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Data Management: In the ICD-10 trenches, coding as an art and science

October 25, 2016
Health IT
From the October 2016 issue of HealthCare Business News magazine

By Crystal Clack

An executive at a hospital or clinic may not understand the important dynamics of a coding professional’s work, past keeping the DNFB low. Many believe coding is an easy trade to learn. After all, coding professionals sit in front of a computer every day and match codes to clinical documentation. That can’t be too bad, can it? In reality, working in the health care coding environment is a challenging, critical thinking-driven, exciting profession. It’s a job with many rules and guidelines that, if ignored, could mean heavy fines and penalties from the Office of Inspector General (OIG), or worse, prison.

A knowledgeable and experienced coder can help keep compliant revenue flowing into a practice at a steady pace. Without him or her, it would be very difficult to make ends meet. To be considered experienced, a coding professional must have a working knowledge of anatomy, physiology, pathophysiology, pharmacology and disease processes, along with critical thinking skills and interpersonal relationship skills. A person cannot learn to code overnight. It takes many years to master the coding systems and understand clinical documentation.

Transitioning to a new coding system
ICD-10, a coding system that provides users with a greater level of specificity in capturing correct codes to match with a patient’s diagnosis, has been in place for a year in the U.S. It was a significant change from ICD-9, but the coder continues to be the artist who paints the patient’s documentation from the provider and turns it into a visual story, explaining why the patient came for treatment, what was done and the outcomes. In this way, coding is an art and science.

Learning the more robust ICD-10 coding system has been a challenge, but after getting used to it, most coding professionals like it better than the old system, as it helps them to be more thorough in capturing the status and health of patients. While there has been the expected decrease in coding productivity due to learning the new system and providers being prompted for greater specificity in their patient documentation, the dire fears that surrounded the transition have proved unfounded.

2017 ICD-10-CM/PCS code updates are substantial. Specific practice updates to coding rules and guidelines should be carefully reviewed to determine the effect on the health care setting. Over the past year, coding professionals have expressed concerns about not having enough time to code, and to understand what it is they are coding. Now that new codes are being released on Oct. 1, 2016, it is more important than ever to allow a coding professional to become both educated, and proficient, with these new coding rules and guidelines.

Making a connection
While the complexities of coding are a daily challenge for health information professionals, they often go unnoticed by health care executives. In reality, the coding professional and leaders in the health care C-Suite rely heavily upon one another. Understanding each other is crucial. Executives should connect with this staff. What do they like and dislike about their jobs? What tools do they need to do their jobs better? What are their struggles and concerns? Reviewing some medical records with a coding professional can be an enlightening way to learn about the coding process. Coding professionals are some of the most important, behind-the-scenes people in health care, and it’s worth the effort to understand the fluidity that they offer to the entire health care system.

About the author: Crystal Clack, MS, RHIA, CSS, is the director of coding and data standards at AHIMA.

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