Diagnostic and Procedural Coding

Clinical coding – transforming words describing diseases, injuries, conditions and procedures into numerical descriptions

Under prospective payment system coding is directly connected to the healthcare facilities financial viability

Billing cannot be done until documentation is sufficient to allow for complete coding

As more healthcare areas migrate to prospective payment the need for effectively managing coded data has increased for credentialed coding professionals

As health information services face pressures of deadlines and outside review agencies, adoption of ethical practice standards becomes increasingly important

Although many rules are involved in coding process – coding selection is based on several different sets of rules and hierarchy

Coders must first understand and utilize rules in the ICD-9-CM coding book

This includes following all sequencing and cross-reference instructions

The agencies that are responsible for updating ICD-9-CM coding system are: The American Hospital Association – the National Center for Health Statistics – the Center for Medicare and Medicaid Services – the American Health Information Management Association

These agencies are responsible for development of official coding guidelines to provide details and official rules

Coding Clinic for ICD-9-CM

Coding Clinic is a quarterly publication of AHA that publishes guidelines that clarify coding processes

We will be learning how to reference and use that advise published in the Coding Clinic

The Bill

A standard form was created to systemize the terminology required by the Uniform Hospital Data Discharge Set

This was originally call the UB-82 It has been updated to compromise

the new data required and is call the UB-04

The Bill

This form permits 18 diagnoses and 6 procedure codes to be submitted

CMS only processes 9 diagnoses codes

Medicare and most other third party payers require the UB-04’s use for inpatient hospitals

The Bill

Non-coding data may be collected by admission and financial services departments – the coding area supplies the clinical coded data and verifies some of the non-coded data such as admission and discharge status and is responsible for insuring that accuracy of this information

Each facility must identify requirements for coded data, coding policies and procedures based on it’s health information needs

Policies and procedures insure that data is consistent

Coding data will not only be used for reimbursement but also for marketing, planning, utilization management, quality of care assessment and research

Facility guidelines should cover areas that have not been addressed by official sources for coding advice or that have been addressed but require expansion or definition for an individual facility

These policies will also be helpful in resolving coding disputes with outside reviewers

Such policies must adhere to official rules

Complete accurate and consistent coding of all diagnoses and procedures documented is required for compliant coding

The number of codes to be assigned depends on the statistical and retrieval needs of the facility

Uniform Discharge Data Set

Defined as a minimum, common core of data, on individual acute care, short-term hospital discharges in Medicare and Medicaid programs

It sought to improve the uniformity and comparability of hospital discharge data

Uniform Discharge Data Set

These definitions have been redefined and updated as healthcare changes

It now includes “non-outpatient” settings including long-term acute care hospitals, psychiatric hospitals, home health agencies and nursing homes

Uniform Discharge Data Set

The prospective payment system uses them as a basis for making payment decisions

Included are definitions for race, residence, admission and discharge dates, provider ID, disposition, reimbursement payer(s), diagnoses, and procedures, definition of principal and secondary diagnoses, and procedures

Diagnoses

All diagnoses that affect the current stay should be reported

Principal diagnosis is defined as: “the condition established after study to be chiefly responsible for occasioning the admission of the patient …”

Diagnoses

Other diagnoses are defined as: “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay”

It is not appropriate for a coder to refer to previous admissions to obtain documentation to support coding of diagnoses for the current admission

Diagnoses

A complication is an additional diagnosis arising after the beginning of the stay that modifies the course of the treatment or illness

Co-morbidity is a pre-existing condition that will cause and increase in the patient’s LOS by at least one day in 75% of cases

Diagnoses

Documentation should indicate that the patient is actively receiving treatment, e.g. medication, other therapy or diagnostic evaluation for each condition entered on the claim

Principal Diagnosis Selection

The principal diagnosis selection is the key to the most appropriate reimbursement as it determines DRG assignment in most cases

There are times when both the physician and the coder have difficulty determining between the principal and the ‘most significant’ diagnosis.

Principal Diagnosis Selection

The ‘most significant’ diagnosis is the diagnosis that has the most impact on the patient’s health, LOS, and resources consumed - which may or may not be the principal diagnosis

Procedures and Dates

All significant procedures must be reported

The provider performing and date of the procedure must also be accurately reported

A significant procedure is one that: is surgical in nature, carries a procedural risk, carries a anesthetic risk, requires specialized training

Procedural Risk

This refers to a professionally recognized risk that a given procedure may induce such as some functional impairment, injury, morbidity, or even death

The risk may arise from direct trauma, physiologic disturbance, interference with natural defense mechanism or exposure of the body to infection or other harmful agents

Procedural Risk

Physiologic risk is associated with the use of virtually any pharmacologic or physical agent that can affect homeostasis

Any procedure in which it is usual to use pre or post-procedure medications associated with physiologic or pharmacologic risk should be consider a procedural risk

Specialized Training

Whenever specially trained staff resources are necessary or are customarily employed in the performance of a procedure, it is considered significant

Procedural risk, anesthetic risk, and special training are defined by the UHDDS – it may be difficult for the coder to determine which procedures this covers

Specialized Training

Healthcare facilities and third party payers have not expected coders to code routing radiology and laboratory tests

Coding policies at each facility should be considered to determine which procedures are to be addressed with a code

Principal Procedure

One that is performed for a definitive treatment rather than performed for diagnostic or exploratory purposes or to take care of a complication

When two procedures appear to be principal, the one most related to the principal diagnosis should be selected as principal procedure

As part of the fraud and abuse prevention legislation penalties can be assessed against anyone who engages in a ‘pattern of presenting a claim for an item or service based on a code the person knows or should know will result a greater payment than appropriate’

Therefore, coders must have access to government publications such as the ICD-9-CM Official Guidelines for Coding and Reporting and other bulletins and memorandums distributed by the federal government or fiscal intermediary

Coders must have access to these publications on a regular basis in order to remain current on all regulations and guidelines published

Often, government bulletins and memorandums can be found though internet access

Coding staff should have regular meetings to share the content of these publications to ensure that all coders are following the same rules as these rules may change frequently