Clinical Terminology and One Touch Coding for EPIC or Other EHR Kathy Fennick, RHIA, CCS

Objectives Define the clinical terminology standards Understand the coding issues Understand the coding guidelines (hospital verses professional) Discuss the coding workflow

Clinical Terminology No single terminology has the depth and breadth to represent the broad spectrum of medical knowledge therefore a group of well-integrated, non-redundant clinical terminologies will be needed to serve as the backbone of clinical information and patient safety systems

Clinical Terminology Describes diseases and care provided Clinical vocabularies Terminologies Coding systems (CPT and ICD) used for reimbursement Recording and reporting patient care Terms cover diseases, diagnoses, findings, operations, treatments, drugs, administrative items etc.

Clinical Terminology A large number of coding and classification systems have been developed for healthcare. Many standards have been proposed but widespread adoption has been slow. Current standards tend to compete. Many classifications overlap. Existing medical vocabularies vary in their coverage and completeness. Historically, vocabulary and classification systems have been designed to meet different and specific goals. Many codes have been designed mainly to support administration (e.g. billing) so have typically included, for example, only a limited number of diagnosis codes for each encounter. Widely-used but essentially administration-oriented system, such as ICD, have been mandated by government agencies and/or payor organizations but capture clinical data at an insufficient level of detail to support clinical needs that lie outside the limited range of activities they were designed to support.

Define the Coder Hospital/Facility coding is often performed by a certified coder and/or other Health Information Management credentialed staff member for the hospital charge/cost (building, supplies, nursing care, etc.). They code the services that are documented in the medical record (i.e. inpatient, ambulatory surgery, x-rays, ER visits) ICD is used for diagnosis and procedures for inpatient ICD is used for diagnosis and CPT is used for procedures and services for outpatient

Define the Coder A Profee Medical coder, is someone who codes services that are done in hospitals and the doctors office for the physician’s service. Most require Medical Terminology and a Medical Billing Course and hold a certified professional coder credential. They code the services that are documented in the medical record similar to the hospital coders (i.e. inpatient, ambulatory surgery, x-rays, ER visits, and physician office/clinic) ICD is used for diagnosis and CPT is used for procedures/evaluation and management for inpatient ICD is used for diagnosis and CPT is used for procedures/evaluation and management for all outpatient

Coding Issues Over and over, coding professionals have been told that they can code “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out” conditions. This guideline is true only for certain settings such as acute care facilities, short-term facilities, long-term care, and psychiatric hospitals. However, a coder coding a physician service may not apply this rule, even if a physician provides the service to an inpatient admission.

Coding Issues Patient admitted to a facility with a progress note documentation of “shortness of breath, rule out pneumonia”. Hospital coder assigns a code for pneumonia Profee coder assigns a code for shortness of breath If this same documentation was applied to a hospital outpatient setting, then the diagnosis of pneumonia would not be coded by either. The third quarter 2000 Coding Clinic validates this guideline, stating, “When coding for physician services whether provided in the hospital inpatient setting or in the physician office, coders should be guided by the Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital Based and Physician Office).”

Coding Issues Evaluation and management (E&M) coding is another area where the guidelines differ between facility coding and professional fee coding. Profee coding and reporting follow the established documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS 1995 or 1997). Facilities may report the same E&M codes but are not required to follow the same documentation guidelines that have been established for professional fee coding.

Coding Issues CPT Modifier usage also differs for professional fee coding and facility coding. Hospital only modifiers apply to hospital OP settings: 73 - Discontinued outpatient procedure prior to anesthesia administration, 74 - Discontinued outpatient procedure after anesthesia administration. Professional fee coding would report modifiers: 52 - Reduced services 53 - Discontinued procedure

Coding Guidelines Reporting V codes is a common challenge in both facility and profee coding. Coding professionals have heard repeatedly that they can’t use V codes because the claims won’t get paid. V codes, however, are valid codes, and when used correctly they result in paid claims. The ICD-9-CM Official Guidelines for Coding and Reporting feature a table that describes when V codes should be used as the first listed diagnosis only, an additional diagnosis only, or a combination of both first listed or additional diagnosis.

One Touch Coding Workflow Identify the keys areas/department that will utilize the “one touch coding” workflow Specialty Cardiac cath lab Electrophysiology lab Interventional radiology Develop the charge codes for the facility and professional

One Touch Coding Workflow The clinical documentation of the procedure or visit is reviewed by the coder Diagnosis codes are entered only once Hospital assigned CPT codes are attached to the hospital specific charge code Coder enters hospital specific charge code Coder adds necessary hospital modifiers Coder enter profee specific charge code Coder adds necessary profee modifiers

One Touch Coding Workflow Physician query is used for documentation clarification Physician Documentation requirement training is performed on an annual basis by the coder Coder collaborates with the physicians regarding EPIC procedure template development

One Touch Coding Workflow Develop EPIC work queue for claim edits and/or CCI coding edits Utilize EPIC Stop Bill function to send updated claims back through the billing process Utilize EPIC Stop Bill function for cases failing medical necessity requirements

Questions? Kathy Fennick, RHIA, CCS kfennick@gmail.com 724-674-9168