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October 16, 2006
HIM departments are generally aware of how vital a service their coders provide. In their daily work of translating the medical diagnoses and procedures into codes, coders enable billing, statistics, and reporting of all types. Because of the “billing’” thing, financial departments may even be aware of the monetary value of their skill and service. But does anyone ever stop and think about the ancillary services provided by the coding staff? Typically, ancillary services are considered to be radiology, laboratory, nursing, and the like. In this case, however, the meaning is different. The coding staff is on point to notice issues that affect other areas as it reviews medical record documentation. It looks at the progress notes, operative and discharge dictations, handwritten procedure notes, and consults in paper charts. Admitting orders, discharge orders, and their exact time and dates are of importance because these can determine the reason for admission and ultimately the diagnosis-related group (DRG) for payment. Coders match the listed diagnoses to the documentation to determine how, and even if, they affected patient care during the encounter. They review charges and validate that the service was documented because everyone who has ever touched a chart should know rule No. 1: If it isn’t documented, it didn’t happen. In teaching facilities, coding staff make certain that if charges are being billed for a day of physician’s services, the information is in the chart to validate the legal ability to bill for services, and that all the components of the level of service chosen are correctly charted and signed. Coders have to be aware of a patient’s status because outpatient services such as day surgery and observation have different coding rules and payment methodology than inpatient services. If that isn’t enough to keep them busy, they not only have to find and analyze all the information that is in the chart, they even have to figure out what isn’t in the chart. When they get all that figured out, they may even have to wade through conflicting documentation about where the patient went after medical services were completed. For the hospital inpatient, that little bit of data can drastically affect payment on DRG payors, such as Medicare (transfer DRGs). Even then, coders aren’t finished. Chances are they have to enter the summarized data and encode it into some sort of database that will interface to and from other billing and reporting software systems. “OK, fine,” you may be saying to yourself by now. “What does wading through a lot of paperwork in order to code have to do with ancillary services?” Your professional coder isn’t only coding. Because of their familiarity with all the components of medical documentation, coders provide an astonishing number of ancillary services to their own departments. It doesn’t stop with internal issues. They also identify trouble spots for the areas that affect them, as well as those downstream from their data flow. Who is likely to notice interface issues that the information systems people don’t even suspect? The coders, who have to work reports to make sure the registered cases flow through the electronic systems properly to be coded and get billed. When there are discrepancies in the worklists, they make sure the appropriate areas are notified to start working on the problems. Often, they’re also the ones working the reports and making sure the corrections are effective for system updates, external and internal glitches, and even system failures. When the coder analyzes the chart for final summary, if a dictated report has discrepancies, they notify the transcription department of the need for intervention. This serves as quality assurance for transcriptionists’ accuracy and can result in corrections being made when the issues are significant and typographical rather than medical. If the wrong patient’s paperwork gets into another chart, the coder will return it to HIM for correction. In such cases, the service provided by the coding staff helps prevent possible medical and/or legal repercussions from incorrect or incomplete reports. If discharge disposition isn’t clearly documented in a manner that fits one of the Medicare reporting criteria, the coder may have to clarify with care managers or even the receiving facility. If a trend is identified, there should be communication with the discharging personnel to help them understand and document the detail needed for financial compliance. The coder has to know when the patient switches from outpatient to inpatient status to determine correct principal diagnosis or evaluation and management codes. This communicates any related status discrepancies. If there’s no match between actual date and time of admission—and when the patient met admission criteria—significant compliance risk for the facility may result. A prompt heads-up from an alert coding staff can head off this risk and facilitate early process correction. Speedy process and documentation correction can prevent retroactive denial of the entire day—or the entire admission—by the payor. Feedback to all front-end users is another ancillary service coders provide. They identify trouble spots for incorrect birth and death times, thus keeping state reporting and even billed days correct. Coders can even spot infection control issues that need to be reported—a sudden rash of methicillin-resistant staphylococcus aureus infections needs to be communicated right away and it may be the coding staff that identifies such a trend before any single caregiver makes the connection. The professional coder stays on top of upcoming code or rule changes that will affect how the facility or physicians get paid. They make sure the information gets communicated to the financial people who need to know before it happens so they can budget or modify processes accordingly and minimize its impact on the facility. Once coders tend to all the documentation that is there, they have to figure out what isn’t there and get that fixed, too. Are there missing signatures? Do teaching physicians need validation? It’s likely to be the coding staff hunting down physicians for completion. Do you have medical care and laboratory results or radiology reports but no diagnosis to justify them? Again, it’s the professional coder who notices their absence and queries the physician to provide the missing piece of the medical documentation puzzle. With all this extra effort, how does the coder even find time to code? That’s a good question and one you may need to look at in your own department. These types of ancillary services can help you meet critical compliance, financial, and HIPAA goals. Although it’s tempting to use coders as chart police for ancillary processes, every time you add to their daily expectations you cut into productivity, quality, or both. Remember that no matter how well spent the time, it is still time spent. For the processes you can fix, do so at once and keep them in control. But in many instances, it’s the coders’ radar on which you rely to identify and communicate errors before they become major problems. While you can’t have coders quit looking out for side issues, you do have to factor in the lost time when calculating staffing and productivity needs. — Judy Sturgeon, CCS, is the hospital coding
senior manager at The University of Texas Medical Branch in Galveston.
While her initial education was in medical technology, she has been
in hospital coding and appeal management for the past 18 years.
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