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Table of Contents

Rethinking Health Care (Issue #2)
January 31, 2024

CMO message from Amy Scanlan.

Why care about coding?

Let’s face it, none of us works for free.  While we are all committed to our patients and to keeping them as healthy as possible, we all want to be paid fairly for our time.  Patient care will always involve a dance between a care provider and someone who is paying for that care.  To have resources for the kind of care we want to provide, we must speak in a language that payers understand.

A very brief history lesson…

Medical coding dates to 17th century England[1] when a French physician and botanist created a system for classifying diseases. Over the centuries, what was once a system of classifying causes of mortality has developed into a granular method of categorizing diseases and procedures in medicine used across the world – the International Classification of Diseases (ICD) system. As we have gotten better at categorizing, collecting, and analyzing this data, we have also been able to better assess the effectiveness of our clinical care.

Payment for medical services developed alongside the growth of disease classification. It was based on a system that rewarded care of a sick person – the patient got sick and went to the doctor; the doctor got paid. Early versions of payment for medical services sometimes involved bartering, and payment in kind. The Medicare system, working with the American Medical Association, created a list of “reimbursable services” and standardized payment amounts – an additional set of codes to describe specific medical services (CPT) and reimbursement values (RVUs) for those paying for care. The addition of this coding system to the existing ICD codes has allowed the development of insights around the cost, and cost effectiveness, of clinical care.

Many of us bristle when coding is mentioned. Coding is often seen as something outside clinical care – describing it, but not contributing to the benefit of patients. Worse, we may see it as making our lives as providers unnecessarily complex and difficult. We expect that coding is something to be done by those billing for the care we give.   I would argue that as we move towards a more value-based system of care, accurate coding takes on a new importance.  Accurate coding and documentation allows us to better assess and communicate the burden of disease. It helps us quantify clinical and financial risk. It contributes to large-scale population health research and allocation of resources to communities who need it most.

And, ultimately, it will determine how we get paid. Payers realize that the current payment system rewards doing more, but not necessarily doing better. Population based payments, incenting us to do better rather than more, are coming. We need to be ready. And that means getting better at telling the clinical story with accurate coding.

[1] 1. Jetté N, Quan H, Hemmelgarn B, et al.; IMECCHI Investigators. The development, evolution, and modifications of ICD10: challenges to the international comparability of morbidity data. Med Care 2010;48:1105–10 10.1097/MLR.0b013e3181ef9d3e [PubMed] [CrossRef] [Google Scholar]

Spotlight: The Coding and Documentation Team

The Clinical Documentation Improvement (CDI) team is a combination of Clinical Documentation Specialists and Certified Risk Coders. The Clinical Documentation Specialists are a team of RNs, Physical Therapists, and Occupational Therapists.  This team provides pre-visit longitudinal record reviews, with a 3-year look back and a post visit pre-bill chart and coding review to ensure the accuracy of coding. 

This team brings clinical conditions to the forefront of the visit. This allows conditions which were missed or inaccurately diagnosed and recommend they be reassessed at the time of the visit.  Once the visit is completed, the coding team then takes the charges and clinical notes and compares them for coding and billing accuracy.  The team makes corrections to the selected diagnosis codes; adds additional diagnosis codes; and removes any diagnosis codes that are not supported.  The entire team plays a role in ensuring that a provider is getting credit for the visit and the patients risk score is accurately reported. The team uses data to identify trends and then works with providers to improve clinical documentation and coding accuracy. 

Some of the initial areas where the team is targeting improvement include:  errors in cancer coding specifically to designate whether there is a history of cancer vs active cancer.  The team also noticed errors in coding peripheral vascular disease and diabetes.  In 2024, the CDI team will focus on documentation and coding accuracy for these conditions as well as focused education to understand the documentation guidelines.

Reflections: Articles and podcasts from outside experts.