cream month!) calendar stating quite simply: "31 Flavors of ice cream - 31 Root Operations."

The ice cream post-it is the only way I can remember how many root operations there are in ICD-10-PCS. I heard a speaker once tell the audience to take a root operation a month and study it in preparation for ICD-10-PCS and then she said there weren't enough months before implementation. And sure enough, here we are in July 2011 and the October 1, 2013 deadline is looming ever closer - only a couple years away.

When I tried to relay that story to one of my audiences, I decided it was pathetic I couldn't tell anyone off the top of my head how many root operations there were. So thank you, Baskin Robbins, for helping me out with this one and loaning me your 31 Flavors terminology. Even though at last count there were more than 31 flavors behind your counter. And even though, in my mind, there is only one flavor of Baskin Robbins ice cream (accolades for proper chocolate-to-ice-cream ratio!).

So there you have it. There are 31 root operations in ICD-10-PCS that hospital inpatient coders must become familiar with. It will be quite impossible to code without knowing the root operations. For ease of use as I have sat down with medical records and began coding my little ICD-10 heart out, I posted the wall charts right in front of my desk, arranged in categories I wish I could take credit for creating:

Root operations that take out some or all of a body part:
  • Excision
  • Resection
  • Detachment
  • Destruction
  • Extraction
Root operations that take out solids, fluids, or gases:
  • Drainage
  • Extirpation
  • Fragmentation
Root operations that involve cutting or separation:
  • Division
  • Release
Root operations that involve putting in or putting back or moving some or all of a body part:
  • Transplantation
  • Reattachment
  • Transfer
  • Reposition
Root operations that alter the diameter or route of a tubular body part:
  • Restriction
  • Occlusion
  • Dilation
  • Bypass
Root operations that always involve devices:
  • Insertion
  • Replacement
  • Supplement
  • Change
  • Removal
  • Revision
Root operations that involve examination only:
  • Inspection
  • Map
Root operations that involve other repairs:
  • Control
  • Repair
Root operations with other objectives:
  • Fusion
  • Alteration
  • Creation
Some root operations have very limited use: mapping is used only for cardiac electrophysiology mapping; the root operation creation has only two possible uses - gender reassignment from male to female or vice versa. Some are more commonplace: excision is removal of part of a body part while resection is removal of the entire body part. That contradicts the way we code today where excision is a complete removal.

But don't worry - this alien new coding system comes with its own set of guidelines that define these root operations and tell you when to code out separate components of a procedure. For example, there is a hierarchy for spinal fusions that utilize bone graft, internal fixation, and cages so you only end up with a single code. On the other hand, placement of a completely embedded vascular infusion device requires two codes: one for catheterizing the vessel, and one for placement of a subcutaneous port.

If you're wondering how to get a leg up on ICD-10, don't bother learning to code it right now. We've all heard that, right? You will forget it unless you use it every day. But you can and should start reading the coding guidelines and become familiar with the table format of ICD-10-PCS. It's different for everyone who codes now (that was spy code for all you novices looking for a level playing field!). ICD-10-PCS coding will identify a whole new population of coders with the skill to properly categorize root operations. It will mean knowing not only the name of the procedure, but what that procedure is trying to accomplish and how it's performed. So brushing up on surgical procedures is a great way to bide your time until it is time to get moving with hands-on training.

So are you ready to test out those 31 flavors of root operations? I will start posting some teasers for you and you can test your ability to name that root operation. If you would like to download the latest version (2012) of ICD-10-PCS, the files are free at CMS' website - guidelines included! Check it out here at: While you start reading, I am going to go hide my car keys and my Ben and Jerry's pint cozy. I suddenly have a craving for ice cream. Weird.

Wednesday, July 13, 2011

Evolution of the Coder

When I started the HIM program at the local community college in... ahem, a few years ago (sly smile), I split my time working as a file clerk in a doctor's office and a catch-all clerk in a physician's billing office. The doctor's office was a family practice managed by the owner of the billing office, which was located just next door. I remember my coworkers asking me why I was going to school to learn about medical records because I was already a file clerk. I also remember hearing one of the billers grumble about an insurance company denying claims for a male patient with pelvic pain and "can't men have pelvic pain?!"

Well, it didn't take me long to realize that the HIM field was more than filing - especially these days as hospitals and physicians move to electronic health records. And it didn't take me long to learn that, at least in the eyes of ICD-9-CM, men can't have pelvic pain - at least not the kind classified to code 625.9, Unspecified symptom associated with female genital organs (as evidenced by the word "female" in the code description and the little female symbol next to the code).

That was a long time ago and a lot has changed in the coding (and HIM) field since then. As a consultant, I work with hospitals to identify areas for coding education and then develop a curriculum and deliver training. It used to be as simple as telling my client to have all their coders at the training at a specific time and date. But not anymore. You see, the coders in a hospital aren't just sitting in the coding unit (physical or virtual) anymore. There could be coders all across a hospital. There could be people coding who don't even know they're coding. There could be nurses working with doctors to improve their documentation to ensure proper code-based reimbursement. There could be clinic coders coding the professional side for physicians working in hospital-based clinics. Finding coders in a facility is a challenge!

In short, coding has evolved.

And this is a great thing - this means that if you have the skill to be a coder - and it is a skill - there are many directions your career path can take you. So what's your passion? Do you relate to transactional work? Are you production oriented? Do you like the clinical puzzle involved in coding and secretly harbor fantasies of being Dr. Gregory House and solving the diagnostic dilemma in front of you? Do you like finance? Are you a data hound? Do you love to do research? If you answered yes to any of the above, there's a niche for you in coding.

The Transactional/Production Coder
I'll be honest. As a coder, my production, in general, stinks. At least it did the last time I did it. Some days I could concentrate very well and knock out a bunch of records. Some days it was like ADD kicked in and I just couldn't concentrate on the documentation in front of me. But there is a group of very special people who are production-based and enjoy transactional work. These are the people who are a coding manager's dream. They come to work, know how many accounts they need to code for the day, and they get it done. I have a lot of respect for those people. I wish that was me!

The Dr. House Coder
I use the TV show, House, a lot in my training sessions and blogs. I watch it and see if I can diagnose the patient before Dr. House. Usually not. But it's fun to try! Physicians and nurses alike are often surprised when they talk to coders to learn how much coders know about clinical practice and disease process. If you read enough medical records in your lifetime and see the treatment plans, it starts to rub off! If you love the clinical stuff like me, there's a lot of opportunity. Clinical documentation improvement (CDI) programs are popping up all over hospitals. The point: get the physician to document as specific as possible to ensure proper reimbursement for the hospital. Clinical documentation specialist (CDSs) are on the floor, looking at charts while the patient is in-house and talking directly with physicians. This is a job that can be done by a nurse or a coder who has been given proper clinical training. Some hospitals employ both coders and nurses as CDSs for a collaborative effort. I don't really have a desire to go back to working for a hospital, but if I did, I think I would like to be a CDS.

The Code-Based Reimbursement Coder
More and more I see coders being placed in the billing departments of hospitals. Or certified coders being given the role of charge description master (CDM) analyst. As Medicare and other code-based payers get really sticky with their billing requirements, it gets more difficult to get a clean claim out the door. Coders working on the revenue side are typically ensuring hospital systems that incorporate the use of codes are updated and interfacing/functioning properly.

A CDM analyst maintains the hospitals list of charges. If you're looking for a picture of what a CDM looks like, it's a massive spreadsheet for each department in the hospital with a line item for everything they could possibly charge for along with prices for those services and supplies. And some of those line items are attached to codes. CDM analysts work with clinical department heads to make sure charges are set up for all their services and supplies. They also make sure CPT and HCPCS codes in the CDM are updated according to regulatory standards. They might be called into a clinical department to assist in training personnel who are responsible for charging.

For lack of a better title, the code-based reimbursement analyst (an aptly named title I borrowed from a former employer where I was responsible for training code-based reimbursement analysts), is a catch-all before a claim goes out the door. Or someone who audits claims and makes corrections. This person may be responsible for working NCCI edits to get claims through the hospital scrubber and may also work closely with the coders, educating them on the latest Medicare reimbursement changes.

Code-based reimbursement analysts may also be placed in departments prone to frequent coding and charging errors, like interventional radiology, wound care, or injections and infusions. These specialty coders often work not only with documentation, but also with nurses entering charges and physicians regarding their documentation. They may also have a link to billing so they can see how their coding is translating to claim denials and errors.

If you like the revenue and compliance side of coding, there are lots of opportunities for you. Students and recent grads interested in this area often ask me where they can get training or certification for this type of job. Well, there really isn't a specific type of training for it. The best thing you can do is try to get your foot in the door and learn on the job. The coding piece of this is probably the hardest - the rest you learn from your employer. Revenue cycle is part of what I do as a consultant and I like it. I particularly like trying to figure out the complex changes Medicare has put into effect and walking that tightrope between ensuring the provider is getting paid as much as possible while maintaining revenue compliance. Let's just call this code-based coder the "Goldilocks" coder - don't code too much, don't code too little, code just right!

The Data Coder
Maybe you like analyzing data. I for one, find it dull after about 15 minutes. But I've had the joy of working with people who love doing that so we can leverage our skills for the greater good. There are many opportunities for the data-oriented coder. Of course, we should all be concerned about data integrity and coding what was done. But there are positions for people who want to slice and dice and interpret coded data. Registry programs (e.g., cancer, trauma, cardiac) often incorporate the use of codes and then some. The plus to being a registrar is that you usually become an expert in one particular area. For example, I know a cancer registrar who has been to enough tumor board meetings where cancer cases are discussed among physicians, she can effectively diagnose skin cancers most of the time (of course, the real diagnosis comes from a physician!).

Coded data is used by many - health departments, clearinghouses, universities, state hospital associations - and the list goes on. As the government becomes more concerned about outcomes of care and pay-for-performance in hospitals, there is a heavier reliance on accurate coded data. Independent companies like HealthGrades rely on coded data to compare the quality of healthcare among providers and report it to consumers. Someone is behind that data ensuring it's accuracy and interpreting it's impact and meaning. That could be you!

The "Why" Coder
I saved the best for last - well, in my opinion anyway. The "why" coder is the one who loves research and wants to know why. Why will Medicare not pay for a biopsy and an excision of a lesion done at the same time? Why does Medicare pay less for certain patients who have been discharged to a nursing home rather than home? What's the difference between two codes that at first glance appear to have identical code descriptions? Why can't men have pelvic pain?! And this is why I have trouble being a production coder. It's hard to produce when you keep asking why. Luckily, I am able to put my investigative skills to work and do research to build training materials for other coders - like production coders - so they can do their jobs efficiently. The best thing about the "why" coder is that it's free. You can learn just about anything you ever wanted to know about Medicare and their why's and not pay a cent. Of course, the price for accessing public domain information is the sheer amount of information you need to paw through to answer a single question - it can be several hundred pages.

So what's your passion? What kind of coder will you be? The opportunities are endless and we need all kinds!

Wednesday, May 18, 2011


Just for the record, it's HIPAA, not HIPPA. The actual legislation is called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), not the Health Information Patient Privacy Act (HIPPA). I can't tell you how many times I've seen the latter referred to. As a matter of fact, a colleague of mine once emailed a company after seeing HIPPA repeatedly displayed on their website. Once she educated them, they offered her a job!

Privacy and Security
It's true - when most of us think HIPAA, we think privacy of health information. And that's a huge part of it. We may even think, as coders, that we are only impacted by HIPAA when it comes to keeping the medical record information we read during the coding process confidential. But HIPAA is much bigger than keeping health information from falling into the wrong hands. The true intent of the law was the make sure people retained insurance coverage as they changed jobs. It includes several provisions for sharing data electronically and in order to enact this sharing of information, it was prudent that privacy and security provisions be built into the infrastructure of HIPAA.

As coders, we will likely be required to sign confidentiality agreements with employers. We will be subjected to criminal background checks and possibly credit checks. We will be forbidden from discussing that interesting ER case in the elevator. We won't be able to look up medical record information for friends and family. Well, I suppose you could, but make no mistake - there is very little to no tolerance for HIPAA violations. I've seen people dismissed immediately for violating patient confidentiality. I saw this most at a celebrity-frequented hospital where people tweeted or posted on Facebook when someone famous was admitted or they released specific protected health information (PHI). In this day and age, it's not uncommon for employers to have a social networking policy that addresses Facebook and Twitter.

And while privacy of PHI is a coder's concern, there are other provisions within HIPAA that impact us. I meet a lot of people who want to code so they can work from home. But setting up a home office as a coder means more than getting a computer and internet connection. Along with ensuring patient privacy comes security of PHI as well. The home workstation must be secure from breaches including hacking of computer systems and stolen computers. It's a natural concern when setting up a home office - who will have access to the work computer and if there are multiple people living in the household, what provisions are being taken to ensure that the workstation is secure? Some home coders may be subjected to a home evaluation by an employer to ensure the workspace is secure.

HIPAA-Defined Code Sets
Still not convinced that HIPAA impacts you greatly as a coder? How about the codes you use? Those are also intertwined into HIPAA legislation. Electronic exchange of information between two different parties requires specific transactions. For example, the submission of an insurance claim by a provider to a payer is one such HIPAA transaction. There is another for communication from the payer back to the provider about what was paid on each account. These HIPAA transactions require a common language between the parties. And that language is often codes. As such, HIPAA defines which code sets are approved for reporting diagnoses and procedures in order to ensure uniformity.

There are six code sets approved for various uses and time periods as defined by HIPAA:
  • HCPCS (Healthcare Common Procedural Coding System, Level II)for ancillary services and procedures
  • CPT-4 (Current Procedural Terminology) for hospital outpatient and physician services
  • CDT (Current Dental Terminology) for dental services
  • NDC (National Drug Codes) for over-the-counter and prescription medications
  • ICD-9 (International Classification of Diseases, 9th Revision) for diagnoses and hospital inpatient procedures - currently used
  • ICD-10 (International Classification of Diseases, 10th Revision) for diagnoses and hospital inpatient procedures - effective October 1, 2013
The HIPAA Version 5010 Standard
Most coders and coding students are aware of the massive effort currently under way to migrate from ICD-9 to ICD-10 in 2013. Many are not aware, though, of the updates to the HIPAA transactions that must occur in order to make ICD-10 data electronically exchangeable. We currently operate under the HIPAA version 4010 and as of January 1, 2012, we will use HIPAA version 5010. This upgrade includes many other updates besides those to get us ready for ICD-10. The impact of 5010 implementation is currently being felt by payers and providers as they gear up for testing these new transactions beginning in July. As of January 1 of next year, CMS will not accept any electronic data in the old format. And that means failure to comply will hold up claims submission and payment.

The 5010 upgrade is probably invisible to most coders in an organization. It's very much an information technology (IT) initiative and involves inventorying systems and working with vendors and payers to ensure everyone has updated to the 5010 standard. In addition to updating the number of bytes available to report ICD codes and allowing for alpha-numeric entry (instead of mostly numeric with ICD-9), it also includes updates to allow for reporting the present on admission indicator, eliminates the release of superfluous PHI for insurance certification and verification, and eliminates numerous other inefficiencies in reporting data electronically.

So keep an eye out for the acronym HIPAA - it will come into play a lot in your career as a coder. As for HIPPA, I still can't figure out what that is. There is no Health Information Patient Privacy Act, so as best as I can tell, a hippa is a baby hippo!

Monday, May 9, 2011

Opportunity Happens: ICD-10 is Mine

To quote my recent Facebook posting, "Ever notice that amazing opportunities are followed by boatloads of work?" That's my excuse for where I've been: opportunities and their resulting heavy workload. For me, opportunity is cleverly disguised as ICD-10. What is your opportunity?

Just to catch you up, I recently accepted a senior consulting position with a new consulting firm. Haugen Consulting Group is based locally in Denver and while I will be pretty much doing what I've been doing - coding consulting and education - I will also be working with a team of amazing consultants as we lead our clients through the ICD-10 implementation.

I am also chairing the Colorado Health Information Management Association's ICD-10 Task Force, which is gaining momentum each month. For the last month I've visited two of Colorado's three regional HIM associations and also had the opportunity to speak on ICD-10 and HIPAA 5010 implementation last month in Montana and do an audio conference on the new leg revascularization CPT codes for HCPro. Later this month I will present at CHIMA's spring meeting on the importance of mentoring our future workforce (I'm going to bat for all of you!) and will also moderate an ICD-10 panel. These speaking engagements lead to more speaking engagements, which is what I love to do. And sometimes the speaking engagements lead to contracts, writing opportunities, and other networking opportunities.

While I've been working on some exciting prospects of my own, some of the people I've been mentoring have also received some opportunities. I recently got a call from a recruiter asking about one such candidate and another recent grad got a part-time position in an HIM department based on her work there as a volunteer. And my advice to them now that they have their feet in the door is to work hard to keep those opportunities coming.

So if you've completed a coding or HIM program and are having trouble finding work, here's a reminder of some of the things I recommend for getting your start:
  • Network! I've received jobs from 4 people I knew or worked with in the past. And I've hired people I've worked with in volunteer organizations. Who you know matters!
  • View everything as a learning experience. Work is work, no matter how much you enjoy what you do. There are days when you won't like the tasks that have been assigned, but there may come a day when you need to tap into that experience.
  • Find a workplace mentor. Once you get your foot in the door, find someone you can go to with questions. This doesn't have to be a manager - it can be a lead, a person who has worked there "forever" or even a team of people.
  • Keep a positive attitude. No one wants to work with someone who is negative and miserable. A positive attitude goes a long way in any industry.
  • Don't give up - because opportunity happens!

Wednesday, March 16, 2011

Upcoming Speaking Engagements

It's conference season! This means I have a lot of speaking engagements coming up. Here's a list of what's on tap for me over the next several months and links to more information. If you have any questions or would like more information, email me at If you're in the area, I'd love to meet any and all of you!

  • Tuesday, March 22 - Coder Coach Event, Emily Griffith Opportunity School, Denver, CO. Topic: "Overview of Health Information Management" (speaker)
  • Friday, April 15 - NCHIMA Spring Meeting, Bella Sera Event Center, Brighton, CO. Topic: "Confessions of a Dyslexic Coder - What it's Really Like to Learn ICD-10-CM" (speaker)
  • Thursday, April 21 - Montana HFMA 2011 Spring Conference, Bozeman, MT. Topic: ICD-10 and HIPAA 5010 Preparation (speaker)
  • Thursday, April 28 - HCPro audio conference. Topic: "Cardiac Catheterization and Peripheral Revascularization: 2011 CPT Coding Changes Explained" (co-presenter)
  • Tuesday, May 24 - Coder Coach Event, Emily Griffith Opportunity School, Denver, CO. Topic: "Introduction to ICD-10-CM (Diagnosis) Coding" (speaker)
  • Wednesday, May 25 - CHIMA Spring Meeting, Denver Marriott West, Denver, CO. Topics: "ICD-10 Implementation Panel" (panelist) and "Mentoring the Future Workforce" (speaker)
  • Tuesday, July 12 - Denver chapter AAPC meeting, VA Medical Center, Denver, CO. Topic: "The Importance of Networking in Coding" (speaker)

Tuesday, March 8, 2011

Two Track Mind: ICD-10 and Vascular CPT Coding

Do I seem like a stranger? Because I feel like a stranger. These days I have two things on my mind: ICD-10 and the CPT coding changes for vascular procedures. And pretty much anything outside of these two topics isn't getting much of my attention lately - including blogging. So in an effort to provide you with a recent blog post - and to keep my attention focused on the tasks at hand - I figured I would blog about what I've been up to recently. This will give some insight into the challenges that existing coding professionals are facing today.

Before I let you in on what's been on my plate, I should mention that there is no crossover between these two topics. They are two very different aspects of coding that use two entirely different parts of the human brain. Or at least, they use two very different parts of my brain! When asked why I am so deeply involved in two areas that are so vastly different, all I can say is, I love a challenge. And challenged I've been!

CPT Code Changes
I know what you're thinking. "It's March, Kristi, the CPT code changes were effective January 1 so that's old news." Well, the reality is, it takes some time to get used to new codes. Since I spend a significant amount of time as a subject matter expert (SME) for my clients in the realm of cardiac catheterization and peripheral vascular interventional radiology coding and charging, I can tell you that 2011 has presented my clients with some significant challenges. First of all - the deletion and nearly complete overhaul of the cardiac catheterization section of CPT. If you have a chance to look at a 2011 CPT codebook (I recommend the Professional Edition since it shows all code changes in color-coded fashion), and compare it to a 2010 book, you'll see what I mean.

My biggest challenge? They changed the code descriptions and code numbers, but in many cases used the same digits - just in a different order. A dyslexic's nightmare and yes, yours truly is dyslexic. There are a couple of perks now - we no longer have to worry about coding left ventriculography separately, it's bundled into the left heart catheterization code, and for the most part, supervision and interpretation (S&I) codes are a thing of the past.

The peripheral vascular coding is getting really interesting. This year the American Medical Association (AMA) decided that leg revascularization procedures could be more effectively reported using bundled codes. This new Wal-Mart approach to coding is becoming more commonplace in interventional radiology (IR) coding. What do I mean about Wal-Mart codes? Well, vascular IR coding has historically involved the separate reporting of all procedure codes, including the catheterization or approach, which is typically a no-no in coding. The end result is often a list of 4 or 5 codes to describe one procedure. Wal-Mart coding is "one stop shopping" where everything is included in a single code. Maybe I should call them Ragu codes for those who remember the old Ragu pasta sauce commercials. You know - "It's in there!" This Wal-Mart or Ragu concept of coding means unlearning many complex IR coding guidelines that have been ingrained in our brains over the past few years.

The new leg revascularization codes are set up based on a heirarchy - angioplasty followed by atherectomy followed by stenting - with newly established vascular territories. The iliac territory consists of three vessels. The femoral-popliteal territory is treated as a single vessel. And the tibioperoneal territory as three vessels. To make things more confusing, the AMA deleted all of the atherectomy codes from Category I in CPT and moved them to Category III.

And because IR is arguably the most difficult area of CPT coding (as an IR SME I may be biased), someone has to research all this and educate coders on the changes. Thus, I find myself updating training materials with these changes and presenting the changes. If the areas of cardiac catheterization and IR interest you, I suggest you acquire a solid foundation on basic medical coding first. These 2 areas are difficult for even the most seasoned coders.

ICD-10-CM and ICD-10-PCS
Well if you're a coder, a coding student, or have done any research at all about the coding field, you know we're in for a huge change with the implementation of ICD-10-CM and ICD-10-PCS in 2013. I would like to say that all organizations are in full swing and getting ready for the transition. What I'm hearing as I talk with organizations, though, is that they are just getting started - a full 1-2 years behind the recommended schedule.

In recent weeks I've taken my ICD-10-CM/PCS trainer recertification through AHIMA and kicked off a Task Force through the Colorado Health Information Management Association (CHIMA). As chairperson of the ICD-10 Task Force here in Colorado, I've had the chance to meet with providers and organizations who will be impacted by the ICD-10 code sets. And I am also embarking on a project through AHIMA to get ensure that Colorado Medicaid is ready for the transition.

In addition to that, I'm preparing presentations for the spring conference season and developing ICD-10 tools and training programs for my company. Here's a shameless plug for The Wilshire Group - just in case you're looking for some additional ICD-10 references! My favorite part is the ICD-10 countdown. I've set this as one of my home pages so I can feel the urgency every time I open my browser!

Prepare for Your Challenge
If you really have a passion for coding, then this commentary got you really excited to learn more. I wish I could properly convey how much more difficult coding is than simply looking up a code in a book. And I wish you could get an accurate depiction of what your daily work will look like as a coder. But the truth is, you don't really "get it" until you get into it and although I know so many are frustrated because they can't get the required experience to get hired, I've said it time and again - keep trying to find an angle to get the experience you need to get your foot in the door. And once you're in, I hope you're ready for the challenge because it's a constant learning experience.

Monday, January 31, 2011

Back Away from the Keyboard...

This morning my alarm clock went off at 7:00am, just as it does on most work days. Like most anal-retentive coders, I have my morning routine, which includes the usual suspects like brushing teeth and shuffling into the kitchen for that all important initial cup of coffee. Once my breath is fresh and my eyelids are open, I flip on the computer and wallah! I'm at work for the day. My work day routine begins by scanning my work, Coder Coach, and client email accounts. Sometimes I venture onto the Coder Coach page on Facebook to see if anyone has posted anything. Maybe I send or receive an IM to or from a client or coworker. Maybe I actually pick up the phone and call someone (not terribly likely). But rarely, in my daily dealings as a remote coding consultant, does my work involve face-to-face communication with people. And frankly, I miss it.

Let me be clear. I love communicating through email. I have relationships with friends in other states solely based on email. I have trouble communicating with people who hate email. I have access to six email accounts, Facebook, Twitter, LinkedIn, and Yahoo IM on my iPhone. In other words, I am always virtually connected to just about any of my contacts at any given time. But there is no substitute for in person communication. And that's part of the reason why my Coder Coach events are not offered in an audio conference format.

I've been asked by several people from out of state to offer my Coder Coach events as webinars. Besides the fact that I have oodles of experience as a webinar presenter - for several years I presented 2-3 webinars per month - and I understand all too painfully well everything that could possibly go wrong with the technology aspect of the presentation (I know Murphy well!), I have no desire to feed into the increasing trend of discouraging face-to-face communication. And speaking of feeding, public speaking is one of my favorite things - it energizes me and feeds my desire to keep going with my career. Webinars just aren't the same. Frankly, my pets don't seem as enthused about learning coding as my human audiences (normally) do!

And it's not just the novices who want to network from afar. This new year means a lot of committee and board work for me. And even though my board meetings are offered in a conference call format, I try to attend the meetings in person. Two of the committees I work with have decided not to offer conference calls for their meetings because the chair persons are growing concerned about the lack of face-to-face networking among professionals. There are more opportunities to get educated remotely and that means that those face-to-face networking opportunities are more important than ever. Because if you're trying to break into the industry, look for a new job, or just (as my father used to say), "blow the stink off," you need to get away from your gadgets, get out of the house, and start talking to people.

So I encourage all of you to back away from the keyboard every now and then... that is, after you've researched online for the best local networking event. And get out and meet someone in person!

For local events near you, visit AHIMA's state component association web page at or the AAPC's local chapter finder web page at:

Happy networking!

Friday, January 14, 2011

I Have a Degree, Why do I Have to Volunteer?

I meet so many people who are out there looking for their initial break into the field of coding. And so many of them are discouraged when they are continuously told that they need experience in order to be eligible for hire. The first recommendation I make is always to volunteer and many times that advice is met with resentment - "I have a degree - why should I have to volunteer?"

Well this is where I usually try to put on my politically correct attitude and explain why but I think what I'm going to start saying is "I have a degree, certifications, and 15 years of experience and I volunteer." As a matter of fact, I can't name a single person in the coding field who's successful who doesn't continue to volunteer because so much of the coding profession is governed by volunteers. And if you're a member of AHIMA or the AAPC and you don't feel like you're getting enough out of your membership (or, like me, you're just really passionate about what you do), you have the ability to get involved and affect change.

So let's talk about what volunteering entails and the kinds of doors it can open.

Pink Ladies and Candy Stripers
If you've ever visited a hospital you've seen them. They sport little lab-type coats in pastel (usually pink) colors and work in the hospital gift shop. They're the volunteers that most of us think of when we think of volunteering in a hospital. Or maybe you were picturing the candy cane jumpers of the candy stripers. Well, there's more to volunteering in a hospital than being a pink lady or candy striper.

There is a department in each hospital responsible for selecting, training, and scheduling volunteers. And since most people who offer to volunteer in a hospital prefer to work directly with patients and the public, this leaves prime voluntary real estate in the HIM department. If you offer to volunteer at a hospital and specifically request to work in the HIM department, chances are pretty good the competition is low (unless you told your fellow classmates about this blog!).

Okay, so volunteering in an HIM department isn't going to be glamorous. You won't be coding charts your first day there. But if they use paper records, you might be hunting for records for the coders to code. You might be scanning in paper forms into the electronic medical record. The point is, once you're in the department, you can start to observe the inner workings of an HIM department. And if you pay attention and ask questions, your experience will come quicker than you ever imagined.

Professional Volunteering
I used to feel bad for not spending more time at the local animal shelter volunteering. I just felt like I needed to be doing something in my spare time rather than meeting my friends for dinner. But I soon realized that I had ramped up my professional volunteering so much, that it was probably okay I didn't have time to go pet 200 cats on a Saturday afternoon. My pets appreciate that I don't come home smelling like 200 cats anymore!

The best career advice I can give is to join one or both of the national coding associations: either the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA). If you want to get hired, you go where the employers are and they're members of AAPC and AHIMA. But becoming a member isn't enough. Now you need to network. And members of the AAPC and AHIMA network at events. So you need to go to the meetings and start talking!

This is usually where someone tells me how expensive those events are. And that cost is on top of the membership fees. If you don't have a job, you don't have the money to attend. Yes, it's a catch 22, but there's a loophole! The people who put those programs together are professional volunteers. And often, as a reward for their work, they get to attend for - wait for it - **free**. Or maybe a hefty discount. The point is, if you really want to attend, there are no excuses.

The professional organizations are made up of local organizations - state and/or regional - and they usually have boards. Boards are made up of elected individuals who are volunteering to run things on a local level. Whether it be a local AAPC chapter or your state AHIMA component state association, the boards get together for regular meetings to keep the organization afloat. They also discuss issues pertinent to the industry and how hospitals and physicians are reacting. Just attending these meetings can be an eye opener to the real challenges HIM and coding professionals face. There's also a lot of networking that happens at these meetings. I've both hired and been hired from networking at such events. And if you offer to chair or sit on a committee, it can be a great way to show off your skills and work ethic and make employers stand up and take notice.

I currently sit on a board that has a student liaison and at one of our meetings I had the opportunity to chat with her. She was so excited to be there and so excited about the chance to be a part of the board. I asked her how she heard about it and she said a mentor recommended becoming a member and from there she took the lead and asked the president about getting involved. We happened to have the student liaison position available.

But once you're in, I recommend keeping up the volunteering. I know a lot of colleagues who complain about how the organizations are run. These are usually people who don't vote in the organization elections or offer to help out either. So I look upon professional volunteering much as I do being an American citizen. I vote to earn the right to complain when things don't go how I'd like. And I volunteer in organizations so I can be a part of the change - even though things don't always go my way!

Put it on Your Resume
Volunteering isn't just a futile exercise to torture you and make you give up your precious time. It's a key component of your resume. Put everything you've done as a volunteer on your resume because it shows your commitment to the industry and it could mean the difference between equally qualified applicants.

When I first started running for board positions, I remember how inconsequential my volunteer experience looked compared to other candidates. But just build them one at a time - we all have to start somewhere. And over time, you'll see your list snowball. Here's an example of my volunteer history, as it appears on my resume:
  • 2010-2011 - First Year Director, Colorado Health Information Management Association (CHIMA)
  • 2011 - ICD-10 Task Force Chair, CHIMA
  • 2009-present - Coder Coach mentor
  • 2009 - Past President, Northern Colorado Health Information Management Association (NCHIMA)
  • 2008 - President, NCHIMA
  • 2007 - President-Elect, NCHIMA
  • 2005-2006 - Program Co-Chair, NCHIMA
  • 1999-2001 - Data Quality Committee Chair, CHIMA
  • 1998-1999 - Alternate Delegate, CHIMA
It's a Small, Small World
Here's an important thing to keep in mind when volunteering. Coding is a very small industry in the grand scheme of things, so be careful what you say about whom when you are working in a voluntary capacity. Or any capacity, really. Don't burn bridges because it's not a matter of if, but when will you come across this person again? And don't think moving out of state is going to help out much. There a lot of coding professionals, myself included, who cross state lines. And rumors spread like wildfire, which can be both good and bad for you. Make sure you're one of the people that when someone decides to gossip, they say, "Have you ever met _____? She did some work on a committee I was on and she has great potential for the future!"

So come on out and join my colleagues and me for some volunteering - it's not just for novices!

Thursday, January 6, 2011

What the Heck is a DRG? And Why Should I Care About Case Mix?

So you want to be a coder. And not just that, you want to be a hospital coder because, on average, they make more money than physician coders. And you don't just want to be a hospital coder, you want to be an inpatient hospital coder because then you get to look at the whole chart and piece together the patient's clinical picture. If this is your goal, then everything you need to know you will not learn in school. And that's mainly because there is so much to learn and practical experience is key.

Most of all, if you want to be an inpatient coder, you need to know diagnosis-related groups (DRGs) because in hospitals, it's all about DRGs and case mix - and compliance. If you have no idea what I'm talking about, fear not - here's a primer on DRGs! I wish I could say I cover it all here, but this is just a beginning!

What is a DRG?
The ICD-9-CM coding system contains about 16,000 diagnosis codes and ICD-10-CM contains over 68,000 codes. Imagine trying to determine a payment amount for each individual condition. And that doesn't include accounting for procedures. The most logical solution is to create a system that allows for broader classification of conditions and services for easier comparison and assignment into payment categories. DRGs were created for this purpose. I look at DRGs as a way to "organize the junk drawer" where patients are grouped into different categories based on similar conditions and cost to treat the patient.

DRGs were first developed at Yale University in 1975 for the purpose of grouping together patients with similar treatments and conditions for comparative studies. On October 1, 1983, DRGs were adopted by Medicare as a basis of payment for inpatient hospital services in order to attempt to control hospital costs. Since then, the original DRG system has been changed and advanced by various companies and agencies and represents a rather generic term. These days, we have various DRG systems in use - some proprietary and some a matter of public record - all of which group patients in different ways. Two of the main DRG systems currently in use are the Medicare Severity DRG (MS-DRGs) and 3M's All Patient Refined DRGs (APR-DRGs). Different DRG systems are used by different payers.

How to Get a DRG
All DRG systems are a little different, but the basic premise is the same. DRGs are based on codes. In effect, DRGs are codes made up of codes. The following elements are taken into consideration when grouping a DRG:
  • ICD-9-CM diagnosis codes
  • ICD-9-CM procedure codes
  • Discharge disposition
  • Patient gender
  • Patient age
  • Coding definitions as defined by the Uniform Hospital Discharge Data Set (UHDDS) - in other words, the sequence of codes on the claim
Back in the 80s, DRGs were grouped manually using decision trees. These days, DRGs are grouped with the touch of a button and DRG groupers are a big part of encoding software. But I would be doing you a disservice if I didn't at least give you an idea of the grouper logic. As I mentioned, there are different DRG systems and probably the most popular is the MS-DRG system, so I will explain how MS-DRG grouper logic works.

MS-DRG Grouper Logic
The first step in assigning an MS-DRG is to classify the case into one of the 25 major diagnostic categories (MDC). These MDCs are based on the principal (first) diagnosis and, with a few exceptions, are based on body systems, such as the female reproductive system. Five MDCs are not based on body systems (injuries, poison and toxic effect of drugs; burns; factors influencing health status (V codes); multiple significant trauma; and human immunodeficiency virus infection). Organ transplant cases are not assigned to MDCs, but are immediately classified based on procedure, rather than diagnosis. These are called pre-MDC DRGs.

Once a case has been assigned into an MDC (with the exception of the transplant pre-MDCs), it is determined to be either medical or surgical. Surgical cases require more resource consumption (that's industry speak for "costs more!"), so they must be separated from the medical cases. If there are no procedure codes on the case (e.g., a patient with pneumonia may have no procedure codes), then it's simple - it's a medical case. But if the patient had a procedure, that procedure may or may not be considered surgical. For example, an appendectomy is quite clearly a surgical procedure. But something like suturing a laceration is not. It's all based on resource consumption - the cost of performing the procedure. In general, anything requiring an operating room is surgical.

Quick sidebar here - this is why skin debridement is such a hot topic in the world of coding compliance. Nonexcisional debridement (code 86.28) groups as a medical case. However, excisional debridement (code 86.22) groups as a surgical case and the change in reimbursement is rather drastic.

Okay, so now that we have our MDC and a designation as medical or surgical, we need to look at the other diagnoses on the claim. Right now, Medicare is able to process the first 9 diagnoses on the claim (even though 18 are reportable). These other diagnoses, depending on their severity, may be designated as complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Medicare maintains lists of CCs and MCCs and updates them annually. CCs and MCCs are conditions that have been identified as significantly impacting hospital costs for treating patient with those conditions. For example, it's been determined that congestive heart failure without further specification does not significantly impact costs and it is not a CC/MCC. However, patients with chronic systolic or diastolic heart failure do have slightly higher costs, so those conditions are CCs. More so, patients with acute systolic or diastolic heart failure have even higher costs, so they are designated as MCCs. Are you beginning to see how slight changes in a physician's diagnostic statement impact coding and thus payment?

DRG Weights
Okay, so we know the MDC, whether the case is medical or surgical, and whether or not there are any CCs or MCCs. How does that translate into reimbursement? Well, if you're using an encoder (and if you code for a hospital, you will), you hit a button and presto! You have a DRG with a relative weight. Now if only you knew what that relative weight meant. The DRG relative weight is the average amount of resources it takes to treat a patient in that DRG. Huh?

Let me demonstrate. The baseline relative weight is 1 and represents average resource consumption for all patients. Anything less than 1 uses less than average resources. Anything above 1 uses more than average resources. So let's compare some respiratory MS-DRGs:
  • MS-DRG for lung transplant has a relative weight of 9.3350
  • MS-DRG for simple pneumonia (no CC/MCC) has a relative weight of 0.7096
  • MS-DRG for chronic obstructive pulmonary disease with an MCC has a weight of 1.1924
You can see how different combinations of codes lead to different MS-DRGs with different relative weights. In order to convert that into monetary terms, we multiply the relative weight by the hospital base rate. Now I'm sure you want to know how to get that hospital base rate. Me too. Well, up to a point. The base rate is exclusive to each hospital and takes a lot of historical, facility-specific data into account, like what they've been paid in the past, whether or not they are an urban or rural hospital, and how much the hospital pays out in wages. That's just more math than my poor little head can comprehend! So for the purposes of this exercise, let's pretend like this hospital - we'll call it Happyville Hospital - has a base rate of $5000. So if we multiply the relative weights above by $5000, our reimbursement for those cases, respectively, is $46,675, $3,548, and $5,962.

Case Mix
You just might be asked in an interview if you understand case mix. It's a good indication of whether or not someone really understands DRGs. And I have to admit, in my sometimes sadistic manner, I like seeing that look of glazed-over confusion on someone's face when I bring up case mix. But case mix is simple. It's the average relative weight for a hospital. So get out a big piece of paper for your hospital and start writing down the relative weights for every single case and then divide to get your average. Okay, so it's computerized now. But that's all case mix is - an average.

In the industry, we officially refer to case mix as the type of patients a hospital treats. Let's say at Happyville, we have a high volume of transplant cases plus a trauma center and a well-renowned cardiac program. These are all highly weighted types of cases and our overall case mix will be higher than say, Anytown Hospital down the street that has no trauma center, no transplant program, and basic cardiac services (they transfer all their serious cardiac cases to Happyville!). Happyville's case mix will be higher than Anytown's.

As a coder, you don't need to know what your specific hospital's case mix is at any given time. But knowing what impacts case mix is an indication that you know your stuff. First and foremost, case mix fluctuates. Most hospitals monitor case mix on a monthly basis because changes in case mix are a precursor to changes in reimbursement. Of course your CFO wants case mix to continue to rise, but that could be a red flag. And he certainly doesn't want case mix to fall. If case mix begins to decrease, the first place hospital administration usually looks is coding - after all, case mix is based on DRGs, which are based on codes. But there are lots of things that can impact case mix and many of them have nothing to do with coding, such as:
  • The addition or removal of a heavy admitting physician - especially specialty surgeons
  • Opening or closing a specialty unit
  • Changes in a facility's trauma level designation
  • Movement of cases from the inpatient setting to outpatient, and
  • Anything else that impacts the type of services the hospital provides
Your Life as an Inpatient Coder
As an inpatient coder your job is to make sure you get all the codes on the claim in the correct order so that the accurate DRG is assigned and the hospital gets paid appropriately. When I put it that way, it sounds so easy! The reality is, with more and more patients being treated as outpatients, those who are admitted as inpatients are sicker than they've ever been. And sicker means harder to code. For instance, the patient comes in with shortness of breath and the final diagnosis is acute exacerbation of COPD, stapholococcal pneumonia, and respiratory failure. How you code and sequence the case will determine the appropriate DRG and reimbursement. The good news is, you'll have an encoder to help you model the DRGs and see what pays what. The bad news is, you have to paw through the medical record to determine the true underlying cause of that shortness of breath.

So are you ready for the challenge? Are you ready to apply DRGs?