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POSTS BY TAG | Diagnosis codes


I’ve worked in health care for many years, and while providers face their fair share of challenges, there’s one question that I’ve noticed almost always bubbles to the top - who do I ask about coding questions? This can be especially distracting as they attempt to focus their efforts on providing the best medical care.

Coding appears to be a thorn in everyone’s side. Why is that? Well, imagine having to enter codes on patients 30+ times a day! Currently, to determine whether you’ve made the correct E&M (evaluation and management) code selection, providers must successfully meet each criterion of the 1997 Documentation Guidelines for E&M Services. Yes, you read that correctly, 1997! 

Let’s take a look at charge code 99213 as an example. While this may seem like a straight-forward, low-level subsequent visit, think again! To correctly select this code, you need to meet two of the following three requirements: 1) an expanded problem-focused history; 2) an expanded problem-focused examination; and/or 3) medical decision-making of low complexity. But, that’s not all. Now answer the following question; how do you define and determine expanded and low complexity? Each of the previously required components is broken down even further into several categories and elements that need to be considered.

As you can see there are many variables that go into selecting the correct code. The question many providers are left with is: who has time to reference the various guides and available resources when trying to complete a patient visit? Unfortunately, inaccurate coding can lead to significant penalties and lost revenue.

The good news is that changes are coming. Starting in 2021, time-based billing will be available for applicable services, dramatically reducing the complexity associated with code selection. CMS alone has reported a 9.2% monetary loss due to incorrect coding and 55.2% loss due to insufficient documentation in the CY of 2019. If you were to submit an incorrect claim to the government, this would violate the Federal Civil False Claims Act (FCA). Penalties may include substantial fines and even possible imprisonment. As frightening as those repercussions are, the most common consequence of medical coding errors is not receiving reimbursement from the insurance carriers. 

It’s about time we actually apply the infamous motto “patients over paperwork” and remove the providers’ burden of having to recite coding guidelines. Thus, eliminating the fear of possible sanctions due to inaccurate coding.

At pMD, we can create customized edits designed to prompt providers to select accurate codes based on specific parameters and requirements, such as charge code or diagnosis criteria, NCCI edits, patient demographics, and much more. This is a quick, seamless process that enables the provider and biller to feel confident in their code selection. Just a few extra clicks based on prompts can assist with accurate and timely claims submission. Additionally, it can result in quicker payment turnaround as well as the appropriate utilization of E&M codes. 

pMD is continuously evolving to serve the billing needs of practices. Contact us to learn more about how pMD can best assist you and your practice!

 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.


Electronic Health Records have greatly benefited health care. However, the wide adoption of EHRs did not come without certain drawbacks, especially for providers.  Do you remember what it was like to go to the doctor 15 years ago? You’d walk in and immediately see a lifetime supply of manila folders behind the front desk staff. When the provider entered the room, they were able to sit in front of you and have an engaging conversation. Today, a majority of providers are having to type into a computer in order to meet electronic documentation requirements. Although EHRs have propelled health care forward in many ways, unfortunately, they’ve added a new burden for providers: having to code from their patient visits with standardized code sets.

What are standardized code sets?

Providers are expected to document within different sets of billing and clinical terminologies. Simply put, these are standardized vocabularies that allow representation of the same health concepts between different health information systems. You can think of health care terminologies as the building blocks that support the entire health care documentation process. They allow patient data to be transferred in a way that can be understood and consumed universally, which is necessary not only for individual patient records but also for public health reporting, statistics, and billing.

ICD-10 and SNOMED-CT

You may be wondering: why is this a problem for providers? To dive in, let’s focus on two code systems often used by providers: 

ICD-10 (International Classifications of Diseases, 10th Edition) is often used for the backbone of diagnoses. The issue is that the coding hierarchy was built for billers and therefore is not provider-friendly. A lot of the terms aren’t expressed in everyday provider language (ie - “myocardial infarction” instead of “heart attack”), and there aren’t enough codes to capture the specificity of many clinical concepts. In general, ICD-10 is appropriate to be used as the backbone for billing but lacks the specificity needed for clinical documentation. 

SNOMED-CT (Systematized Nomenclature of Medicine – Clinical Terms) is a clinical term that includes diseases, clinical findings, etiologies, procedures, and health outcomes. It was the terminology required to meet Meaningful Use Stage 2 certification standards back in 2014 and is what providers typically use to document clinically in the EHR. Although this is a more comprehensive, clinical-based terminology, it still forces providers to document using the language of the code system rather than being able to document using their everyday language. There are several complexities to each code set - such as having to post-coordinate on a term to make it more clinically specific. 

This is burdensome because providers are, on top of their growing list of patient responsibilities, now tasked with learning multiple coding languages - which was something that was previously handled exclusively by billers and coders. With the wide adoption of EHRs, it moved the clerical task of coding to the providers, which shows that EHR technology is not assisting the providers, but rather the providers are assisting the technology. Why make providers learn all of these different code languages instead of allowing them to document clinically in the way they were trained?

Are there any solutions?   

Thankfully, there are solutions that help to ease this new coding burden on providers. Here at pMD, we accomplish this on the charge capture side by making the diagnosis and charge lists extremely customizable - not only to each practice but down to the individual provider. We can rename ICD-10 and CPT terms based on the provider’s preference, float important terms to the top, and delete terms that are not necessary. By offering a highly customized pick list, we eliminate the need for providers to memorize multiple coding languages. 

There are also clinical interface terminology solutions that serve as a bridge between code sets and providers. These companies offer expansive clinical vocabularies that have multiple synonyms and ways of documenting each term (ie - “type 2 diabetes,” “t2dm” and “diabetes, type II” would all be options for documenting the clinical concept of type II diabetes mellitus). They are very helpful to providers documenting in the EHR where more in-depth documentation is required. Overall, EHRs have helped propel health care forward, but pMD helps to take the coding burden back away from providers. 

 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrysecure messagingclinical communication, and care navigation software and services, please contact pMD.