ICD-10: are you ready for a brave new world?

The ICD-10 transition will be an evolutionary process. Relying on the EHR or certified coding staff alone will not be sufficient. The EHR can facilitate easy search tools that assist the provider in selecting a diagnosis. Billing staff are an invaluable resource to help validate that coding and documentation are in sync but the burden will clearly rest on the provider. The provider will be juggling a new code structure, drilling down to new levels of complexity and ensuring their documentation supports the specificity of the new codes selected, all while managing a full patient schedule. Education for the provider will be of paramount importance as they navigate this brave new world.

SNOMED CT implementation: implications of choosing clinical findings or observable entities.

Internationally, it is a priority to develop and implement semantically interoperable health information systems.[1] One required technology is the use of standardised clinical terminologies. The terminology, SNOMED CT, has shown superior coverage compared to other terminologies in multiple clinical fields. The aim of this paper is to analyse SNOMED CT implementation in an Electronic Health Record (EHR). More specifically, differences and consequences of applying clinical findings (CFs) as an alternative to observable entities (OEs) is analysed. Results show that CFs represents the content of the templates with better coverage, with more parent concepts and with a higher degree of fully defined terms than the OEs. We discuss the possibility to further evaluate the observable entity hierarchy to overcome a potential overlapping use of the two hierarchies.

Mapping medical records of gastrectomy patients to SNOMED CT.

The purpose of this study is to explore the ability of SNOMED CT to represent narrative statements of medical records. Narrative medical records of 281 hospitalization days of 36 patients with Gastrectomy were decomposed into single-meaning statements, and these single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problems and treatments were mapped to SNOMED CT concepts. A total 4717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and treatments, about 85.5% statements were fully mapped to SNOMED CT. The rest of the statements were partially mapped. This mapping result implies that physicians' narrative medical records can be structured and used for an electronic medical record system.

Burden of concomitant asthma and COPD in a Medicaid population.

BACKGROUND: Asthma and COPD can significantly affect patients and pose a substantial economic burden for both patients and managed-care plans. This study compares utilization outcomes in patients with asthma, COPD, or co-occurring asthma and COPD in a Medicaid population, and assesses the incremental burden of COPD in patients with asthma. METHODS: We queried medical claims of Medicaid patients aged 40 to 64 years with asthma and/or COPD filed between January 1, 2001, and December 31, 2003, from encounter data. COPD patients were identified based on at least one claim with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes 491, 492, 496; and asthma patients were identified on the basis of ICD-9 code 493 as diagnosis. We analyzed annual utilization and cost of hospitalizations, physician, and outpatient services attributable to asthma and/or COPD. RESULTS: The analysis included a total of 3,072 asthma, 3,455 COPD, and 2,604 COPD/asthma patients. COPD/asthma co-occurring disease has higher utilization of any service type than either disease alone. Compared with asthma patients, COPD patients were 16% and 51% more likely to use physician (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.01 to 1.34) and inpatient services (OR, 1.51; 95% CI, 1.31 to 1.74), respectively; and 60% less likely to use outpatient services (OR, 0.40; 95% CI, 0.35 to 0.46). Compared with asthma patients, COPD patients and COPD/asthma co-occurring patients cost 50% (OR, 1.50; 95% CI, 1.3 to 1.74) and five times (OR, 5.25; 95% CI, 4.59 to 6.02) more for total medical services, respectively. CONCLUSION: Our data suggest that patients with COPD and co-occurring COPD/asthma were sicker and used more medical services than asthma patients. The incremental burden of COPD to patients with asthma is significant.

[The German diagnosis-related groups in urology: reproducibility and quality of coding]. / G-DRG-System für die Urologie : Reproduzierbarkeit und Kodierqualität.

BACKGROUND: The German diagnosis-related group (G-DRG) system is based on the belief that there is only one specific coding for each case. The aim of this study was to compare coding results of identical cases coded by different coding specialists. MATERIAL AND METHODS: Charts of six anonymous cases -- except final letter and coding -- were sent to 20 German departments of urology. They were asked to let their coding specialists do a DRG coding of these cases. The response rate was 90%. RESULTS: Each case was coded in a different way by each coding specialist. The DRG refunding varied by 6-23%. The coding differences were caused by different interpretations of definitions in the DRG system and also by inaccurate chart analysis. CONCLUSION: The present DRG system allows a wide range of interpretation, leading to aggravation of the ongoing disputes between hospitals and insurance companies.

Practical issues in using SNOMED CT as a reference terminology.

SNOMED CT was created by the merger of SNOMED RT (Reference Terminology) and Read Codes Version 3 (also known as Clinical Terms Version 3). SNOMED CT is considered to be among the most extensive and comprehensive biomedical vocabularies available today. It is considered for use as the Reference Terminology of various institutions. We review the adequacy of SNOMED CT as a Reference Terminology and discuss the issues in its use as such. We discuss issues with content coverage of various clinical domains, data integrity and validity, and the update frequency of SNOMED CT, and why SNOMED CT alone is not adequate to serve as the Reference Terminology of a healthcare organization.

Classifications used by Australian forensic odontologists in identification reports.

Forensic odontologists are repeatedly called upon to assist in the identification of deceased persons. A great deal of information is available in the literature as to how and why comparative dental investigation of identification is performed but there is little information on the descriptive terms used in reporting these identifications. A forensic odontology report sets out the findings of a comparison between antemortem and postmortem evidence and indicates the odontologist's opinion on the identification. This opinion needs to be defendable in a court of law. This paper investigates the classifications utilised in the six states and two territories of Australia and reflects on the differences. Three states of Australia use American Board of Forensic Odontology classifications, whilst the remaining regions use a modified format. Since there are no significant legal, cultural or religious differences, and similar practitioners and clients, variation between regions within Australia would seem hard to justify. National standard terminology should be encouraged.

Using SNOMED CT codes for coding information in electronic health records for stroke patients.

For a project on development of an Electronic Health Record (EHR) for stroke patients, medical information was organised in care information models (templates). All (medical) concepts in these templates need a unique code to make electronic information exchange between different EHR systems possible. When no unique code could be found in an existing coding system, a code was made up. In the study presented in this article we describe our search for unique codes in SNOMED CT to replace the self made codes. This to enhance interoperability by using standardized codes. We wanted to know for how many of the (self made) codes we could find a SNOMED CT code. Next to that we were interested in a possible difference between templates with individual concepts and concepts being part of (scientific) scales. Results of this study were that we could find a SNOMED CT code for 58% of the concepts. When we look at the concepts with a self made code, 54.9% of these codes could be replaced with a SNOMED CT code. A difference could be detected between templates with individual concepts and templates that represent a scientific scale or measurement instrument. For 68% of the individual concepts a SNOMED CT could be found. However, for the scientific scales only 26% of the concepts could get a SNOMED CT code. Although the percentage of SNOMED CT codes found is lower than expected, we still think SNOMED CT could be a useful coding system for the concepts necessary for the continuity of care for stroke patients, and the inclusion in Electronic Health Records. Partly this is due to the fact that SNOMED CT has the option to request unique codes for new concepts, and is currently working on scale representation.

Effects of form length and item format on response patterns and estimates of physician office and hospital outpatient department visits. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2001.

OBJECTIVES: This report describes effects due to form length and/or item formats on respondent cooperation and survey estimates. METHODS: Two formats were used for the Patient Record form for the 2001 NAMCS and OPD component of the NHAMCS: a short form with 70 subitems and a long form with 140 subitems. The short form also contained many write-in items and fit on a one-sided page. The long form contained more check boxes and other unique items and required a two-sided page. The NAMCS sample of physicians and NHAMCS sample of hospitals were randomly divided into two half samples and randomly assigned to either the short or long form. Unit and item nonresponse rates, as well as survey estimates from the two forms, were compared using SUDAAN software, which takes into account the complex sample design of the surveys. RESULTS: Physician unit response was lower for the long form overall and in certain geographic regions. Overall OPD unit response was not affected by form length, although there were some differences in favor of the long form for some types of hospitals. Despite having twice the number of check boxes on the long form as the short form, there was no difference in the percentage of visits with any diagnostic or screening services ordered or provided. However, visit estimates were usually higher for services collected with long form check-boxes than with (recoded) short form write-in entries. Finally, the study confirmed the feasibility of collecting certain items found only on the long form. CONCLUSION: Overall, physician cooperation was more sensitive to form length than was OPD cooperation. The quality of the data was not affected by form length. Visit estimates were influenced by both content and item format.

Avoiding audits by benchmarking your E/M coding.

Providers are well aware that appropriate coding is the key to prompt payment of claims submitted for services. Payers do reserve the right to review payments at a later date, however. The auditing process is costly, time consuming, and often traumatic for practices. This article provides an overview of the coding and payment process. The author suggests that practices audit their own clinical records on a periodic basis and compare the distribution of their codes with national and/or specialty benchmarks. In addition, practices must weigh whether the coding level is supported by appropriate documentation.

Accuracy of Medicare claims data for rheumatologic diagnoses in total hip replacement recipients.

This analysis was performed to examine whether Medicare claims accurately document underlying rheumatologic diagnoses in total hip replacement (THR) recipients. We obtained data on rheumatologic diagnoses including rheumatoid arthritis (RA), avascular necrosis (AVN), and osteoarthritis (OA) from medical records and from Medicare claims data. To examine the accuracy of claims data we calculated sensitivity and positive predictive value using medical records data as the "gold standard" and assessed bias due to misclassification of claims-based diagnoses. The sensitivities of claims-based diagnoses of RA, AVN, and OA were 0.65, 0.54, and 0.96, respectively; the positive predictive values were all in the 0.86-0.89 range. The sensitivities of RA and AVN varied substantially across hospital volume strata, but in different directions for the two diagnoses. We conclude that inaccuracies in claims coding of diagnoses are frequent, and are potential sources of bias. More studies are needed to examine the magnitude and direction of bias in health outcomes research due to inaccuracy of claims coding for specific diagnoses.

The content coverage of clinical classifications. For The Computer-Based Patient Record Institute's Work Group on Codes & Structures.

BACKGROUND AND OBJECTIVE: Patient conditions and events are the core of patient record content. Computer-based records will require standard vocabularies to represent these data consistently, thereby facilitating clinical decision support, research, and efficient care delivery. To address whether existing major coding systems can serve this function, the authors evaluated major clinical classifications for their content coverage. METHODS: Clinical text from four medical centers was sampled from inpatient and outpatient settings. The resultant corpus of 14,247 words was parsed into 3,061 distinct concepts. These concepts were grouped into Diagnoses, Modifiers, Findings, Treatments and Procedures, and Other. Each concept was coded into ICD-9-CM, ICD-10, CPT, SNOMED III, Read V2, UMLS 1.3, and NANDA; a secondary reviewer ensured consistency. While coding, the information was scored: 0 = no match, 1 = fair match, 2 = complete match. RESULTS: ICD-9-CM had an overall mean score of 0.77 out of 2; its highest subscore was 1.61 for Diagnoses. ICD-10 scored 1.60 for Diagnoses, and 0.62 overall. The overall score of ICD-9-CM augmented by CPT was not materially improved at 0.82. The SNOMED International system demonstrated the highest score in every category, including Diagnoses (1.90), and had an overall score of 1.74. CONCLUSION: No classification captured all concepts, although SNOMED did notably the most complete job. The systems in major use in the United States, ICD-9-CM and CPT, fail to capture substantial clinical content. ICD-10 does not perform better than ICD-9-CM. The major clinical classifications in use today incompletely cover the clinical content of patient records; thus analytic conclusions that depend on these systems may be suspect.

Billing for psychiatric evaluations: options for coding and reimbursement.

The complexity of the current practice environment challenges clinicians to master complicated billing and coding regulations. Failure to properly bill and code can result in reduced potential revenue for services providers and, if improperly done, could lead to paybacks or penalties for the clinician. The purpose of this article is to assist psychiatrists in choosing the optimal coding for new evaluations and to understand the documentation requirements. Comparisons are provided between the "psychiatry codes" and the "evaluation and management" series. Details of required history, examination, and medical decision-making are listed in order to provide the tailed knowledge necessary to appropriately utilize some higher paying evaluation and management coding options for psychiatric evaluations.

Coding and billing for gastrointestinal endoscopy.

The complexities associated with the coding, billing, and reimbursement process seem to increase daily. Keeping abreast of the changes in this environment is, to say the least, a challenge. To succeed in today's billing environment the gastroenterologist should surround his or her practice with staff, resources, and education. Experienced skilled staff, preferably a certified professional coder should be employed. Certified coders bring advanced coding skills to ones practice, which allows increased proficiency with the coding and billing process. Provide the necessary resources for staff. Current coding material is crucial to the financial success of the practice. CPT-4, ICD-9, and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, managed care newsletters, and so forth) aids the staff with the necessary tools to carry out their duties. In addition, specific gastroenterology coding subscriptions are available to assist in staying ahead of the ever-changing billing and coding environment. Continuing education in the billing and coding process for both the physician and staff is essential. Numerous workshops are offered periodically. It is imperative that staff attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars. More and more physicians are now aware of their responsibility in the billing process and have begun to participate in the coding education along with their staff. This is a significant indicator of a physicians' intent to have a compliant and financially successful practice.

Evaluation of three Swedish ICD-10 primary care versions: reliability and ease of use in diagnostic coding.

If computer-stored information is to be useful for purposes other than patient care, reliability of the data is of utmost importance. In primary healthcare settings, however, it has been found to be poor. This paper presents a study on the influence of coding tools on reliability and user acceptance. Six general practitioners coded 152 medical problems each by means of three versions of ICD-10, one with a compositional structure. At code level the reliability was poor and was almost identical when the three versions were compared. At aggregated level the reliability was good and somewhat better in the compositional structure. Ideas for improved user acceptance arose, and the study explored the need for several different tools to retrieve diagnostic codes.

Disparity in coding concordance: do physicians and coders agree?

Increasing demands for large-scale comparative analysis of health care costs has led to a similar demand for consistently classified data. Evidence-based medicine demands evidence that can be trusted. This study sought to assess managers' observed levels of agreement with physician code selections when classifying patient data. Using a non-sampled research design of both mailed and telephone surveys, we employ a nationwide cross-section of over 16,000 accredited US medical record managers. As a main outcome measure, we evaluate reported levels of agreement between physician and information manager code selections made when classifying patient data. Results indicate about 19 percent of respondents report that coder-physician classification disagreement occurred on more than 5 percent of all patient encounters. In some cases, disagreement occurred in 20 percent or more instances of code selection. This phenomenon shows significant variation across key demographic and market indicators. With the growing practice of measuring coded data quality as an outcome of health care financial performance, along with adoption of electronic classification and patient record systems, the accuracy of coded data is likely to remain uncertain in the absence of more consistent classification and coding practices.

Benchmarking variation in coding accuracy across the United States.

The objective of this study was to measure the consistency of coded medical data through information managers' reports of the overall coding error level in patients' medical records. Using a cross-sectional design, we examined the reported percent of records containing coding errors significant enough to change a diagnostic related group (DRG). Results indicate about 87 percent, 9 percent, and 5 percent of respondents reported that significant coding errors existed in less than 5 percent, 6-10 percent, and greater than 10 percent of the medical records in their institutions, respectively. Significant variation was found in the accuracy and consistency of coding practice and associated data quality across key demographic and organizational variables. Significantly large error rates in coded data exist in some organizations. Given variations across key demographic characteristics, providers may tend to distrust all coded data, when aggregated. As the United States moves toward an evidence-based medicine environment, the use of current patient data classification methods may be of limited value without increased attention to coding practices.

Did we do it right?--an evaluation of the colour coding system for antenatal care in Malaysia.

Identification of pregnancies that are at greater than average risk is a fundamental component of antenatal care. The objective of this study was to assess the level of appropriate management and outcomes among mothers with hypertensive disorders of pregnancy, postdates and anemia in pregnancy, and to determine whether the colour coding system had any effect on the maternal mortality ratios. A retrospective follow-through study confined to users of government health services in Peninsular Malaysia was carried out in 1997. The study areas were stratified according to their high or low maternal mortality ratios. The study randomly sampled 1112 mothers out of 8388 mothers with the three common obstetric problems in the selected study districts. The study showed that the prevalence of anemia, hypertensive disorders in pregnancy and postmaturity among mothers with these conditions were according to known international standards. There was no significant difference in the colour coding practices between the high and low maternal mortality areas. Inappropriate referrals were surprisingly lower in the areas with high maternal mortality. Inappropriate care by diagnosis and by assigned colour code were significantly higher in the areas with high maternal mortality. The assigned colour code was accurate in only 56.1% of cases in the low maternal mortality areas and in 55.8% of the cases in the high maternal mortality areas and these two areas did not differ significantly in their accurate assignment of the colour codes. The colour coding system, as it exists now should be reviewed. Instead, a substantially revised system that takes cognisance of evidence in the scientific literature should be used to devise a more effective system that can be used by health care personnel involved in antenatal care to ensure appropriate level of care and referrals.

Coding on the home front.

Recently, a group of coders participated in a survey about their day-to-day experiences as remote, or at-home coders. The survey asked a series of questions related to the positives and negatives of coding at home versus coding in the more traditional office setting. Below is a summary of the survey findings.