Health & Medical Medical Coding in Healthcare Delivery Discussion

Jessi Marin Guarin posted Aug 27, 2023 7:31 PM
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Optimizing Medical Coding Practices: Ensuring Accuracy
and Efficiency
The correct payment, compensation, and information
collection all depend on precise medical coding, which is a critical
component of healthcare administration. This essay examines the
situation of Lenore, who had a straightforward birth, and considers
how that affected the assignment of codes. Additionally, it discusses
difficulties brought on by inadequate physician paperwork and offers
solutions for efficiently handling such circumstances.
The importance of accurate coding is demonstrated by
Lenore’s uneventful delivery, which was reported as having no
difficulties before delivery, throughout the birth, or after delivery.
The Result of Birth code [a Z code -(V37.0-V37.9)] indicates delivery
facts according to the ICD-10-CM coding system. In her situation,
choosing a code from this range would be dictated by the lack of
problems.
Additionally, a precise account of the occurrence depends on
the delivery’s code. Given that Lenore delivered normally, the code
would indicate the delivery method (vaginal) and other important
information. This situation emphasizes the need for thorough
documentation. Coders can select precise codes thanks to accurate
records, which ensures accurate billing and payment.
The duties performed by medical coders in a healthcare
institution with conflicting clinician recordkeeping are complex.
Coders cannot choose proper codes from insufficient data, which
may result in incorrect charges and an interruption in compensation.
Coders may find it difficult to assign the proper codes if a clinical
record is missing crucial individual or procedural information.
Additionally, insufficient evidence may result in codes that have too
few characters, making them incorrect. Revenue is impacted, and
rejections of claims may follow, aggravating operational difficulties.
Healthcare organizations should take a holistic strategy to
address the issues brought on by insufficient physician
documentation. First and foremost, it is crucial to support ongoing
and dynamic physician education. Physicians need to be aware of
how their decisions in documentation affect subsequent coding and
billing processes. This increased knowledge may function as a
motivator for more accurate recordkeeping procedures.
Implementing a clear and effective query process is also
crucial. By serving as a link between coders and doctors, this
procedure streamlines the exchange of information and
clarifications. Such a technique avoids potential delays while
speeding up the coding process. Additionally, healthcare
organizations ought to spend money on programs that specifically
increase documentation. These programs include training seminars,
workshops, and helpful critique loops to help doctors improve the
record of their procedures. The business can reap significant
rewards in terms of increased efficiency and accuracy by better
matching these processes with the need for correct coding.
Additionally, using sophisticated coding tools that include
prompts and alerts for inadequate documentation can dramatically
improve coder productivity. These tools act as navigational aids,
enabling developers to quickly find and fill in any gaps in the
specification. Finally, promoting collaboration across functions
among coders, doctors, and managers is extremely beneficial. A
sophisticated awareness of the difficulties each stakeholder faces is
fostered by frequent communication between several departments.
This coordinated effort will eventually end in the development of
more thorough and effective remedies for the complex problem of
insufficient evidence. Healthcare organizations can prevent problems
caused by insufficient documentation by putting these methods into
practice. This adds to better healthcare for patients and efficient
operations as well as improving the accuracy of the coding and
billing procedures.
In summary, the accuracy of medical coding serves as a
cornerstone in the complex web of healthcare management. Lenore’s
straightforward delivery serves as a case study for the beneficial
interaction between rigorous documentation and precise coding.
Additionally, the difficulties posed by insufficient medical
documentation highlight the necessity for strategic interventions.
Healthcare companies can negotiate the challenges of incomplete
documentation by adopting physician education, effective inquiry
methods, documentation refinement projects, technological tools,
and peaceful collaboration. This coordinated set of tactics not only
guarantees efficient payment and coding but also significantly
enhances the provision of first-rate treatment for patients and the
overall efficacy of the healthcare facility.
Jewel Sanders posted Sep 5, 2023 9:02 AM
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1.
2. Lenore delivers a healthy baby girl. Her medical
documentation indicates that she has had a normal
delivery with no complications antepartum, during the
delivery, or postpartum. How does this information
influence which codes you assign? [Tips: Think about
Outcome of Delivery code [a Z code -(V37.0-V37.9)] and
code for delivery].
3.
4.
5. You work for a healthcare organization where several
physicians are not providing specific information (i.e., the
location of the pain, etc.). Due to the issue, it is
impossible for the coder to complete their work. Keeping
in in mind that a code is invalid if it has not been coded to
the full number of characters available for that code. If
appropriate documentation is not provided by the
physician, the coder cannot complete their work, and the
insurance company will return the claim to request
additional information, thereby delaying payment. How
would you handle this situation? What would you do?
What would you recommend to correct the problem?
6.
Coding every single detail correctly is imperative as
we’ve learned thus far in class. Although it was a healthy
delivery, there are multiple details that must be coded
correctly. Lenore’s birth doesn’t specify whether she gave birth
vaginally or by cesarean, so those are two separate codes. If
she gave birth vaginally, we would use code: Z438.00 found in
ICD-10-CM; if she gave birth by cesarean section, we would
use code: Z38.01. Even with this being a perfectly healthy
delivery, we still need more details because these are two
completely different codes that need to be sent to insurance.
Furthermore, code Z37.0 is a single live birth so this would
apply to Lenore’s case as well. I would also like to add code
080 from ICD-1-CM to describe the details of her healthy
delivery (which we don’t have so we would have to reject the
claim till the physician provided us with these details). This
code signifies there were no problems throughout the entire
duration before, during, or after the delivery with a baby born
full term, which we were not told but for the purpose of this
assignment, I will assume. In the real world, we would want to
get more information regarding the details of Lenore’s birth.
This example just goes to show that there are various details
we need in the case of a childbirth, and this is just an
unproblematic birth!
Some other options for coding the outcome of the
delivery include Z37.0 through Z37.9 from the ICD-10-CM. A
few other options for outcomes are Z37.1 which signifies a
stillbirth and Z37.2 which signifies twins born. There are so
many things that may go wrong during a childbirth that need to
be coded correctly when submitted to insurance. Childbirth is a
complex situation so many details are needed before the coder
can submit a claim.
If a physician is failing to provide all of the details
necessary for coding, that is a problem because then there
could be issues with insurance if the coder is just making
assumptions like I did in the first example. In this instance, the
correct thing for the insurance company to do is reject the
claim till they get the details they need such as the location of
pain. This obviously slows down the process of paying the
medical bill because insurance is not going to pay it until
they’re sure they have all of the necessary details. I would
handle this problem by confronting the situation. I think the
most efficient way would be to send a mass email to all
physicians explaining the issue and why it is important that
we’re receiving all of the relevant information. I would also
explain how healthcare workers all need to work together to
take care of each patient and medical coders are a part of this
healthcare team. I would explain all of this very kindly in the
email because the physicians are very busy and likely didn’t
know they weren’t including all of the necessary information. I
would also attach a simple slideshow outlining all of the details
needed for each type of birth: vaginal, cesarean, stillbirth,
multifetal, in order for coders to have all the information to
accurately submit a claim. I would keep in mind that this may
need to be repeated every 6 months or so. The physicians
don’t know what they don’t know, if there are issues with
claims, the coders should reach out to them to address these
said issues. Like I mentioned, in healthcare everyone in the
team must work together as cogs to take care of each patient.
I referenced how healthcare workers are like a cog
because it is imperative that they all work together to achieve a
task. Medical coders can be easily forgotten about but they are
very much so a part of the team and they shouldn’t have their
job made harder by physicians not providing them all of the
details they need. Medical coders are every bit as a part of the
team because they ensure that all details are included and
submitted accurately.
Emily Landewee posted Sep 4, 2023 1:30 PM
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The Importance of Correct Coding in Healthcare
Coding is such an important part of the healthcare world. While
some may believe it is only used to charge them outrageous
amounts of money, it can also help organize a patient’s health
information. This can involve things like their illnesses,
conditions, and treatments. I have seen coding mistakes
firsthand at my job. A patient will come in for a scan they
believe to be on their left leg because that is the one that they
are experiencing pain in. However, the doctor accidentally
ordered a right. The sonographers are not allowed to begin
scanning the patient until they check with the provider and
establish the correct order. Sometimes this can take a few
hours, delaying the patient’s scan. This is why it is so important
for the coding to be correct, because one wrong code can
drastically affect how the patient receives care. This paper will
examine two instances involving medical coding and my
proposed solutions to the problems.
The first example given is of a patient named Lenore who
delivered a healthy baby girl. Everything before, during, and
after her delivery has been indicated in her medical
documentation as normal and with no complications. This
information is very important when deciding which codes to
use. For example, a single liveborn infant that is delivered
vaginally would be represented by ICD-10 code Z38.00.
However, if this infant were born by a cesarean section, the
code would be Z38.01. There are also many other details that
can affect the coding process including the number of infants
born, the place in which the birth occurred, if the infant was
liveborn or stillborn, if the infant was full-term, etc. This shows
just how important the details are when it comes to coding.
Z37.0-Z37.9 are the ICD-10-CM diagnosis codes for outcome
of delivery. Some examples of these include single live birth
(Z37.0), twins both liveborn (Z37.2), and single stillbirth (Z37.1).
These codes are to only be used on the mother’s record. In
Lenore’s case, I would assign her the code Z37.0 since she had
a single live birth. I would also use ICD-10-CM Code O80 to
describe the normal delivery. This code is used for a normal
full-term delivery in which a single healthy infant is delivered
and there are no complications antepartum, postpartum, or
during the delivery. This perfectly describes the information
given about Lenore. Since ICD-10-CM Code O80 describes a
normal birth with no complications, the only appropriate
diagnosis code for outcome of delivery that can be used with it
is Z37.0 which is the other code I assigned to Lenore. If Lenore
had any complications or other circumstances to her pregnancy
and delivery, her coding would have been much different.
There are so many complexities when it comes to pregnancy
and delivery that there is an array of codes to describe each
and every situation. This is why all the details, large and small,
are important when deciding which codes to use.
The second example given is about a healthcare organization
who has physicians who do not list enough information for the
coders to do their jobs properly. They do not give out the
location of pain or any other specifics that allow the coders to
complete their codes. The insurance companies will return the
claim to request additional information before they pay,
therefore delaying it. If I were a member of this organization, I
would start by talking to the physicians about providing the
specific information needed for the coders. It is part of their
duties to provide this specific information in the patient’s chart
where those taking care of the patient can see it whether they
are a coder, nurse, etc. However, I do know that there is a
physician shortage everywhere these days, so many of these
physicians are overworked and see so many patients that they
do not have the time to document their notes properly or they
may not even get to spend as much time with a patient as they
need. If this were the case, I would offer to have an assistant
follow them around and take notes for them. Providing
worksheets that request certain information be filled out could
also be beneficial because then no little details that a coder
needs would be left out. These are just some of the solutions
that could help this organization.
A huge part of healthcare is everyone working together
cohesively to provide the best patient care possible. Something
the hospital I am employed at does to make sure everyone is on
the same page is to assign education modules. Every year, there
are general modules due, however, throughout the year, there
will be some random modules assigned. Recently, a module
about hand hygiene was assigned. Everyone in a hospital should
know when and how to wash their hands. However, since flu
season is coming around the corner, they implemented this
module to make the employees check their actions and bring
attention to something extremely important. It is not only
significant for the employee’s health, but for the health of their
patients as well. This is something that employees need to be
implementing in their daily jobs year-round to protect their
patients, their community, and themselves.
This brings me to another solution for the healthcare
organization issue above. To spread the word across the
healthcare organization, I would assign a healthcare education
module to all employees about the importance of healthcare
coding. Many may think that is something only the coder
should worry about, but in all reality, everyone plays a part in it.
I would have modules designed for different categories of jobs
and would put a lot of emphasis on the physicians’ modules
because they are the main cause for all of the confusion. I think
something that would also be beneficial in the module would be
mentioning how the coding process works and how it affects
the reimbursement the organization gets back from insurance
companies. I think that would help put more emphasis on their
roles and would make them realize that they need to include
more details for the coders to do their jobs correctly.
Every job is important in a healthcare system. Missing one
piece would make an organization fall apart. Coders are
extremely important in keeping patient information
documented correctly and organized. Their job is certainly not
easy, but with the help of physicians and other hospital staff
providing them the correct information they need, then they
will have a smoother coding process. Overall, I believe
everyone within a healthcare organization needs to look at the
big picture of their work, and that is providing the best care to
their patients.
References
Obstetric Coding in ICD-10-CM/PCS. Journal of AHIMA.
(n.d.). https://library.ahima.org/doc?oid=100639#:~:text=Outc
ome%20of%20delivery%20codes%20%28Z37.0%E2%80%93Z
37.9%29%20are%20intended%20for,on%20subsequent%20rec
ords%20or%20on%20the%20newborn%20record.
Obstetrics Coding and Documentation Reference
Guide. BlueCross BlueShield of Alabama.
(n.d.). https://providers.bcbsal.org/portal/documents/10226/3
06297/Obstetrics+Coding+and+Documentation+Reference+G
uide/8f5f1b65-1fd2-49a5-8708-6819a162098e?version=1.0
Outcome of Delivery Z37. ICD10Data.
(n.d.). https://www.icd10data.com/ICD10CM/Codes/Z00Z99/Z30-Z39/Z37-
Module 3 Discussion Paper
Contains unread posts
Alli Kallenbach posted Sep 5, 2023 11:51 AM
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The Importance of Coding in Health Care
Coding is a very crucial and tedious job in the world of health
care. It must be done accurately and precisely. In order for
correct payments to be made successfully to both the physician
and patient, the coding must be completed very professionally
as well as coding the correct information.
In one example, Lenore had a normal, uncomplicated birth—
antepartum, during delivery, and postpartum. Now it is time for
the coders to assign information for Lenore. This uneventful
delivery would be under the “Outcome of Delivery” Z code-
V37.0 in the ICD-10 CM. Z code- V37.0 is “Outcome of
Delivery” code for a single live birth. In Lenore’s case of her
delivery, she would be assigned the “Outcome of Delivery” Z
code- V37.0 because it is the only code applicable to her
situation. The code O80, which describes a normal pregnancy,
would be beneficial in assigning a code to Lenore. Z codeV37.0 is the only appropriate use with code O80. In this coding
system, the patient has to have the correct information needed
to fit the criterion of the code. There are a copious number of
codes out there for pregnancy-related conditions. It becomes
even more complicated when you add in a mother who may or
may not have pre-existing conditions. You also have to factor
conditions which may developed antepartum or postpartum. In
addition to the mother’s possible complications, you have to
factor in the baby’s. Whatever the other codes may be, the
health care facility and the coders have to do an accurate look
at all sides of the situation to understand the circumstances
before assigning a code. Even if it is something like an
uneventful delivery, there should always be someone to make
sure the code is assigned meticulously.
Furthermore, the codes must be very specific, as they hold
important information. This will tell us what kind of delivery
Lenore had (vaginal, cesarean) and if anything else that was
significant happened. As you can see, there are a vast number
of codes that coders could mistakenly use. If these mistakes
happen, they can interfere with billing. If there is a discrepancy,
Lenore’s insurance company might file a claim to request
information. In such a case, the coders would want to make
sure they have the correct code input. Even the slightest typo
could mean a completely different condition. However, it is
always important that the coders are given the correct
information, so they can assign the correct code to the correct
patient.
If physicians are not providing coders with the information
needed to complete their work, then they cannot do their job
sufficiently. As stated earlier, the slightest typo could mean a
completely different condition, and a code is made up of
complex characters. Coders cannot just choose a code if all of
the crucial information is not recorded. It would be based off of
insufficient data which would result in incorrect billing and
compensation. Even more so, the patient may not be able to
receive the full extent of his treatment if he is assigned to the
wrong code. His situation may be more drastic, but the doctors
were not providing enough specific information to the coders
for them to code correctly. If coded incorrectly, any patient’s
insurance company can file a claim to request information
about the patient. While it may seem that the coder is at fault, I
would disagree. How do we prevent this from happening again
in the future? I propose a few solutions to put in place.
One solution is to hold physicians accountable for withholding
information. The coders cannot do their jobs without
physicians, so they need access to special information. I know
there is a health care worker (nurses, lab technicians, etc.)
shortage, so it is very difficult to document everything when
you have many patients and extra responsibilities. Regardless of
the circumstances, coders should be able to get the correct
information needed to assign a code to a patient available.
Coders should also reach out to physicians to build a rapport.
By doing this, coders can work closer with the physician. The
physician in turn could learn a little about the importance of
coding. The physicians can even learn what coding is like
outside of patient information and learn about patient billing
and insurance reimbursement. Then, they could understand
how difficult and confusing it is when not all of the information
is present. This coding education would allow them to be more
mindful when documenting patient information. It is crucial that
they are knowledgeable about the coding process and are
confident that when they input information, it will make sense
to the coder.
Although after this, physicians and coders may now have better
relationships, I feel there will be confusion still. Physicians will
better understand the importance of coding, but there are
things that physicians understand that coders do not. For
example, each kind of specialty physician has its own set of
special medical terminology. While coders are very
knowledgeable, I think it would be a good idea to have the
coders learn more about medical terminology. This way they
could better communicate with physicians and may be able to
interpret any information that can be used for coding.
In summary, coding is a very important task, especially in health
care. Codes are used to keep information organized correctly
and accurately. Coders need very specific information in order
to get the patient’s code correct. As stated above, one wrong
mishap can lead to disaster— wrong diagnosis, wrong billing,
wrong payment, and the patient’s insurance company can file a
claim to request information. In Lenore’s case, she had an
uneventful delivery. The coders still have to assign the correct
code to her in order to ensure that she did not receive an
insufficient code. In turn, the coders must also make sure she
fits the criterion for this code. It is also difficult to assign
someone a code when not enough information about the
patient is given. When this occurs, coders and physicians
should begin to work together. Physicians need to make the
needed information more readily available. This way coders can
do their jobs correctly. While physicians get educated about
what coders do and their importance, coders can get educated
about how to better communicate with physicians when
accessing information. Everything in health care works as a
cohesive unit, so coding is an integral part of that unit that
cannot be overlooked.

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