Coding in the Time of EHRs

May 27, 2010 at 10:01 am Leave a comment

While developing OpNote, we’ve encountered some push back and criticism from the various organizations. But the most pointed barbs of criticism have come from medical coders at the hospitals and ambulatory surgery centers (ASCs). Based on the way that we have constructed OpNote, physicians automatically capture the Current Procedural Terminology (CPT) codes and the International Classification of Diseases (ICD) codes. While the coding is evident – and users can search by codes, if so desired – surgeons are not forced to navigate through codes, but instead they find the proper procedure and diagnosis by using words and common phrases.

Some coders have balked at the idea of doctors coding their own procedure. There are nuances to the coding structures that could easily be missed by those who have not made it the primary focus of their jobs to know how codes are generated or what factors in the report lead to changes in the coding process. The number of physicians that confidently know medical coding is increasing, but there will always be various subtleties to coding that really only come from education and experience. However – that doesn’t mean there isn’t room for improvement.

As I mentioned previously, coders have initially thought of us as competitors. They saw that OpNote captures codes and therefore believed we were out to replace them. We’ve had to demonstrate that we’re not interested in replacing their jobs. However, we are interested in making their jobs easier. True, we believe that, with practice and time, physicians will be able to handle the basic codes of their operations; this means they should be able to successfully codify the procedure and the diagnosis. However, as most coders know, there’s a lot more to the whole process. For inpatient procedures, the surgical codes only make up a part of the entire DRG code generated for patients, with other parts comprised of the types of treatments and medicines the patient receives in his/her stay at the hospital. Nonsurgical coding is outside of our knowledge base; we only deal with surgery. Coders in hospitals will still have plenty of other events to codify.

As I’ve mentioned in other posts, the postoperative report that OpNote generates is in structured data form. That means that while the reader can easily construct a narrative out of the points captured in the report, each moment and action is separate. Therefore it’s easier to see all of the components that make up the whole. OpNote users capture the initial codes for the procedure, or what they perceive the initial codes to be, so it becomes a starting point for the coders.

In OpNote, coders can quickly look through the operation description with ease as each part of the procedure is, essentially, “itemized.” It would be easier to find the specific phrase/action that would change that original code – for example, if a physician selects Hernia with no mention of gangrene, but then writes in the findings that he treated gangrene, it is much easier for the coder to see the disparity and to make the change necessary.

Furthermore, the fact that the coder is reviewing the codes of the surgeon and making the revisions in the report means that there will be one set of procedural codes. This is important for facilities that are facing federal audits like those conducted by agencies working on RAC and MAC. The unified code means there is no disparity between a surgeon’s codes and the hospital’s codes – and therefore no chance of being penalized or losing compensation.

There are many people who are trying to automate medical coding. There are a number of products that recognize keywords or force the physician to spend a lot of time searching for the appropriate codes. Perhaps as collaborations between coders and products like OpNote continue to happen, there can be a more perfect system. But, until then, we must still rely on the expertise of these workers and let them guide us through the intricacies of codifying medical procedures. Healthcare will improve only if we’re willing to educate each other in our respective fields and open to sharing our unique knowledge.

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