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healthcare by numbers: diagnosis codes - procedure codes

Sucked into a jet engine? There's a code for that

By Jody Robbins


In 2016, the United States switched from a decades-old coding system to a new one that is much more detailed and in sync with standards being used around the globe. That’s where some healthcare providers are struggling.

In the healthcare industry, data and data analysis is very important. In the case of medical billing and coding, those numbers come from the International Classification of Diseases (ICD-10). Its relatively recent overhaul saw the number of available codes increase exponentially.

These cover everything from a torn ACL (including which side, right or left) to “V97.33CD, which indicates you were sucked into a jet engine, and this is your subsequent visit to a doctor,” according to Dina Fine in her article, Why You Should Care About the New Major Changes in Medical Billing, published in the Scientific American.

In Medical Coding, Change Comes … Slowly

With more than 20 years in the coding industry, Melanie Endicott, long-time trainer at the American Health Information Management Association (AHIMA) and VP of HIM Practice Excellence, worked on the ground floor of the 2015 transition from ICD-9 to ICD-10.

Though the U.S. implemented ICD-10 in 2015, the World Health Organization issued the system in the early 1990s. That is to say, these transitions don’t happen overnight or often. For instance, Endicott told The Fuse that ICD-11 is in the works, but won’t be implemented in the U.S. for coding purposes until decades from now.

Here’s how it works.

“The World Health Organization (WHO) works on a base model to be used around the entire world and each country has to use it for death certificate coding so we can consistently track that throughout the world,” Endicott says. “When it comes to medical billing and coding, each country takes that base model and uses it how they like. It’s their choice. The U.S. was one of the last to implement it, since it has to go through lots of steps, including Congress, to be approved.”

What doesn’t come slowly are the updates, and that keeps Endicott and her industry busy. “In 2015, the entire industry had to be converted, but now we’re three years in. We concentrate on the [quarterly] updates from the American Hospital Association (AHA),” she says. “Every coder is required to follow them and supplemental rules that give explanations on the definitions of certain codes. New codes emerge while others are modified or deleted. Our job is to bring clients and students up to speed on changes in the guidelines and codes, both on the diagnosis and procedure side.”

Overall, though a lot of work on her part, she believes that the ICD-10 update in 2015 was positive for the healthcare industry in multiple respects. “It’s been a positive change. The codes are much more specific and the data derived from it more effectively paints a picture of what’s going on with the patient.”

Want To Get Paid? Code Right!

When medical billing is up to date and correctly executed, it can mean the difference between profit and loss for companies of all sizes.

DeVry professor Lisa Campbell, a medical billing and coding expert, cuts to the chase in an interview with The Fuse: “Healthcare is highly regulated and if you don’t know the rules, you’re not going to get paid.”

Those who understand the system underpinning the financial side of the modern healthcare system in the U.S. need to make sure they are both current and actively working to improve both billing for healthcare and patient care itself.

Medical providers of all stripes have struggled to adapt to ICD-10 and that’s where experts on the matter like Campbell have an important role to play. She teaches in DeVry’s College of Health Sciences, has her Ph.D. and a long list of other certifications, including being an American Health Information Management Association approved ICD-10-CM/PCS trainer.

Campbell works with physicians to improve their documentation and she brings that in-the-trenches experience with her back to the academic world. “I like to bring what’s happening right now into the classroom,” she says. “Providers know how to take care of patients, not necessarily the importance of documentation as it translates to reimbursement.

Not all physicians go to business school, but the insurance companies are starting to deny payment for non-specific documentation. It’s no longer enough to document abdominal pain. They want to know exactly where it is.”

Not doing so can affect a provider in more ways than one. “As a medical billing professional, you should know that insurance companies can use data to recognize issues within a practice, like non-specific diagnoses,” Campbell says.

Sounds pretty straightforward, however it’s anything but that for some.

“I had an older physician call me who was informed Medicare will no longer accept claims submitted on paper,” Campbell says. “The transition to electronic health records is more than a trend at this point.“

Another critical component of the medical billing and coding industry: big data. It’s key to the world in which we live today, so data analytics are critical—both retrieving and analyzing them. While those looking for a basic certification may merely need retrieval skills, those seeking advanced degrees will delve more into understanding what those analytics can mean to a provider’s bottom line.

Medical Coding: The Good & The Bad

For those considering a career in medical billing and coding, there are opportunities. However, there are barriers to entry and being new in the field can be one of them.

“This is why it’s important for me to bring that experience into the classroom, so that when my grads are interviewing they can convey that knowledge,” Campbell says, noting that in her experience many providers don’t have the time or resources to train employees new to the field. “We cannot submit a claim until the services are coded, so someone brand new that’s slower with more questions, [providers can] spend more time training them than processing claims.”

One way to work around that is for students to gain practical experience by working in clinics and/or hospitals to both learn and to demonstrate their knowledge and professionalism. “Even with the certification in hand there are still challenges to entering and maintaining a place in this field,” Campbell says. “It’s always changing so much. You have to troubleshoot and use critical thinking skills to solve problems.”

So, in a highly technical and data-driven field, success can still come down to the human touch.

To learn more about the Medical Billing and Coding program at DeVry University, click here.