Posts tagged ‘Coding’

Sea Changes Can’t Be Overnight Occurrences

September 30, 2013

Patients receiving treatment at a health facility in the US will be assigned ICD-9 codes for their diagnoses.

October 1, 2013

Patients receiving treatment at a health facility in the US will be assigned ICD-10 codes for their diagnoses.

…What a difference a day makes.

As mentioned previously on this site, ICD coding system is an excellent, standardized way of tracking important diagnostic information. The current system in place is ICD-9, which has about 17,000 codes, and is used for symptoms, diagnoses, injuries, diseases and all other disorders facing patients. The new system is ICD-10, and it will have 155,000 codes – covering the same grouping of symptoms, diagnoses and the rest as ICD-9 – but with a lot more specificity.

I’ve been of the opinion that this transition wouldn’t be too painful. In fact, with the intelligent structure of the ICD-10 codes, where each character represents a specific quality of that code (such as location in the body, severity, etiology, etc.), I thought it could be a real boon to medical professionals. Sure, it would be a hard adjustment, but it’s one that’s about 15 years overdue. As I continue to read about ICD-10 and its impending implementation, I was curious about the plan for phasing it in to the current workflow. Based on everything I’ve read so far – I have a confession to make:

I was wrong – this is going to be a disaster.


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October 12, 2010 at 10:44 am Leave a comment

Coding in the Time of EHRs

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

Demo Video – How to Use Defaulted Reports in OpNote

Behold the latest video from mTuitive that demonstrates how users can utilize the default report option in OpNote to quickly generate postoperative reports for their most common procedures:

May 3, 2010 at 1:25 pm Leave a comment

Dictation is Public Enemy #1

Pete O’Toole

Healthcare is the biggest political issue in the US right now.  It’s a huge financial problem for everyone – individuals, businesses, the government and healthcare providers themselves.  It’s become so overwhelming that it has gridlocked congress.  The word “healthcare” just deflates everyone in the room each time it is uttered.  Despite all the frustration and everyone’s acceptance that “healthcare is broken,” most of us can’t name concrete problems in healthcare.  There is a vague sense that sometimes too many tests are ordered, but when it’s you who may need the tests, it’s not a problem.  Personally, I think that modern medicine is amazing, and nowhere in the world is it taught or practiced better than in the US.

I prefer to look for solutions to this crisis in places that do not take away from patient care.  For me, the first place to look is not in cutting screening for cancers – even if “only” 1 in 1000 people in a certain age range may actually test positive.  I think 1 person in 1000 is actually quite a lot to dismiss.  I realize there are excesses in the administration of healthcare — doctors who might be gaming the system, patients who might be hypochondriacs and lawyers who force doctors to practice overly defensively — and that it needs to be addressed.

The world's most powerful computer at Columbia University's Watson Lab, 1954.

There are many other places we can look to save money in healthcare.  One problem that will probably only get worse is medical transcription.  Decades ago, it made more sense for doctors to speak into a microphone and let a professional typist translate that dictation into a typed sheet of paper, than it did to try to make every doctor a professional typist.  When the first computerized medical records came out in the late 1960s, this practice naturally moved right over to support entry into these systems.  In fact, these systems were little more than glorified word processors, and many of them unfortunately have not progressed much beyond that point.  Early computer applications, although exciting, were hard to use.  Human-computer interaction as a field was barely born and would not influence the industry for a long time.  In the 1960s, this workflow made perfect sense.  Let doctors treat patients and let typists type.

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March 15, 2010 at 5:33 am Leave a comment


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