ICD-10 Remix: What the Heck is a DRG and Why Should I Care About Case Mix?

I originally penned this blog post in 2011 and while the essence of DRGs hasn't changed much, the coding system has.  So here is the ICD-10 update to one of my most popular blog posts of all time.  Enjoy!

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-10-CM coding systems contains over 72,000 codes. Imagine trying to determine a payment amount for each individual condition. And that doesn't include accounting for procedures (over 78,000 ICD-10-PCS codes). 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-10-CM diagnosis codes
• ICD-10-PCS 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. For the most part, anything requiring an operating room is surgical.

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 18 diagnoses on the claim. 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
Now that 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 10.7863
• MS-DRG for simple pneumonia (no CC/MCC) has a relative weight of 0.6821
• MS-DRG for chronic obstructive pulmonary disease with an MCC has a weight of 1.144

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 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 $53,932, $3,411, and $5,720.

Case Mix
You just might be asked in an interview if you understand case mix. It's a good indication of whether 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, staphylococcal 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?

How to Get Started in a Medical Coding Career

I'm trying something new and launching a video blog.  You may have noticed that I haven't written much lately and that's mostly because I can't write anything quickly without a million edits.  And with a full time job and small child, ain't no one got time for that!  Not that the videos aren't without outtakes and redos, but they do seem to be quicker (when I put all vanity aside and ignore the bad hair days).  The frequency of videos is yet to be determined, but you can bet it will be related to how often I decide to do hair and makeup while working from home!  It only took me just over a month to get the nerve to post this first video.

This episode was inspired by countless social medial posts where people are asking how to get started as a medical coder, so that is answered here.  Where do you find a program?  AHIMA or AAPC?  CCS or CPC?  Don't enroll in a medical coding program without watching this video first!  And share this video with anyone you know who wants to be a medical coder.

In the video, I mention two websites and here are direct links to the pages that will help you locate coding schools:

• AHIMA
• AAPC 

Both websites have information about coding schools with face to face instruction as well as web-based instruction.  Best of luck to you!

Slim Year for ICD-10 Coding Updates

Just like the past couple of years, we've been waiting rather impatiently over the last couple of months for the release of the fiscal year (FY) 2019 ICD-10-CM and ICD-10-PCS code updates.  While the PCS code sets have been out for a month or two, the CM updates were released just last week, sans coding guidelines, which we are still eagerly awaiting.  FY 2019 codes will be implemented on October 1, 2018 (the federal fiscal year runs from October 1 through September 30).  In case you're wondering how the code changes stack up to previous years, what the process is for updating the code sets, or why they aren't released at the same time, this post is for you!

In comparison to past years, it's a slim year for code updates.  When the code sets were unfrozen for FY 2017 after ICD-10 implementation, we saw a whopping 2,710 CM and 4,330 PCS code changes.  Last year, for the FY 2018 release, there were 731 CM and 6,029 PCS code changes.  FY 2019 has a pretty sharp drop for both code sets with 473 CM and 616 PCS code changes. 

If you've been playing along at home and waiting for the code releases, perhaps you've been wondering why the CM and PCS updates are not released at the same time.  Even though both code sets are presented to the Coordination and Maintenance Committee for review and discussion before the Cooperating Parties and general public, each code set is maintained by a separate government agency. 

ICD-10-CM is maintained by the National Center of Health Statistics (NCHS), a component of the Centers for Disease Control and Prevention (CDC).  ICD-10-PCS is maintained by the Centers for Medicare and Medicaid Services (CMS).  Twice a year (every March and April), both agencies present proposed code changes at the Coordination and Maintenance meetings in Baltimore and then each agency works to finalize the code sets. 

Over the past couple of years, we've noticed that PCS changes happen more quickly and are released earlier than their CM counterparts.  CMS presented code proposals for FY 2019 as late as the March 2018 meeting.  On the other hand, most of the code proposals that NCHS presented for CM in March were for consideration for FY 2020.

The other trend we've been noticing since converting to ICD-10 is the last thing to be released is generally the ICD-10-CM Official Guidelines for Coding and Reporting.  We are still waiting for the FY 2019 coding guidelines to be released.  It's been common for NCHS to release the code sets first and the guidelines at a different time, whereas CMS has been pretty consistent with releasing the PCS code sets along with the ICD-10-PCS Official Guidelines for Coding and Reporting.

If you read this post hoping I would give some spoiler alerts, you'll have to wait for the webinars I'm presenting in August for Haugen Consulting Group.  I hope you'll click the links to the marketplace and register for one or both (CM and PCS) updates webinars where I will outline the changes with some background information and a healthy dose of Haugen fun.  Well, fun is relative - we're still talking about coding, but who said that has to be boring!

Here are the links to help keep you updated for FY 2019!

• 2019 ICD-10-CM Updates: Diagnosing What You Need to Know
• 2019 ICD-10-PCS Updates #FirstToKnow

Spotlight on Certification: Certified Interventional Radiology Cardiovascular Coder (CIRCC®)

Lately I've heard a lot of buzz about the AAPC's credential, Certified Interventional Radiology Cardiovascular Coder (CIRCC).  Interventional radiology (IR) coders are in demand because of the complexity of the field and the notoriously high error rates seen on audits. It may sound like a great credential to get, but before you make any sudden movements, here's what you need to know about the CIRCC exam.

Why this credential exists
I've been coding now for 22 years and I've seen quite a bit.  I helped train the workforce in ICD-10-CM and ICD-10-PCS. I've audited ICD-9, ICD-10, CPT and HCPCS codes.  I've read the Federal Register on DRGs and APCs.  But the hardest thing I've ever had to learn to code is IR and cardiology.  The coding rules are complicated, ever changing, and often inconsistent for different parts of the body.  Learning how to code IR and cardiology procedures by just looking at the CPT book is tough enough, but not all the rules are written there.  There are other societies that develop suggested guidelines and then there are the payer's rules and interpretations.  In a hospital setting, an understanding of IR and cardiology coding also usually requires an understanding of hospital charging and how departments are credited revenue.  This credential exists to show that you've mastered these areas of coding.  In my mind, this is the most difficult area of coding there is.

This is not an entry-level credential
I took the CIRCC exam four years ago with about 10 years of experience under my belt.  It was a tough exam.  As a matter of fact, it was the hardest multiple choice exam I've ever taken and I would put it up there with the Certified Coding Specialist (CCS) test as one of the toughest.  If you are thinking you will get the CIRCC and then land a job as an IR coder without any experience, think again.  This is the test you take after you've been coding those types of cases for a long time and feel confident in your abilities.  AAPC recommends, but does not require, at least two years of coding experience before taking the CIRCC exam.

What's on the test
The CIRCC exam is spotlighted for its focus on IR coding, but it also includes cardiology procedures.  The procedures we're talking about are surgical-type procedures done in a radiology suite or cardiac cath lab using radiological (fluoroscopic) guidance.  For IR, this can be vascular studies (angiograms) and interventions (e.g., angioplasty, stenting, thrombectomy) or nonvascular procedures (e.g., placement of biliary stents, nephrostomies, and fluoroscopically-guided biopsies).  For cardiology, this can be diagnostic cardiac catheterization, angioplasty and stenting, and cardiac electrophysiology studies and arrhythmia ablations.   If you don't know what any of that means, I don't recommend taking the test until you learn more!

What it costs
At the time of this writing, the cost to sit for the CIRCC exam is $400.  But the cost of taking the CIRCC doesn't end when you register and pass the exam.  Like other credentials, you need continuing education units (CEUs) to maintain the certification.  But unlike most other AAPC credentials, there are limited vendors from which you can get those CEUs.  Before you decide to take the test, look at the CEU requirements and visit the vendor websites (the AAPC has links) to see how much your CEUs will cost you and be very realistic about what you can afford.  If your primary job is coding these types of cases, check with your employer to see if they will reimburse you for any of the costs.  This is an expensive credential to maintain, but if it's valued by your employer, they may cover the costs.

Read all about it
I could regurgitate the contents of the AAPC's website about the CIRCC exam, but instead of doing that, I will direct you to their website with this simple instruction: Do your homework!  There is a plethora of information on the AAPC's website for this exam and it will tell you everything you need to know from the breakdown of the exam questions, approved manuals and materials (yes, you can bring anatomy cards showing selective vascular ordering), certification requirements, history of the exam, and FAQs.  If you were going to spend $400 on a new smartphone, you would probably read up on the different models before making a final decision.  Why wouldn't you also do this for a credential?  Don't take this exam until you've read all the fine print.

Preparing for the exam
Once you decide that you're ready to pull the plug and take the test, it's time to prepare.  Even if you've coded these cases for a long time, there is still preparation to be done.  Here is my list of recommendations:

• Get the right CPT book.  The AAPC's website is very clear that they will only allow you to use the American Medical Association's (AMA) version of CPT.  If you have a CPT book from any other publisher, you cannot use it.  I recommend the AMA's Professional Edition of CPT for its color coding and pictures.  It's more expensive than the standard edition, but I think it's worth the money.
• Mark your CPT book.  Don't waste time writing in the things you already know, but I do recommend making cross-reference notes for any codes that have a one-to-one relationship.  For example, I wrote all of the C codes for drug-eluting stent placements next to their CPT counterparts so I didn't have to open another book during the test.  Sometimes CPT includes instructional notes in the Surgical section directing you to the Radiology component code.  And sometimes it doesn't, so I wrote those in too.  Especially if you are used to using an encoder, make sure you have your book set up so you can flip to different code sections fast.
• Get the exam prep book.  Yes, it costs more money and no, I am not being paid by the AAPC to push their products!  The exam prep book will go over what's on the test.  It will give you practice questions and show you the type of questions that will be on the exam.  The one thing I remember from the exam prep book is it said in several places that none of the questions are meant to be trick questions.  That might sound like a no-brainer, but when you really get into IR coding, you'll see why that's an important thing to remember.
• Spend your study time on your weak areas.  Don't waste your time studying things you already know.  If there is an area that is not your strongest, make notes on those CPT sections and find tricks to help you remember.  When I took the test, I was strong in vascular IR and cardiology, but not so much on nonvascular IR, so those sections of my book had the most notes.  Remember: you can write notes in your CPT book, you just can't put any loose pieces of paper in them.  
• Take a prep class.  If you can find a class that will cover part or all of the exam content, enroll now.  I am teaching a vascular interventional radiology class in October 2017 in Denver, which covers some of the trickiest IR coding.  I would love to see you there and chat about your CIRCC aspirations!

If you've ever considered taking the CIRCC exam, I hope you found this post useful.  Want to learn more about IR coding?  Stay tuned - more posts to come!

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.  

The Reality of Coding from Home with Children

These days I have more going on than audits, updates, and continuing education for CPT and ICD-10 as I eagerly await the arrival of my first child.  The beauty of the internet means I can order all kinds of things for my pregnancy and the baby from the comfort of my recliner and have them delivered directly to my doorstep.  One recent package included a packet of "stuff"  - everything from a baby bottle, to gift cards for obscure things I'm pretty sure I'll never order, to coupons, to a flyer telling me I can work from home as a medical coder while I take care of my baby.

It was the last item that really jumped out at me and gave me pause.  I wasn't really surprised by the claims about making lots of money while working from home.  It wasn't the statement about the "prestige" of working for physicians.  What caught my eye were the pictures on the flyer of women sitting in front of computers with infants on their laps.  Because while I don't know what it's like to be in charge of a baby all day (yet), I do know what it's like to be a coder working from home and the job doesn't lend itself to simultaneous babysitting.

Most days I love working from home.  It's awesome on those days when you know you have to get work done but you don't really feel like taking a shower or being in public first thing in the morning. So yeah, it's great if you are not a morning person! On those days, there's nothing better than shuffling down to my office, coffee cup in hand (okay, so it's half-decaf these days), flipping the switch on my computer, and easing into my day.  Some days I am joined by my eternal lap cat, who could sit on my lap all day if I were a statue.  On some days she wants to sit on my lap while I work, which is generally only okay if I am on a conference call where I don't need to take notes.  Which is pretty much never.

Here's the big secret the flyer doesn't advertise: coding requires an immense amount of concentration and some days I can concentrate pretty well and block out the world.  Other days, I have to shut off all email, the ringer on my phone, and the radio just so I can focus on work.  On those days, I shoo the cat off my desk/lap and try to direct her to her bed in the corner.  If necessary, I can put her in the hallway and close the door.  You can't really shove your kid aside when you need to concentrate.  And you can't code effectively and efficiently with a kid on your lap.  And if you can, then your child isn't getting the attention he/she needs.

The point: coding from home is a nice perk, but it is not a substitute for child care.  Like most other new parents, I'm discovering the joys of budgeting for child care after maternity leave.  And I get it - it's expensive.  

Just in case this post hasn't quite convinced you, maybe this will.  Many remote coding contracts include a clause on child care.  You may be required to promise in writing that you will not engage in child care when you are on the clock.  So if your reason for wanting to code from home is so you can save on child care, coding isn't the job for you.

Top 10 Cringe-Worthy Things Wannabe Coders Say

My blog is over six years old!  Seriously, I just checked.  In the last six years as I've put myself out there as the Coder Coach, I've spoken either personally, over the phone, or via email to hundreds - okay, it's really probably dozens - of coders and tried to answer their questions about what it takes to be a coder.  I've been amazed at how those answers have changed since then, from the evolution of technology, which allows most coders to work remotely to finally seeing ICD-10 come to fruition. So I figure it's about time I published my top 10 list: the most cringe-worthy things people say when they tell me they want to be a coder.

Don't get me wrong.  My intent is not to put anyone off, but over the last six years, this coding thing has really caught on and I wouldn't want to steer anyone into a career that isn't right for them.  So take a moment to read through the list and decide if you're guilty of any of these. Since David Letterman's Late Show is no longer a thing, consider this my replacement Top Ten List.

And before you get upset, please read the sign: I'm not arguing, I'm just explaining why I'm right.  In other words, I'm being a coder (occupational hazard).

Number 10:Which type of coder pays the most?

Answer:  A really good one.  Focus your efforts on landing a job and then mastering it.  If you choose your work setting solely for making money, you may find yourself miserable and (maybe) sort of well off.  If you choose to follow your passion, the possibilities - and pay check - are pretty much endless.  Employers are willing to pay good money for really good coders who don't complain about how much they hate their jobs.  I don't actually do any hiring, but if I did, I would hire the hungry novice coder with a good attitude and a willingness to learn over the experienced grouchy coder who seems to hate her job.

Number 9: Should I be a hospital or physician coder?

Have you ever seen the movie City Slickers?  The answer is in that movie when Jack Palance says the meaning to life is "one thing."  Billy Crystal asks him, with great interest, what that one thing is.  The answer: that's what you've gotta figure out.  You and only you can decide which setting is right for you and there is no right or wrong answer.  I love getting an inpatient hospital chart and trying to figure out the latest surgical procedures and how to code them.  I would rather poke my eyes out with a dull pencil than assign an E/M level to a physician's chart.  I know other coders who love E/M coding.  It's like being a cat person or a dog person.  You will probably find that you like one more than the other and there is no wrong answer (unless you are not a cat person, and then we can't be friends anymore).

Number 8: No one will hire me with the coding credential I have; they all want something else

This is probably going to sting a bit, so brace yourself.  Why did you pay to get credential without first looking at local job postings and doing some research?  If you are reading this before going to school or getting certified, then do your homework before you pay any money to any educational institution.  All kinds of people will tell you anything to get your money.  Only local employers will be honest about what credentials they want.

Number 7: Where can I get free continuing education credits?

Free CEUs are out there, you just have to look for them.  Most AAPC local chapters offer free monthly educational sessions.  There are opportunities to summarize articles and get credit.  Coding Clinic offers a quarterly webinar that is free.  Other organizations offer free CEU credits.  Do an internet search and you may be surprised what you will find.  Did you do something, like attend grand rounds at a hospital, that you thought was very educational but you don't have a certificate?  Contact the certifying body and see if they will grant you CEUs for it.

Number 6: I can't afford to join AHIMA or AAPC

This one might sting too.  Find a way to make it happen.  As far as I'm concerned, when I hear this, it tells me you don't want it bad enough.  Granted, I started very young and was still living at home when I first joined AHIMA, but make no mistake, I worked hard to get where I am today. Find a way to afford that membership and show people you are serious about a coding career.  And if you have a credential through and let your membership lapse, you likely lose the credential.  You worked hard for that credential - don't let it go.

Number 5: This is my second (or third) career; I can't afford to start at the bottom

This is a great second or third career for people who discover they missed their passion until later in life.  But here's the reality: you still likely have to start at the bottom.  I've seen people find their way into coding by some very unusual means, but the ones who make it are the tenacious ones who won't take no for an answer.  Pretty much no one starts out in their dream coding job.  You will have to pay your dues.  And please don't think that means  I can't appreciate your experience in your previous profession.  There are definitely things you can bring to the table, but remember that in coding, you are a novice.  I'm a great coder, but I'm pretty sure if I decided to change careers tomorrow and become an aerospace engineer, there would be a bit of a learning curve. 

Number 4: Will you mentor me?

It's an innocent question and I'm flattered.  Really.  But I decided a long time ago that I would mentor from afar by penning this blog.  I don't have a consistent schedule to be able to spend a lot of quality one-on-one time mentoring.  But if you email me a specific question, I will do my best to answer it.  My advice is to find someone local to mentor you.  Ask them if they can meet you once a month for lunch and come prepared.  What are the questions you want answers to?  What challenges have they had in their career that they wish someone would have told them when they were getting started?  This is a great entry into your local coding network.

Number 3: I went to school for (fill in the blank) months/years and I'm certified; I'm qualified to be a coder anywhere

No.  You're really not.  I went to school too for two years and let me just tell you that even though I learned some good fundamentals, the real coding world is nothing like I thought it would be.  I learned everything I really needed to know about being a coder on the job, not in school.  I've now been coding for more than 20 years and I hold four different certifications and I have a news flash for you: I am not qualified to code anywhere.  I lack the practical experience of a physician office coder.  I find coding radiation oncology charts waaaaaayyyy outside my comfort zone.  And please don't ask me to fill out an IRF-PAI for inpatient rehabilitation.  In other words, after 20 years, I am not all that and a bag of chips, so please don't insult the world of experienced coders by thinking you have this all figured out.  I learn something new each. and. every. day.  Keep an open mind and be willing to learn - and admit when you're in over your head.  Natural curiosity and a willingness to learn is a good thing.  Acting too big for your britches is not.

Number 2: How can I get experience if no one will hire an inexperienced coder?

I would give anything if people would stop asking me this question.  Because honestly, I don't know the answer.  I don't know what your background is.  I don't know what your aptitude for coding is - and it is a skill that many people don't possess.  I don't know where you've applied or how hard you've tried to sell yourself.  And probably most importantly, I don't have a clue what it's like to try to get a job today because the atmosphere is so different from 20 years ago.  But this is what I do know.  Don't limit yourself to coding jobs.  Find a job - any job - that will require you to have coding knowledge.  When you do an online job search, search on the code sets (ICD-10 or CPT) and not the word coder.  There are so many jobs out there that revolve around coding that aren't traditional coding jobs.  Getting your foot in the door is one step closer to getting that traditional coding job - or something even better than you ever imagined.  And don't forget to network.  If you want to work with coders, surround yourself with coders.  Who you know may be your golden ticket.

And the Number 1 Cringe-Worthy Thing Wannabe Coders Say is: I want to be a coder because I want to work from home

AACK!!!!  Not a good lead in!  And if this is the first statement out of your mouth when you go into an interview, you probably won't get hired because here's a huge industry secret: hiring managers hate hearing that's why you're there.  It's like going on a first date with someone you just met and gushing about how badly you want to get married and have 6 kids. It's just not done.  If this is the real reason you want to be a coder, please re-evaluate.  Coding is a great career if you love it.  If you don't love it, you will be miserable for 8 hours every day.  And if you are miserable at home for 8 hours a day, that can be really depressing.  Also think about the child care aspect.  I often hear people say they want to work from home because they can't afford child care.  Many coding contracts require you to have child care in place.  Coding takes intense concentration and you can't babysit a kid at the same time.  Working from home is a great perk, I will admit, but it is not the reason I have the job I have.  I refer you back to Number 10 above: follow your passion.  If you're lucky, you can make some good money while you do what you love... from home... in your bathrobe.

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.

So Many Books, So Little Time - Part 3

Yes, it's true.  There are so many books and so little time, I haven't even had time to blog for the last two weeks because I had my nose in two of them.  Thank God for smartphones and long waits at the car wash, or who knows how much longer it would been before I posted again!

In my first post of this series, I gave one of my favorite quotes: "ICD is from Mars, HCPCS is from Venus."  So let's move on to Venus for a bit.  Don't worry, we'll be back to Mars, but I like to talk about the present before I talk about the future (ICD-10), so let's get on with it.  I apologize for the length of this post, but I have a lot to say today!

Three Levels of HCPCS
The Healthcare Common Procedure Coding System (HCPCS) has three different levels and just to make things more interesting, Level I is not usually called HCPCS, it's called CPT.  The Current Procedural Terminology (CPT) was developed and is maintained by the American Medical Association (AMA).

By Physicians for Physicians
What makes CPT so unique is that it is the only coding system in the HIPAA-approved code sets that is developed by physicians for physicians.  The codes you see in the CPT code book are the result of various medical and surgical societies coming together with the AMA to decide which procedures deserve their very own CPT codes.  Every year at the AMA's CPT Symposium, coders from around the country gather in Chicago to listen to these physicians present the coding updates for the coming year.  It's an expensive but valuable conference that I think every coder should experience at least once.  

CPT codes are primarily used by physicians to report procedures and services performed in every possible setting where a physician - or qualified health practitioner - may see  a patient: his office, the hospital, a clinic, a nursing home, etc. But it doesn't stop there.  CPT is also used to report hospital outpatient procedures. Of course, since there are still a lot of procedures that are performed solely as inpatient, hospital coders use a small number of CPT codes in comparison to pro-fee (physician) coders. 

Three within Three

So now that we know that CPT is one of three levels of HCPCS, let's delve a little deeper into this major code set. CPT has three categories of codes and this is still a pretty new concept for me because when I was learning, there were no categories, just CPT codes. 

Category I Codes

Category I codes are the original CPT codes they're what I like to call "grown-up" CPT codes. In order to get a grown-up CPT code, a procedure has to meet some pretty stringent criteria: 

• The procedure must have FDA approval
• The procedure must be commonly performed by practitioners nationwide
• The procedure must have proven efficacy

Once these criteria are met, a five-digit numeric code is assigned to the procedure and unlike ICD (different planet, remember?), these codes do not have decimal points. The codes are arranged in sections by type of procedure or service:

• Evaluation and Management (E/M) (codes beginning with 9)
• Anesthesia (codes beginning with 0)
• Surgery (codes beginning with 1-6)
• Radiology (codes beginning with 7)
• Pathology and Laboratory
• Medicine (the rest of the codes beginning with 9)

The Surgery codes are divided by specialty, for example, the cardiovascular codes begin with 3 and neuro codes begin with 6. After coding for a while, you should be able to look at a CPT code and have a general idea of what it is. A common newbie mistake is to look for the E/M codes in the back of the book. After all, they begin with 9!  But remember that CPT is a coding system that was developed by physicians for physicians and since physicians use E/M codes more than any others, they are in the front of the book for quick reference. 

Here are a few examples of Category I CPT codes:

• 99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity
• 12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6cm to 7.5cm
• 75625, Aortography, abdominal, by serialography, radiological supervision and interpretation 

Category II CPT Codes

Category II CPT codes are located behind the Category I CPT codes in the book. These are the only CPT codes that are optional. They are used by physicians for tracking performance measures. The purpose of these codes is to decrease administrative burden on providers while collecting information on the quality of patient care. Category II codes are five-digit alphanumeric codes that end in "F."  Here are some examples:

• 1040F, DSM-5 criteria for major depressive disorder documented at the initial evaluation (MDD, MDD ADOL)1
• 3775F, Adenoma(s) or other neoplasm detected during screening colonoscopy (SCADR)12

Category II CPT codes are implemented throughout the year and may be implemented before they actually appear in the CPT book.  Code updates can be accessed on the AMA's website. 

Category III CPT Codes

Category III CPT codes, or "baby codes," as I like to call them, are for emerging technologies that do not meet the criteria of a grown-up Category I CPT code. The Category III codes are found behind the Category II codes in the CPT book. For procedures that are not commonly performed, lack FDA-approval, or don't yet have proven efficacy, Category III codes are assigned. These are temporary codes for a period of 5 years. It has become common practice to see Category III codes reach Category I status with each annual update. For 2015, one of those procedures that was moved was transcatheter mitral valve repair with a prosthesis. The MitraClip uses this relatively new technology to treat mitral regurgitation and it received FDA approval in 2013. 

These are five-digit alphanumeric codes that end in "T." The codes are added throughout the year and may be implemented before they are published in the CPT book. Here are some examples of some Category III codes:

• 0387T, Transcatheter insertion or replacement of permanent lead less pacemaker, ventricular
• 0274T, Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

Updates to Category III codes can also be found on the AMA's website throughout the year.  

Staying Updated

Back in the day, it was important just to make sure that you had the most recent year's CPT book to ensure you were using valid codes. However, with the Internet, now it's also important to monitor the CPT updates and errata on a regular basis since changes are made throughout the calendar year. I find it easiest to put a reminder on my calendar the first of each month to check the AMA's website for updates to the errata, which is a list of corrected errors in the CPT code book, as well as changes in Category III codes. Since I don't use Category II codes, I forego that update, but if you are coding them, be sure to look for those updates too. 

By the way, the errata is on the list of approved materials for the AAPC exams. The year I took the CIRCC exam (Certified Interventional Radiology and Cardiology Coder), there were a lot of errors in the electrophysiology code notes and the errata was something I really needed.  Be sure to check it out!

Modifiers

HCPCS codes have a concept specific to HCPCS codes only: modifiers. Think of modifiers like moons that are specific to a planet (and please forget for a moment that Venus doesn't have any moons!). Modifiers apply to HCPCS codes only, not ICD-9-CM codes. They are added to HCPCS codes to provide additional information, such as a bilateral procedure or an unusual service or to indicate that a procedure was discontinued. CPT modifiers are two numeric digits that are appended to a HCPCS code with a dash (e.g., 75710-59). 

All CPT Coders are not Created Equal

The people who assign CPT codes are just as complex as the coding system. Since hospital coders code only a subset of CPT codes, they don't have the same skill set that a pro-fee coder has. Remember that hospital inpatient coders use volume 3 of ICD-9-CM to code procedures. Hospital outpatient coders assign CPT codes for procedures that are found in the outpatient setting. So while the pro-fee coder coding for the cardiologist will code everything from a clinic visit in the physician's office to an angioplasty in the hospital cardiac cath lab to a full blown coronary bypass in the hospital's OR (all using CPT, of course), the outpatient hospital coder would only use CPT to code the angioplasty. Hospitals don't follow conventional E/M rules and coronary bypass is an inpatient procedure that gets coded using ICD-9.   In addition, many of the modifiers used by hospitals are different than those used by physicians. 

These differences are one of the reasons it's so difficult to make the crossover from hospital to pro-fee coding and vice versa. I personally hate E/M coding but I know people who love it. So if you find that one area of coding is not really your cup of tea, fear not!  You may find another area very rewarding. 

I also really can't talk about CPT without bringing up a little tiny thing from the hospital side called a charge description master (CDM), or as it's more commonly called, the charge master.  It's as masterful as it sounds: a line-item listing of everything a hospital department charges for.  Each line item has a description of the charge, charge amount, and sometimes a CPT code.  One of the most difficult transitions I see in pro-fee coders crossing over to the hospital side is not understanding that the coder doesn't code everything.  There are many codes that are assigned automatically by the charge master when a charge is applied to the bill.  This is the case when the CPT code doesn't require a lot of subjective reasoning (e.g.,  lab test or x-ray).  For those procedures and services, such as operative procedures, that require subjective reasoning, a real-live coder will assign the code.  It may sound counter intuitive, but this actually increases the amount of coding-related jobs in a hospital.  The charge master analyst requires coding knowledge as he/she works with hospital departments to set up charges, research appropriate CPT codes for the procedure or service, and determine if it will be hard coded (by the charge master) or soft coded (by a person in coding).  

CPT Made (Too?) Simple
This posting really oversimplifies the CPT code set (that's right, it gets more complex!), but it's a start if you're still finding your way in the coding field.  I have a love-hate relationship with CPT because I find it both challenging (love!) but also frustrating when I hear conflicting coding advice between CMS, the AMA, and medical/surgical societies (hate!).  If you find that you love all aspects of CPT, then you can have a very lucrative career in either the pro-fee or facility coding arenas.

Stay tuned to this series...  Next up is HCPCS Level II.

So Many Books, So Little Time- Part 2

ICD-9-CM Has Procedure Codes?

In part two of my blog series about coding systems, I'd like to present ICD-9-CM, Volume 3. If you've taken classes that are preparing you to take the CPC exam, it might be news to you that ICD-9-CM has three volumes. Or procedure codes. So that's it: volume 3 of ICD-9-CM is procedure codes. 

Hospitals Use It

In part one of this series, I mentioned that HIPAA defines which code sets are used for each health care setting. Volume 3 ICD-9-CM codes are only mandated for hospital inpatient claims. They are a major factor in the determining DRG assignments, which drive hospital inpatient payments. 

Some hospitals also assign ICD-9-CM volume 3 codes for hospital outpatients as well. This is solely for data collection purposes but the codes get "scrubbed" off the outpatient bill and don't go to the insurance company. ICD-9-CM codes may be used to analyze volume of a particular type of procedure performed either as inpatient or outpatient. For example, most appendectomies are performed as outpatients, but if there are complications, a patient may need to be admitted as an inpatient. Hospitals often pull procedure volume for physician credentialing or planning purposes (e.g., to determine if a new specialty unit or more operating rooms are needed).  As a coding manager, which was a long time ago, I wrote reports that pulled data based solely on ICD-9 codes. We didn't use CPT codes to pull data at all at that time. 

Why You May Have Never Heard of It

If you've never heard of volume 3 codes in school, then it's likely that you are taking a coding course for physician coding and billing. Physicians don't use volume 3 of ICD-9. But as mentioned above, hospital coders are using it and if a hospital requires its coders to assign ICD-9 codes on outpatients, they are coding procedures using both ICD-9 and CPT procedure codes. That isn't as complex as it sounds because most hospitals use encoder software that has a crosswalk between the two code sets. Unfortunately, any time you try to map from one code set to another, there can be errors. If they were easily translatable, we wouldn't need two code sets!

Here's another critical tip: if you are buying ICD-9-CM code books, it can be super confusing because there are various publishers and lots of code books with different-yet-similar titles.  If you purchase an ICD-9-CM code book for physicians, it will have only volumes 1 and 2.  If you buy ICD-9-CM for hospitals, you get all three volumes, or the complete ICD-9-CM code set.

What the Codes Look Like

The code format of volume 3 ICD-9-CM codes is different from other code sets with two numeric digits followed by a decimal point and then one or two more numeric digits. The code category ranges are 00-99. It's the most straightforward of all of the HIPAA code sets. 

Some examples of volume 3 codes are:

• 47.0, Appendectomy
• 36.97, Insertion of drug-eluting coronary artery stent(s)

Commentary on ICD-9 Volume 3 and Argument for ICD-10

If you weren't trained on ICD-9-CM procedure codes, let me tell you, you aren't missing much. It is the least robust of all of the coding systems. There just simply aren't enough three to four-digit codes to keep up with rapidly evolving healthcare technology. We have run out of available codes. This is my biggest argument for ICD-10 implementation. I hate to say that we can live without a diagnosis code update, but in comparison to procedures, the need isn't as great. We absolutely need a new procedural coding system for ICD in order to keep up with emerging technologies. Plus - and this drives the OCD coder in me crazy - there are hernia repair codes in the eye procedure chapter because it's the only chapter with available codes!  

If you were trained in CPT first and have to learn ICD-9 volume 3 codes, you may find it very difficult, but only because you are trying to find codes as specific as CPT. You will be disappointed because ICD-9 codes aren't that specific. While there are appendectomy codes in CPT for open and laparoscopic approaches, ICD-9 appendectomy codes don't differentiate between open and scope procedures. 

Who Needs to Learn it?

If you're planning to take a certification exam, here are the certifications that have traditionally tested on volume 3 ICD-9-CM codes, but keep an eye on test details for the testing switch over to ICD-10:

• CCA (Certified Coding Associate) from AHIMA
• CCS (Certified Coding Specialist) from AHIMA
• CIC (Certified Inpatient Coder) from AAPC (new)

The COC (Certified Outpatient Coder), formerly called the CPC-H (Certified Professional Coder Hospital-based) does not focus at all on ICD-9 volume 3 codes. It does focus on hospital-related CPT codes and, of course ICD-9 diagnosis codes because we all use that. 

The bottom line on volume 3 codes, in my opinion, is that it is a coding system with a limited shelf life that isn't worth learning at this point in the game if we really move forward with ICD-10-CM/PCS in October (or unless you are planning to take one of the above-mentioned certification exams before ICD-10 is implemented).  There are enough existing coders to focus on the ICD-9 back work that will be involved after ICD-10 implementation and since this code set is only required for hospitals, it affects a pretty small population of coders overall.  But hey, at least you now know what it is and can have an intelligent conversation about it. 

Next up: Level I of HCPCS (AKA CPT)...

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...

All I Want for Christmas is Fewer RAC Denials

This December, coders across the country got the ultimate Christmas present: a bill passed the House and Senate without the addition of language that would further delay ICD-10 implementation.  As we breathe a sigh of relief and get ready for a worry-free Christmas (at least as far as coding is concerned), we aren't fully exhaling until the end of March when the SGR bill comes up again for a vote.

But how many people are aware that there is another type of legislation at work that could cut down on the number of RAC denials we get?  Sounds almost too good to be true, doesn't it?  While the legislation is real, it's in very draft form right now.  Unfortunately, from where I sit, it also seems to be flying very low under the radar among my peers and I think it deserves some attention.

First of all, if you are not yet familiar with RACs, those are the Recovery Audit Contractors hired by Medicare to recoup improper payments to hospitals and physicians and return that money - with penalties - to the Medicare program.  The idea is great - run all the claims data through proprietary software and analyze it to see what looks weird.  This can be anything from improperly coded claims to admitting a patient to the hospital for a short stay rather than treating them as an outpatient.  Side note: contrary to what a lot of Medicare patients are told, hospitals do not get paid more for outpatient claims; they actually get paid less.  Medicare patients pay more out of pocket for hospital outpatient services and in most cases, hospitals get paid less than if patients were inpatient.  But if hospitals admit patients who could be treated as outpatients for short stays, they can have to pay the money back plus RAC penalties.

There are two types of RAC audits: automated and complex.  Automated reviews can be identified just by looking at data without reviewing the medical record.  Complex reviews require review of the medical record (e.g., for coding errors).  But the RACs don't have the final say; there is a rather lengthy appeals process that providers can - and should - take advantage of because several RAC denials have been overturned.  The problem is, there are about eight levels of appeals that end with the administrative law judge and currently there is a backlog of appeals at the administrative law judge level.

Enter the Hospital Improvements for Payment (HIP) act of 2014 (don't you just love that so many healthcare laws start with "hip?!").  This is a draft proposal aimed at reducing RAC audit backlogs by creating a new Hospital Prospective Payment System (HPPS) for Medicare short stays (less than 3 days length of stay), including observation services.  In short, it calls for the following;

• Creation of the new HPPS by the year 2020
• Creation of an alternate reimbursement system for short stays from fiscal year 2016 to fiscal year 2019 as data is gathered for the 2020 system
• Elimination of RAC reviews for short hospital stays until HPPS is implemented

By now, there may be a lot of people jumping up and down with joy, but of course there is a catch.  The proposal calls for dual submission of claims by hospitals in fiscal year 2016 in order to establish payments.  This means that hospitals would have to submit both ICD-10-PCS and CPT codes for short hospital stays for 2016.  Yes, the proposal assumes that we will be coding ICD-10-PCS in fiscal year 2016, which incidentally, begins on October 1, 2015.  The proposal would also implement an ICD-10-PCS to CPT crosswalk.  If the dual coding of claims didn't make you nervous, the crosswalk should.  I've never met a crosswalk I trusted.  Let's face it, if one coding system easily crosswalked to another, then we wouldn't need two different coding systems, would we?  I can see lots of operational challenges starting with the productivity dive that would surely occur and ending with training challenges since it's getting harder to find inpatient coders who code CPT and many facilities have decided not to train their outpatient coders in ICD-10-PCS.

Read All About It

This is just a small snipit of what HIP is about, but I encourage you to read up on it yourself, starting with information from the House Committee on Ways and Means and checking out the industry commentary to see where you stand.  Here are some links you should check out:

• Document from the House Ways and Means Committee - section by section of proposed bill 
• AHA Comments to Rep. Kevin Brady Re: Hospital Improvements for Payment Act of 2014 Discussion Draft dated December 18, 2014

Let Your Voice be Heard

For more information from the House Ways and Means Committee, including information on submitting comments, click here.  This proposal has the potential to rock the world of hospital reimbursement (again) and has some definite pros and cons.  While it's still only a draft and is not a done deal, it's time to take the opportunity to let our voices be heard and submit comments.

I don't want to live in a world where Ebola is sold out at the Giant Microbe store - and there's no code for it

There is a super cute little toy shop in Coeur d'Alene, ID called Shenanigan's Toy Emporium that sells vintage toys and other unique items.  When traveling there on business, we usually make a stop in to shop from their wall of amazing salt water taffy and check out their selection of toys that don't come with a power button.  You know, the kind of toys we had prior to the Atari and Game Boy era!

Shenanigan's also has a great display of giant microbes - small plush renderings of everything from the common cold to diarrhea.  I am still marveling at how they could create a plush toy out of liquid stool!  I'm sure it's just the geeky coder in me (and my colleagues), but we decided to buy a few and put them out during our training sessions along with our baskets of Play Dough, pipe cleaners, and candy (we like to have FUN in our training sessions!).  Needless to say, they were a big hit with our clients and we noticed on one of the tags that there was a website where we could order more.  By now your interest is surely piqued, so be sure to check out the online Giant Microbes store.

You're probably thinking what I'm thinking right about now, which is, wouldn't these giant microbes make great white elephant gifts for Christmas?  My thoughts immediately went to what would be appropriate for my family's white elephant gift exchange.  Don't worry, my family has a great sense of humor - there's still a copy of Pamela Anderson's novel (yes, she wrote one) complete with the "naughty" pages clipped together courtesy of my grandmother who was sheltering her daughter from the filthy parts.  And what better gift for someone in 2014 than the Ebola virus?  There's just one problem.

Sold out.

Apparently I am not the only person who thinks that Ebola would make a great Christmas gift.  It's a sign of recent headlines that this virus, which is actually kind of cute in plush form, is unavailable.  What's even more worrisome given that this was the year Ebola came to the US, is that we don't have an ICD-9-CM code to report it.  Here's the best we can do in ICD-9:

• 065.8, Other specified arthropod-borne hemorrhagic fever
• 078.89, Other specified diseases due to virus

What about ICD-10-CM?  How about this?

• A98.4, Ebola virus disease

YESSSSSS!  Way more specific!

In previous years as we've prepped for ICD-10 implementation, the opponents have given a laundry list of extensive and admittedly ridiculous (yet fun!) ICD-10 codes that begged the question, why do we really need this?  And this year, Ebola was delivered to our health system and we have nonspecific codes to report it.  But in ICD-10, we have a very specific code.  Hmm.  Perhaps this ICD-10 thing really could help with reporting and impact patient care.  Just a thought.

So Santa, if I can't have Ebola for Christmas this year, could I please have ICD-10 so that I can code it for those people who did get it?

Author's Note: I am not affiliated with Shenanigan's Toy Emporium or giantmicrobes.com in any way. I am just a really big fan!

Diversity - and Flexibility - is Key

I've been pretty quiet lately around the blogosphere and some may even think I've disappeared.  And for about a year, up until about October, I really had disappeared a bit to plan and live through my wedding.  After a couple months of an identity crisis, I'll announce here that Coder Coach Kristi Stanton has disappeared and the new Coder Coach is now Kristi Pollard.  The new last name will take a couple of decades to get used to, but I am hopeful that if I'm quoted in the future, it won't be as the first actress to play Buffy the Vampire Slayer. True story.

For the last couple of months I've been waiting for inspiration to strike so I could once again become passionate about the blog.  I've been observing.  Don't get me wrong, with all the legislation and talk about more ICD-10 delays, I've also been writing my congressmen, participating in Twitter rallies (follow me at @codercoach), and making posts on Facebook, but I've spent more time just watching.  Watching the industry.  Watching my colleagues.  Watching hopeful coding professionals trying to break their way in.  And this is what I've deduced: if you want to make it in the coding field, you've got to diversify.

It didn't take long after the ICD-10 delay was announced in March to see the fallout.  Some of our clients stayed the course while others postponed some training.  There have been very few canceled trainings all together for ICD-10. A couple of months ago, I dusted off a couple of our CPT training manuals that hadn't been updated in awhile to get them ready to train in 2015.  It was comforting to fall back into something that still required the skill of a senior consultant that was a sure thing.  Of course, I hope for a future with ICD-10 and will continue to advocate for it, but there's always CPT as well.

Here is my message to the coding students and aspiring coders.  Coding is not steady and it's not comfortable.  Even without ICD-10, annual updates to the coding industry can rock your world (case in point all the new lower GI endoscopy CPT codes for 2015).  This field has a tendency to attract detail-oriented people who like to organize everything in pretty and neat little black and white buckets.  As coders, we don't like gray areas.  Well, as a coder, be ready for gray, purple, and yellow polka-dotted areas.  You need to be flexible.  You need to be ready when the House throws language into a bill at midnight the night before a vote that will impact your daily work.  And you need a backup plan just in case.

I feel a bit like a financial adviser as I tell you you need to diversify.  DI.  VER.  SI.  FY.  Don't put all your coding eggs in one basket.  As someone who has coded in ICD-9-CM, ICD-10-CM/PCS, CPT, and HCPCS, I understand what I'm asking you to do.  It's not easy.  They all have different rules and methodologies.  I understand that I'm asking you for a lifetime of education.  But the payoff for doing the work is immeasurable.  And the more you have exposure to, the more marketable you are as a coder.