Posts tagged ‘Medical 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

Don’t Panic: Assuaging Concerns as ICD-10 Approaches Our Shores

The times they are-a becoming quite different. In a few years (by October 1, 2013 to be exact), the US will adopt ICD-10 as the official (and sole) system for coding diagnoses. This will mean that the volume of codes available for diagnosing patients will explode from 14,000 to over 155,000 different codes. This astronomical expansion of the numbers of codes is a way of addressing the need for greater refinement of codes and data capture. But let’s take a step back and examine the origins of ICD and what the future of this coding system will hold for all of us.
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August 11, 2010 at 3:56 pm 2 comments

Health Information Managers – We Want to Hear From You!

While developing OpNote, mTuitive has sent out numerous surveys to various sectors of the healthcare industry. We’ve heard from surgeons, coders and hospital administrators to help us figure out the best ways to improve postoperative reporting. By gaining feedback from domain experts (and our targeted customers), we can identify issues that need to be addressed in the current system and more accurately create solutions for everyone that would be affected by adoption of mTuitive OpNote.

We are now reaching out to HIM professionals to gain their perspective and build the business case. If you are unfamiliar with the design of OpNote, please follow this link for an example of a completed report. OpNote’s goals are to make better use of transcription resources, streamline the reporting process and capture discrete data for use in disease registries, outcomes analysis and quality reporting initiatives.

Thank you for your time and your input!

Click here to take survey

June 2, 2010 at 5:13 pm 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

Introducing the OpNote Consultants: Carl Brown, MD, MSc, FRCSC

While creating our surgical reporting product, the OpNote, we at mTuitive have been working with many highly skilled surgeons.  These surgeons are from a diverse group of specialties and backgrounds and help to shape the future and efficacy of the OpNote.  We’re introducing these consultants to all of you in the coming weeks.

Dr. Carl Brown completed medical school at McMaster University in 1995 and his general surgery training at the University of Calgary in 2003.  He subsequently worked as a general surgeon at the Peter Lougheed Centre in Calgary.  In 2004, he moved to Toronto to train as a sub specialist in Colorectal Surgery. Concurrent with his fellowship, Dr. Brown completed his master’s degree in clinical research at the University of Toronto.   In 2006, he joined the surgical staff of St. Paul’s Hospital in Vancouver.

Dr. Brown is the chairman of the Research and Outcomes Evaluation Committee at the British Columbia Cancer Agency and an active member of the Colorectal Cancer Outcomes Unit. He is a member of the Surgical Oncology Network of British Columbia Executive. The goal of these groups is to improve the outcomes of patients with colorectal cancer through research initiatives.

Dr. Brown is the assistant program director of the general surgery residency program at the University of British Columbia. He coordinates the Surgery Leadership Program for general surgery trainees.  Over the past three years, Dr. Brown has published several studies on surgery for colorectal cancer, the ileal pouch procedure and surgery for Crohn’s disease. Furthermore, he has taught courses in laparoscopic colorectal cancer surgery.

How did you get interested in medicine?

I was always interested in science but, more importantly, I like interacting with people and helping people.  While it may seem cliché, [medicine] has turned out to be everything I had hoped it would be.  I do get to help people every day.  There’s never a day that I go home after work without feeling satisfied that I’ve accomplished something.

Wow – that’s great.

Yeah, it’s really true.  You know, it sounds kind of clichéd and maybe even a little cheesy, but it is so true.

What attracted you to surgery?  What made you go with that specialty out of all the possible paths in medicine?

Firstly, I’m a fix-it kind of guy.  I like to fix things.  It’s always been something I’ve been fairly strong at – growing up in a small town, we always took it upon ourselves to fix things around the house.   A lot of what we do in medicine is tweaking things: giving a little medication to make someone feel a little bit better.  And that is very important.

But I like the “fix”.  I like the stress and the pressure of having someone who has a life threatening illness and taking on the incredible responsibility and trust of that person by operating on them.  Many times what I do cures the person of that problem.  It’s very gratifying – very immediate.  It’s sort of what I think medicine’s all about.

How did you first hear about mTuitive and the OpNote product?

I’m an academic surgeon at a major Canadian university.  My main research interest for over seven years now has been synoptic reporting and improving processes of care in surgery.  About 6 years ago I published an article in the journal Surgery about synoptic reporting and its benefits.  It’s always been an interest of mine.

Concurrently, as I’ve worked through my career, I’ve become more interested in cancer.  There’s a big push to have synoptic reporting in cancer surgery – much like there is excellent synoptic reporting in cancer pathology.  I feel strongly that [synoptic reporting in surgery] is a simple thing that we can add that can potentially improve patient care and save lives.

Through my work with the provincial organization in British Columbia I was introduced to the mTuitive products.  I saw it as a possible solution to a lot of our problems.

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March 26, 2010 at 4:18 pm Leave a comment

Introducing the OpNote Consultants – Dr. Seth Goldberg

While creating our surgical reporting product, the OpNote, we at mTuitive have been working with many highly skilled surgeons.  These surgeons are from a diverse group of specialties and backgrounds and help to shape the future and efficacy of the OpNote.  We’re introducing these consultants to all of you in the coming weeks.

After 27 years as an otolaryngologist/facial plastic surgeon in Rockville, MD, Dr. Seth Goldberg launched a new career as a health care consultant specializing in clinical information technology development, utilization management, continuous quality improvement, and risk management. He conducts accreditation surveys of outpatient medical facilities for the Accreditation Association for Ambulatory Health Care. Dr. Goldberg holds board certifications in Otolaryngology-Head & Neck Surgery, and Facial Plastic and Reconstructive Surgery.

He earned his B.S. degree in Molecular Biophysics and Biochemistry from Yale University, and his M.D. degree from Tufts University School of Medicine. He recently received his Masters of Medical Management degree from Carnegie Mellon University. Washingtonian Magazine and Washington Consumers Checkbook have included him in their list of Top Doctors.

In conjunction with his solo clinical practice, Dr. Goldberg was Chief of Otolaryngology at Holy Cross Hospital in Silver Spring, MD, and Shady Grove Adventist Hospital in Rockville, MD. He also served as a member of the Peer Review Committee of the Montgomery County Medical Society and as a peer review consultant with the Delmarva Foundation, Medical Mutual Liability Society of Maryland and the Medical Chirurgical Society of Maryland.

How did you get your interest in medicine?

I’m at the leading edge of the baby boom generation and my role model was – and we can joke about this – it was the TV show “Marcus Welby, MD.” He was a very respected individual and it was clear, back in the sixties, that physicians were highly respected members of and contributors to the well-being of  society.  So I think that’s what originally piqued my interest.

There were other factors, of course – I excelled at science and math.  I had an inquiring, experimental mind – I worked as a lab assistant for one of my biology teachers in addition to taking Advanced Biology as an elective in high school.  I taught tomato plants to say, “feed me, Seth.”

(Laughs)

Once I got into college, I fast tracked into medicine – that seemed to be the thing to get into at the time.  So I did my pre-med and the process for getting into medical school was actually pretty easy.  I had an interview at Tufts that consisted of the interviewer informing me that they had already decided to admit me.

(Laughs) So then you clearly felt like “I nailed it!”

(Laughs) Basically, yeah – I felt like I had nailed it, right.  Also, at the time, there was this other little thing called the Vietnam War.  I had a high lottery number, or I guess it was actually a low lottery number.  So there was only one other choice and that was be cannon fodder.

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March 17, 2010 at 10:25 am 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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