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!
Showing posts with label compliance. Show all posts
Showing posts with label compliance. Show all posts
Wednesday, July 13, 2011
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.
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:
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:
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:
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?
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
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
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
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?
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