What You Need to Know About Coding Using EMRs and Encoding Software

I haven't been perusing as many coding sites and Facebook pages recently as I was a couple of years ago, but I did recently come across a post that captured my attention.  Someone was asking if there was a way to get trained in a popular electronic medical record (EMR) to help them meet the requirements of a job.  It seems many employers are looking for work experience with a certain EMR before considering a person for a position.  Is this fair?  Well, it may not seem fair if you've never worked as a coder, but if you have, chances are pretty good you've had exposure to some of the major EMR software vendors.  For those of you who don't have any practical EMR experience, here's what you need to know.

Is it reasonable to require EMR experience?
First of all, if you've never coded before and your coding school didn't have a relationship with an EMR vendor allowing you to learn the system, any reasonable hiring manager is not going to expect you to have experience.  And if they aren't reasonable, then you don't want to work for them anyway (problem solved!).  If I pick up your resume and see you have taken some coding classes and have never worked in the healthcare field but are "proficient" in EMR software, I am going to have more than a few questions for you.  How did you get your EMR experience?  Which systems did you use?  What did you like or not like about it?  In other words, I won't believe you have experience with it and I will try to weed that out of you.  Or even worse, I may be inundated with resumes and feel like you're lying about something on the resume and I may not have the time or energy to do any investigating.  Your resume may be relegated to the "no" pile.

Fact: your employer will train you
Here's a fun fact.  Even if you've worked as a coder for 2 years using a certain EMR software, you will have to have training at your new facility.  You may think you know everything there is to know about a certain EMR software, but they are all customizable.  As a consultant, I've used the same EMR software at several clients and they are all a little different.  You may find documents stored in different places.  Your favorite EMR feature at Hospital A may not have been "turned on" at Hospital B.  So expect to be trained on the same software you've already been using every time you change employers.

EMRs are from Mars, encoders are from Venus
EMRs aren't the same as encoders.  Of course the EMR is where you will find the medical record documentation, but it is also where you will find financial information and abstracted data.  Encoders and computer assisted coding (CAC) software are usually separate from the EMR.  As a matter of fact, there aren't a lot of EMR vendors who are also in the business of encoder software.  That makes two different kinds of systems you need to be aware of.  But have no fear: while it's a plus if you have been trained on an encoder, you can expect your employer to train you there too.

You need to understand interfaces
Rather than obsessing over how to get trained on a particular EMR or encoder, here's something more important for you to focus on: you need to understand software interfaces.  Because your EMR and encoder are coming from two different vendors and they have to talk to each other, they rely on interfaces.  How that's set up is not important to you (although it's very important to the information technology department), but how and why you enter data the way you do is based on interfaces.  I've coded for lots of hospitals with lots of different computer systems, but in general, here's how it works:

1. You pull up the patient in the EMR.
2. If you work with a CAC product, you launch the CAC by clicking a button in the EMR.  This opens the CAC using an interface, so that it automatically pulls up the patient you are working on in the EMR and displays medical record documentation for coding.
3. If you don't have a CAC, you review the medical record documentation in the EMR and then launch the encoder using a button in the EMR.
4. Once you are in the CAC/encoder, you code the record.  This software allows you to look up codes and save them to a list.  When you're done, you click a complete button, and then you find yourself back in the EMR in the abstracting screens.
5. If the interface is working properly, everything you entered in the CAC/encoder is shown on your abstracting screens.  This is also where you can assign surgeons and dates to procedures as well as any other abstracted data your facility chooses to collect.
6. You send the account to billing in the EMR by indicating the account is complete.

(Most) EMRs don't have grouper software

Groupers are the magic software that calculate DRGs and APCs based on assigned codes.  Grouper logic is something that is built into CAC/encoder software, but not into EMR software.  If you ever need to make a change to codes to rebill an account, you can't just change the code in most EMRs.  It's pretty standard practice to reopen the account, relaunch the CAC/encoder, make corrections, send them back to the EMR through the interface, and then send for rebill.  This concept is something that many coders don't understand and, I would argue, this concept is more important than knowing the ins and outs of any particular EMR product as a new hire.

Knowing how to code is more important than anything

After all this, the most important thing you need to know to get a coding job is how to code.  Your employer can teach you everything I've mentioned above specific to your facility.  And they can also work with you on enhancing your coding skills.  But it's more important for you to focus on coding, coding guidelines, and a cursory background in coding reimbursement than it is for you to know an EMR inside-out.  

So Many Books, So Little Time - Part 1

What's Your Idea of a Best Seller?
Every once in a while I page through a magazine taking keen interest in the best seller and "must read" book lists that everyone is talking about.  I usually tear out the pages for books that are interesting so I can download them later.  And then I rarely read them.  Or it takes me literally months to finish a book.  I love to read, but frankly, after a day of reading code books, and spending a lot of time writing, I just don't have the eye or mental energy to crack a book for fun.

My idea of a best seller is a string of code books that I use every day.  Don't worry though, I find other ways to have fun that have nothing to do with coding!

The last time I moved, I had lots of friends helping me lug boxes and it didn't take long for them to zone in on the heaviest ones: they were labeled "code books."  I have code books for various coding systems going back several years and yes, they are heavy.  And it's hard to explain to the layman why I need so many books in such an electronic age.  I've found it can also be challenging to explain the different code sets to novice coders.  But alas, I am going to give it a try in a series of blog posts because you may not be exposed to all coding systems in coding school, but depending on the setting you work in, you may find you have to become familiar with something new.

I Don't Hate Encoders
Let's get one thing out of the way first, though.  I have no issues with computers or encoders.  In fact, I use a computer for almost everything and, like so many people, I am pretty addicted to my iPhone and iPad.  But as a coding trainer, I learned by the book and I teach by the book and will always default to the book when I have a question.  Encoders are only useful when the user understands the logic behind the program and that logic is based on the book.

ICD is from Mars, HCPCS is from Venus
In healthcare, we deal with two major planets of coding systems: the International Classification of Diseases (ICD) and the Health Care Common Procedure Coding System (HCPCS).  And as if that wasn't enough, those coding systems are divided into further classifications with different uses. Coding for a physician practice?  Then you'd better brush up on different parts of the coding spectrum than what you'd see in a hospital. Coding outpatient services for a hospital? Then you need to know something different than what you would need to know if you were coding hospital inpatient services.  Want to know how to code everything?  Then it's time to become familiar with your new best seller list.  This post will start with the basic coding system that everyone uses.

ICD-9-CM Volumes 1 and 2: Everyone Does it 

You probably aren't surprised to hear that the government determines which codes we use in the U.S.  But you may be surprised to hear that the law that defines those coding systems is a little law called HIPAA. Yes, the same law that addresses privacy and security of medical information also tells us which codes we must use to report healthcare services.  This is why some code books boldly state on the cover that they support HIPAA compliance.  In order to make health information portable and comparable,the Healthcare Portability and Accountability Act of 1996 (HIPAA) makes sure we're all speaking a common language, expressed in codes, before we exchange data electronically. The privacy and security provisions are simply byproducts of making sure health care data can be shared electronically. 

Every health care case, regardless of provider and setting, has one code set in common: ICD diagnosis codes. This coding system was developed by who?  That's right - it was developed by WHO: the World Health Organization. Here in the U.S. we currently use an adaptation of WHO's ICD, which is currently the ninth version. We call the U.S. version a clinical modification. And thus, we have ICD-9-CM: the International Classification of Diseases, 9th Revision, Clinical Modification.

ICD-9-CM has three volumes. The first two volumes include the diagnosis codes.  This includes the tabular (Volume 1) and index (Volume 2). I'll address volume 3 in part 2 of this series. Bottom line here: every HIPAA-covered entity, which includes hospitals and physicians (and excludes workers' compensation and car insurers) utilizes ICD-9-CM codes to report diagnoses on a claim.

ICD-9-CM codes have 3-5 digits with a decimal point after the first three digits. All codes are numeric except for V codes, which start with a V and then have two numeric digits and may have up to two more digits after the decimal point; and E codes, which start with an E and have three numeric digits and may have an additional digit after a decimal point. E and V codes are actually "supplementary" codes that are not included in the main part of the ICD-9-CM volumes 1 and 2 code set.

Here are some examples of ICD-9-CM codes:

• 486, Pneumonia, organism unspecified
• 401.9, Essential hypertension, unspecified
• 250.00, Diabetes mellitus without mention of complication, Type II or unspecified type, not stated as uncontrolled

Examples of supplementary codes:

• V08, Asymptomatic HIV infection status
• V27.0, Outcome of delivery, single liveborn
• V76.51, Screening for malignant neoplasm of colon
• E961, Assault by corrosive or caustic substance, except poisoning
• E885.3, Fall from skis

Regardless of who you plan to code for, you will be using ICD-9-CM diagnosis codes for billing.  As such, this is likely the first coding system you learn.  

Frozen

You may notice in my picture that my most recent ICD-9-CM code book is from 2012.  That's because that was the last year that we had updates to the coding system.  ICD-9-CM is under a permanent code freeze as we optimistically await ICD-10 implementation.  Don't worry, I will address ICD-10 in future posts.  For now, you are safe using an ICD-9-CM code book from 2012 or newer, but I wouldn't waste money on a new book if (heaven forbid), ICD-10-CM is not implemented this year.  ICD-9-CM remains forever frozen and is no longer being maintained.  If you want to bone up on ICD-9-CM coding guidelines, they are printed in the front of your code book.  Or you can do what I do and download the PDF document so you can easily search the document for something specific.  Here is a link to the last version of the ICD-9-CM Official Guidelines for Coding and Reporting.  

Next up: ICD-9-CM Volume 3...

Recovering Encoderaholic

Most coding students spend semesters learning to navigate ICD-9-CM and CPT code books and maybe a little class time plus internship experience learning how to code using an encoder. And then they graduate and, if they move on to a position at a hospital, they start using an encoder almost exclusively. In fact, many hospitals don't purchase code books for their coders because they pump so much money into encoders. The result can be coders who forget how to use their code books all together.

In case you aren't familiar, encoders are software programs that automate the code book. This makes coding faster for the coder and also allows for inclusion of coding and billing edits and coding guidelines and advice. Not to mention, it helps us remember to put fifth digits on all those diagnosis codes! There are two types of encoders: logic-based and book-based. Logic-based encoders are probably the most popular. They ask the coder a series of questions that ultimately lead to code assignment. Book-based encoders are computerized code books in which the coder looks up codes just like in a hard copy book with a few enhancements. Both types tend to include crosswalks from ICD-9-CM to CPT and vice versa.

Sounds great, right? What could possible go wrong?

Well, a lot, actually. And I speak from experience as a recovering encoderaholic.

Don't get me wrong, I like encoders - love them, actually - and can't do my job efficiently or completely without them. But even when I have my encoder up and running, my code books are at my finger tips. And when I teach, I prefer to teach from the book. This was a hard won lesson for me. I remember a coding auditor coming to audit my coworkers and me and, in her exit interview, she made an example of me. She asked me how I came up with a CPT code and my response was "the encoder took me there" and she asked me where my CPT book was and I pointed to the enclosed bin over my desk. And she read me the riot act for not having my CPT book on my desk - and I was coding day surgeries. She then told me what I tell the coders I audit now - "the encoder took me there" is not a valid excuse.

If you're wondering why you have to spend so much time becoming familiar with using the code book, it's because it's the fundamental of coding. If your elementary learning experience was like mine, you had to learn how to do long division before using a calculator and you had to learn to tell time on a clock face before you got a digital watch. Learning to use the code book is important because you need to know the logic behind the encoding programs in order to "check your work" - to steal a phrase from math class! How will you know the encoder led you wrong if you don't know the logic?

If that's not a good enough reason for you, then chew on this. Many people are not passing coding certification exams these days and it's not because they don't know how to code. Many of them have been coding for years - with encoders. And since they have to use books on the test and they aren't efficient in looking up codes in the book, they are unable to finish the test.
You may be asking if encoders will replace the need for coders and many industry experts agree that while there is some limited application to computer-assisted coding (e.g., radiology), the skill of reading a medical record and translating it into code is a subjective skill that requires a human. So don't worry about there being no future in coding due to computerization; just worry about how you will use coding software to enhance, not replace, your coding knowledge.