Reflections of a Coder Coach: Ready to Get Back to Normal

A few weeks ago, it occurred to me that my job hasn't been "normal" for the last six years.  Right around this time six years ago is when I first went to AHIMA's ICD-10 Academy and earned my status as a trainer.  Creating and presenting ICD-10 training materials came soon after that and it wasn't until recently I realized that my job hasn't been normal for the last six years.  And since I've only known my husband for four years, one could argue that he's never known me when I'm normal... er.. at least when my job is normal!

As I look around the articles and social media related to coding, a lot has changed in this industry in the six or seven years that I've put myself out there as the Coder Coach.  When I first started blogging and meeting once a month with coding students and wanna-be's, there weren't a lot of people out there looking to mentor coders.  Now, my voice is one of many as people who never heard of coding before ICD-10 jump on the bandwagon to get a piece of the action.  There have been questions about certifications - which ones to get and how to make sure ICD-10 certification requirements are met.  There have been questions about how to code things we never had to think about before - initial vs. subsequent encounters for injuries and poisonings and root operations based on procedure intent.

I have to be honest and say that in my abnormal day-to-day life as a coder over the last few years, I've had trouble finding my voice and giving advice as a coding mentor.  I no longer feel qualified to tell a coder how to break into the industry because things are so different than they were 20 years ago when I got my start and coding is something that many people are now aware of - not something that people kind of fall into anymore.  Since I fill my days adding to my own intellectual bank by researching procedures and learning how to explain them - and how to code them - I wonder what it is that new coders need right now.  And for everyone who is trying to learn coding, I just want to reach out and give them all a virtual hug because this is, in my humble opinion, about the hardest time to learn this industry.

This week I am working on something I haven't done in years.  I'm reading the Final Rule for the 2016 MS-DRG changes.  That is something I used to read and summarize every year for my clients.  And even though the codes are different and there are some new sections to read in this super long file, I had a moment of realization, a sigh of relief if you will, that this... this is normal!  After we flip the switch on October 1 and everyone starts using ICD-10 (because I have pretty much zero faith in our congressmen to accomplish any earth shattering legislation in two weeks when they're so focused on Donald Trump's run for president), I'm sure there will be a few things that don't go as planned.  But for coders, it's a time for us to return to "normal."  I miss having a general confidence in assigning codes (although this has gotten better as I train more coders!).  I miss code updates!  Oh, how I miss those code updates!  We've had frozen ICD code sets for four years!  I've been following the recommendations made to the Coordination and Maintenance Committee and I can't wait to see which changes they decide to adopt on October 1, 2016.

And maybe when the dust settles a bit and we see how many people really want to stick with coding in ICD-10, I will find my voice again as the Coder Coach.  I sincerely hope so, because I miss meeting people with a passion to learn about my passion and giving them little nuggets of wisdom to help them make a difference in this industry.

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.

History
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?

It's Coding Season!

I'm sometimes asked if there's a busy time of year for coders or if it's pretty much status quo. As a matter of fact, there is a busy time of year for coders and this is it!

Every year, we gear up for all the upcoming year's coding changes. That means letting coders know which codes have been deleted, expanded, and added and letting coders, physicians, administrators, and revenue cycle personnel know how code-based reimbursement will be affected in the coming year. This may seem rather straightforward, but since we work with more than one code set with different implementation dates, fourth quarter of each year can be pretty crazy!

ICD-9-CM Codes
The ICD-9-CM diagnosis and procedure codes are updated annually with the Center for Medicare and Medicaid Services' (CMS) fiscal year (FY), which begins October 1. These codes are used to report diagnoses for all health care settings and procedures for hospital inpatients. Right now, you will find coders acquiring their FY 2011 ICD-9-CM code books and attending seminars on the code updates. Some of this year's highlights include:

Diagnosis Codes:

• A new code for obesity hypoventilation syndrome
• Expansion of fluid overload code to differentiate between transfusion-associated fluid overload and other causes
  
• Expansion of the avian flu codes to include manifestations of the disease
• Expansion of the blood transfusion incompatibility codes to differentiate between ABO and Rh incompatibility
• Additional personal history codes
• Expansion of the body mass index (BMI) codes up to allow for classification of BMI in varying increments up to 70 and over
• A new section of V codes to report retained foreign body fragments
• A new section of V codes to report the number of placentae associated with multiple fetal gestations

ICD-9-CM diagnosis codes are within the public domain and the 2011 revisions can be found on the National Center for Health Statistics' (NCHS) website.

Procedure Codes:

• New code for placement of a central venous catheter under imaging guidance
• New codes for carotid sinus stimulation components and devices

Changes to the ICD-9-CM procedure codes are within the public domain and are available on CMS' website.

IPPS and MS-DRGs
The inpatient prospective payment system (IPPS), the system used for Medicare payments for inpatient hospitalizations, is also updated each year on October 1. This includes recalibration of the relative weights for the classification system used under IPPS - the Medicare severity diagnosis related groups (MS-DRGs). This year, the major changes to the MS-DRGs include:

• A documentation and coding adjustment of -2.9%, wherein CMS will discount payments in FY 2011 to hospitals by 2.9% in order to remain budget neutral. The attempt to remain budget neutral is to counteract the financial impact of implementing a severity-based DRG system 3 years ago.
• The addition of 12 new quality measures to be reported by hospitals under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
• A revamping of Medicare's 3-day rule, which bundles payment for outpatient services provided within 3 days of inpatient admission into the inpatient payment.

Changes to the IPPS and MS-DRGs are available in the public domain through CMS' website as well as the Federal Register.

CPT Codes
Changes to CPT codes become effective with each calendar year on January 1. These codes are used to report procedures and services for physicians and hospital outpatients. Because CPT codes are owned and maintained by the American Medical Association (AMA), they are not available in the public domain. As such, finding a list of upcoming CPT code changes is often a closely guarded secret until the CPT book is published, generally around November or December each year.

The best way to get updates on upcoming CPT codes is to attend either the AHIMA's Annual Clinical Coding Meeting (September 25 and 26, 2010 in Orlando) for the national code update or the AMA's CPT and RBRVS Symposium (November 10-12, 2010 in Chicago). After the AMA's Symposium, it's common to see articles appearing in coding journals and publications discussing the upcoming coding changes.

HCPCS Codes
HCPCS codes are developed and maintained by CMS to report services, supplies, and procedures that are not found in CPT. They are utilized by physicians and hospital outpatient reporting. HCPCS codes are potentially updated quarterly, although an update isn't always required that frequently. HCPCS codebooks may be purchased on an annual basis with the calendar year and quarterly updates are found on CMS' website. HCPCS codes are in the public domain and general information about their use can also be found on CMS' website.

OPPS and APCs
The outpatient prospective payment system (OPPS) is the payment system utilized by Medicare to pay for hospital outpatient claims. This is updated on January 1 each year, along with the CPT and HCPCS codes. The proposed rule was published in the Federal Register on August 3 and CMS accepted public comment on that proposed rule through August 31. CMS will review the comments, make final determinations, and finalize the rule by November 1.

OPPS changes include recalibration of the relative weights for ambulatory payment classifications (APCs), the categories used to group similar procedures for payment.

Some highlights of the proposed rule include:

• Two areas that have undergone frequent changes or requested changes will remain static for 2011: drug and substance administration and hospital outpatient evaluation and management visit guidelines
• Establishment of a list of services that must be performed under physician supervision
• Removal of three orthopedic codes from the inpatient-only list, making them reimbursable as outpatients under Medicare
• A new method of paying for separately payable drugs
  

Information about OPPS and APCs can be found on CMS' website.

Physician Fee Schedule and RVUs
Physician payment, as outlined in the physician fee schedule, is updated annually on January 1 by Medicare. The proposed rule was published in the Federal Register on July 13 and the comment period ended on August 24. The physician fee schedule outlines the relative value units (RVUs) for each CPT code based on the amount of work the physician performs. Information on the Medicare physician fee schedule and RVUs is within the public domain and can be found on Medicare's website.

Too Much Information?
It sounds like an awful lot of information, but remember this - not every coding professional needs to learn the ins and outs of every coding and payment system. Because I work with hospital clients, I will be focusing on everything but the physician fee schedule. And those who work in physician offices will focus on ICD-9-CM diagnosis code changes, CPT/HCPCS code changes, and the physician fee schedule only. Even so, it's enough of an impact to call fourth quarter "coding season!"