In 1983, billing categories and the prospective payment system were established. The first diagnosis-related groups (DRGs) were defined by the Social Security Amendments of 1983 and coding took on a focus toward payment that, at times, overshadows its original development and intent. In 1988, the Medicare Catastrophic Coverage Act mandated that healthcare providers submit the appropriate ICD-9-CM code for each procedure, service, or supply billed under Medicare Part B, re-emphasizing the payment priority of the codes themselves. Today, it becomes more and more evident that the statistical origin and purpose of the ICD-9-CM code system needs to be embraced once again.

As national committees, government agencies, and private organizations struggle with how to coordinate implementation of ICD-10 in this country, we must look at the reason why it is both needed and feared. There is no doubt that the current system is inadequate for the reporting needs of national and international entities. In a data-driven analysis of healthcare and disease process, the current system leaves much to be desired—especially when detail is needed where only general codes are available.

Each year, scores of codes are expanded, new categories are created, and still the practice of medicine outstrips the capability of ICD-9 to keep up. The ICD-10 has such detail built into the process of coding that, at least in theory, data reporting will be greatly simplified across a spectrum of diseases and pathophysiological coding challenges.

Why, then, would it be feared? First, because it’s unfamiliar. Second, the expanded knowledge of anatomy and physiology and disease process that the coder must have to “build” the correct code is a greater challenge than ICD-9-CM requires in today’s world. Third, and perhaps most formidable, is the specificity of documentation required by the treating physician. Today, getting a doctor to clarify some of the most basic diagnosis and procedure issues can daunt even the most stalwart of coders. ICD-10 leaves little opportunity to select codes “not elsewhere classified” and “not otherwise specified.” We may even speculate that coding and billing could grind to a halt while the providers figure out how to get the technical information needed for coding, while at the same time enabling physicians to focus on patient care instead of spending hours browsing a medical dictionary-thesaurus-ICD-10 translation guide.

While implementation of the new system is still years away from a Medicare mandate for coding and reporting, the desperate need for clean and consistent data is here right now. What can the provider do to fill this requirement within the current code system?

Education: In the budget crises that permeate the healthcare industry, never cut costs from the line items for education of your coding staff. They need training on new technology, disease treatment, and surgical techniques to deliver correct coding. Cut the donuts, cut the field trips, shut the light off when you leave the office, but you simply must keep staff current on ICD-9-CM and Current Procedural Terminology (CPT) changes, updates, provider notices, and bulletins. It will be their basic skill and competency that form the “base” in database.

Consistency: If you don’t already have an official coding policy at your facility, seriously consider developing and enforcing one. What do you always want reported? Left to follow their own preferences, some coders will report every noun in the chart while others will stop at the exact number of codes allowed on a claim. Some will pick up every secondary condition that affects patient care, while frugal coders will quit looking as soon as the DRG has a CC—and only then if it even requires one.

If you want your staff to pick up every case of constipation, every x-ray, and family history of disease, expect to modify your productivity standard accordingly. On the other hand, make sure the coding staff is aware of what you really need to report for quality data and allow for the appropriate productivity standard that will result.

Start with basic ICD-9-CM and CPT coding guidelines and then add facility-specific needs as long as they are not contraindicated by the basic rules themselves. The education you provided will pay off here as well. You don’t want your data to include a collection of general symptoms when the documented disease should have been coded instead; you don’t want overcoding of minor procedures that are a component of a larger surgery.

Compliance in billing is not the only beneficiary—your data will be more accurate and credible for the people to whom it will ultimately be presented.

Coding Review: It’s good to have faith in the skill of your coding staff and a proven group may need less intense review than one with less experience or a shorter track record. Don’t drop the process—even the best coders can miss a rule change or have difficulty understanding a disease process or procedure technicality.

The review can be peer to peer in some circumstances. It can be part of the regular duties of a proven coding supervisor or a senior coding staff member. Some prefer to outsource the process to a professional coding agency on a regular basis. Even for those with good in-house review resources, you may consider performing an outside audit periodically to validate that your proverbial fox is not guarding its own henhouse.

Use this key component to assess the results of the education and any shortcomings in coding consistency.

Communication: Do the people creating the reports understand the data fields they will query to make the report? Do the people needing the data realize what they need to ask to get what they want? Do they even know the difference between a DRG and a code?

If someone wants to find out how many cancer patients they treat in one year, they may ask the reporting group to get them the patients in the cancer DRGs. Or they may ask for the patients with principal diagnoses of cancer. If your staff just reports what they request, rather than clarifying the request further, they will miss all the cancer patients admitted for nausea and vomiting due to chemotherapy. They won’t get the patients who had excision of a brain tumor because it’s going to be in a neurosurgery DRG, not one that says “malignancy” in the text of the DRG.

Someone with a comprehensive understanding of the data format itself must be available to interface with the reporting staff, and another person on the reporting staff must be intimately familiar with the data fields and software capabilities and limits. Then, both of those staff members need to make sure they understand what the customer really needs, instead of just what they request.

It isn’t an impossible task, and it’s a critical one. Tend to the needs of your coding and reporting staff, and they’ll tend your data. Don’t forget that while you’re coding for payment, you’re also coding for data that will determine future decisions impacting the entire healthcare industry.