A community of 30,000 US Transcriptionist serving Medical Transcription Industry

Medical coding is so difficult? - curious

Posted: Mar 15, 2014

Where I work, I do prior auths for various tests and procedures that the physicians order. We are in EPIC and in the patient's chart, all the diagnoses have the codes listed right after them and any new diagnoses listed on the orders also include the code. So when I go to start the prior auth, the only codes I have to look up are the CPT codes for the test, which are referenced rather easily in the CPT coding book. Just the other day I had to get pre-determination for testing on a patient that required lots of diagnoses codes (again all in EPIC). I know our coders enter a lot of this information, but our doctors and nurses do as well when they put those orders in for new diagnoses not yet in the patient's chart. So my question is why do people say coding is so difficult? There are reference books for the diagnoses codes and CPT codes and with all the prior authorizations and pre-determinations that insurance companies require, if a person has a problem with their medical bill, it doesn't necessarily mean it's the coders fault because we have had doctors enter wrong code types and the patient calls after they receive the bill and if in fact it's wrong, the doctors WILL change it. I read posts below where they were talking about 95% accuracy ratings for coders and how it can impact your bill. So I was hoping someone could elaborate on that as well as elaborate on why they feel there are so many gray areas in coding. I am not a coder by the way, getting prior auths and pre-determinations are just a part of my job description as a medical office assistant.

Gee, I was hoping to hear more about these - gray areas and billing issues.

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Here is an idea. Ask that question on the coding board. - I am sure you will get more intelligent answers.

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That is if you dare.

I posted it here - because

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Of posts below from threads that had gotten too long to follow. Every since MModal announced their coding program, this board has been flooded with coding threads and apparently coders as well. I was hoping to hear more from those that prompt me to start this thread. Apparently they've moved on. And what do you mean by if I dare?

Just checked the coding board and there has been more - action on this board than

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That one. Nobody posted over there at all today, seems all the coders have migrated to this board lately.

Other Coding Board?? - luvtotype

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Probably a stupid question on my part, but I thought that this is the only Coding/Medical Billing board on MT Stars. What coding board are you referring to?

This started out on the M+Modal board, - but got moved here

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Nomsg

There are various difficulties - L&L

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with various types of reports. I used to work side by side with coders. Apparently on an op report, you get to charge extra for an extra incision. Don't know about an extension of an incision. As I noted before, just as clinic notes and routine procedures are easy for MTs, they are easy for coders. Just as certain procedures and operations can be difficult for MTs, they can be difficult for coders. Coders generate the income, so everything they do needs to be absolutely precise down to the pennies.

Answer - Coder

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The answer is that what the doctors, nurses, and you are doing, while it involves codes, is not the job of coding. It is just looking up codes.

Because you don't understand what coders actually do, especially a hospital setting, it is natural that you would think that what you DO see is "coding." Probably, everyone is calling it "coding," too, confusing things further.

A lot of what you see may be inaccurate. If your dctors change diagnoses after the patient gets a denial from his insurance, something is inaccurate somewhere. This inaccuracy is not such a critical factor at your office. Keep in mind, though, that you have apparently never seen Medicare come in to review your records or demand repayment of hundreds of thousands of dollars.

Coding in offices is easier because the scope of it is limited. It is more repetitive. You are just looking up test codes, which is relatively easy. You are just looking up diagnosis codes, and your office is unlikely to have anything terribly complex or to state it in a complex fashion, making it easier. You are also unaware if what you are doing is correct or not.

Looking up codes, however, isn't "coding" any more than looking up a phone number is making a call or getting a shopping cart from the corral is doing grocery shopping. Those are components of it, but they aren't the WHOLE activity.

Looking up codes is just a small function. We can do that with a book, or software, or maybe the EHR provides choices. Or, we can just know what the code is. Coders learn how to do this correctly, but that isn't the whole job. It is just a skill, just as being able to write letters of the alphabet is a small skill involved in writing sentences and paragraphs.

Coding is not entirely focused on billing, as it is in your office. On a larger scale, it affects very complex hospital revenue measures, national disease reporting and statistics, the tracking and monitoring of cancer, infectious diseases, birth defects, influenza, and medical research. Even when it is done for billing, that type of coding is much more complex.

That type of coding is not done by dropping in a number to match a medical word or the name of a test.

The code assignment done in offices can be learned with a chapter in a medical billing book. The coding done in hospitals and large facilities, especially at the auditing and compliance review levels, requires the equivalent of a year of college courses, at a minimum, and can require 4-year degree. There are some jobs that require a master's.

Here is the difference. In an office, you have a diagnosis and look up the matching number. You have the name of a test, like CBC or CXR, and you look up the matching number. Diagnosis --> number. Test name --> number. And, your doctor tells you the level of service he provided.

A coder in an extensive outpatient setting reads the documentation to identify the diagnoses, levels the service based on medical necessity and content of the documentation, identifies anything that should have been documented but wasn't, and balances it all with guidance from several different sources, and submits definitive coding. The coder is professionally responsible for this. Doctors and billers don't come along and change it. These coders are also responsible for providing education to doctors on their coding and documentation.

Inpatient coders do much the same thing, but on a far more extensive level. They code entire inpatient stays, reading entire records. They identify the principal diagnosis and sequence codes using many pages of rules and guidelines. They examine test results to identify conditions that should have been documented but were not. They determine the correct procedure from the content of the operative report, not the title. They are even more responsible for this than the outpatient coders, and it is very unlikely that anyone changes what they do. This type of coding has very far-reaching implications for the hospital and nationally.

Sorry, that did have paragraphs, but - they dont show.

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Nm

Paragraphs that dont show? Hmmm, how - odd, nm

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x

No One I work with is calling this coding. - I know full well there is a

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Difference. I didn't make it much further than the first few sentences of your posts because its so bunched together and since it's so much, I'm sure it will be hard to follow. But I wanted to make it clear that I do know my job is NOT coding.

Sorry it was inconvenient - Not my intent

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I am sorry that post ended up that way. I even put extra lines between the paragraphs, but they still don't show up. I have tried several times to fix it.

I am disappointed because I spent a lot of time on that trying to explain what coding is. It is disappointing because you feel it is inconvenient, but it is especially disappointing because you seem to have taken offense to it without reading it.

Nowhere did I criticize you or your work, so I am mystified as to how you could have objected.

I am using a tablet, too, which is likely the problem. Perhaps there is someone who can cut and paste it into a new post and add some paragraphs in appropriate places. I would appreciate it.

I very much appreciated your explanation - MTLC

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I have pieced together from other information on this board the difference between coding and looking up codes, but I really enjoyed reading your detailed response. The illustrations about the phone book, shopping cart, etc., were also helpful.

I am helped to see the complexity of coding.

Thanks!

Thank you. I no longer feel that I wasted - my time.

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You made me feel better.

Excellent post, even without the paragraphs. - Laurie G.

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Thank you!

Thank you, too. - Coder. nm

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Nm

Also, about that 95% - sm

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It isn't that coders have 95% accuracy ratings.

Rather, it is that 95% is the minimum acceptable accuracy for many facilities. For others, 98% is the minimum, but most compliance plans recognize the inherent difficulty with coding and accept 95%. The MINIMUM. Most coders exceed that. Landing ON it is usually a warning sign. Anything below that necessitates a corrective action plan.

I can

Okay, I understand and agree - with this post and

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This is actually the type of response I was hoping to see as I had read some things in previous posts, on the mmodal board which prompt me to start this thread and originally, I posted it there as the people I was trying to hear from would (one in particular) could have learned something from this response.

I'm not saying I disagree with the first post, because I really didn't follow it well and couldn't really elaborate on my questions. I'm sorry, but I use either my phone or my tablet and long posts without paragraphs are hard for me to follow.

Gray areas in coding - Not ready for prime time

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OP, you said yourself that you are not a coder. In addition to those codes the physicians choose, there are CPT modifiers that have to be assigned as well as DRG codes for Medicare patients that when not done correctly will cause the payment to be denied. The difference between 95% accuracy and 99% accuracy could mean a bill getting held up by the insurance company and the facility not being paid in a timely manner. If something gets missed and is not coded, that is also lost revenue. If documentation is missing from a chart, sometimes coders need to follow up on that with the provider in order to code the chart. Where I work, doctors don't fix their mistakes. It comes to the coders and they have to follow through on it. We have people who are involved with providing coding in-service to the providers to help them when there are deficiencies. There cannot be "gray areas" because there is only one correct code. New coders (I did this myself when I was in school) sometimes have a tendency to over code and that could constitute fraud if someone thinks it was done to try to collect more money for the facility. Facilities have coding audits and coders can be found liable, which is why accuracy is a huge deal. I can only speak to the ambulatory care side because that is where I work, but in hospitals coders do much, much more.

OP here again - see msg

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You said "there cannot be gray areas because there is only one code."

I agree with this as well and totally comprehend that. Again, this all originated from posts on the MM board from people saying they were coders. A true coder knows there are no gray areas.

There were 3 questions in my original post, 1 for my own clarification which was the first question and the other 2 were asked based on previous misinformation being posted by people claiming to be coders on MM board.

RE: To not being ready for prime time, no I'm not and never claimed to be. I know my job is not the same as a coder. I am a medical office assistant (and former MT). I do prior auths and get pre-determinations, which involve codes, but I never said it was the same as being a coder and I have no intention on becoming a coder.

There must be more than one person going by - the name "coder" sm

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On the MM board the person going by "Coder" is adamantly saying there are gray areas.

I understand - Not ready for prime time

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I was trying to address your question in regard to the accuracy requirements. Basically, it sounded as if you thought all there was to coding was looking something up in a book or in the Epic data base, I was trying to explain that there was more to the job than you realize.

I think the fact that some coders think there are gray areas - also explains their 95% accuracy rate

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The doctors and nurses are notorious for picking wrong codes or omitting them entirely. A coder can look through a chart and find codes that were missed, and at least with what I do, that happens a lot. That can really add up to a lot of money. I don't do inpatient coding, but that is a whole other ballgame as far as difficulty.

Lets not misrepresent what was said, ok? - This was explained already.

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No one ever said that coders' accuracy WAS 95%.

We said that the usual expectation is that they maintain AT LEAST 95%. That is the minimum allowable. Most exceed it considerably.

If you choose to believe that this represents widespread mediocrity, more power to you.

It does not represent mediocrity, nor does it have any relationship whatsoever to whatever standards MTs are held to.

Things are a lot more clear coding outpatient than inpatient, so let's not judge what we don't know.

And I *am* the original coder who was posting in this topic when it was on the MM board.

If you aren't a coder you don't have a clue - I am not a coder.

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I have only a passing acquaintance with what coders do, which is why I think some of the MTs yearning to be one of the 60 MModal coder trainees haven't got a CLUE what goes into coding or what they are getting themselves into.

For all I know, or anyone not a coder knows, a 95% could be for 1 error. The calculations have no resemblance (I am guessing) to how MTs get QA'd.

Anyway, I acknowledge my ignorance.

Well, I am, and there ARE gray areas in coding. - Coder

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There are so many gray areas in coding it looks like fog.

I'll go as far as saying that if you can't see those gray areas you are either very inexperienced, very poorly trained, or channeling Pollyanna.

As for those MM MTs who are applying for the coding positions, I am sure they don't have a clue what they are getting into, but I do, and what they are getting into is doable, worthwhile, pays well, and nobody's business but their own. We don't need to warn them about it.

It is always a good practice not to preach on what you don't know.

You apparently aren't a reader either. - I was backing you up.

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Dang, you just want to be mad and argue.

You just went OFF on a non-coder backing you up!!! That thread yesterday included a bunch of NON coders who don't know what you do.

Whatever. It's obvious you just want to be angry, sorry to interrupt.

"If you arent a coder you dont have a clue??" - ??

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NM

Yeah, that's right, if you aren't a coder - you do not know what they do

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Is that not a fact??

I didn't say anything wrong. If you are not a coder, how would you know what they do and what the requirements are and why. Heck, even if you are a coder, you don't know the QA requirements for other facilities. The whole argument kind of seems ridiculous on its face actually.

As an MT, you don't know what the QA numbers mean. You don't know what and how much an error is charged at for QA.

I am not a coder. There could not only be gray areas, there could be pink and purple ones too.

I participated in yesterday's thread as an MT when it was on the MModal board. Just trying to apologize for even saying anything yesterday about the 95% or gray areas.

Pardon me for that.

Example - Coder

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Let's say 10 of your cases are reviewed. If one contains an error, your accuracy rate is 90%.

Or, possibly, 10 of your cases are reviewed for procedure code errors. Let's say there are 20 procedure codes in all. If one is wrong, your accuracy is 95%.

See how fast the number drops? The only way to, maybe, avoid that is to audit larger numbers of cases, which is too labor-intensive.

Wow, that is some tough QA. - Gives perspective.

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I am an MT so will leave the coding board now, but that was really great insight. Thank you.

I have thought about going to school for coding but it looks very tough and like it requires a certain personality (do NOT take that as an insult), meaning very detail and number oriented. I am more a word person.

I bid you peace coder ladies/gents.

No, it is more word oriented!!!!! - Not numbers at all

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Nm

Really? See, I definitely have NO clue what you do. - But I have been asked to leave.

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this board, so I hang my head in shame as I depart for ever daring to enter the coder board.

No, you didn't say anything wrong - Anon

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There is a frequent poster on the coding board who is very hostile. She has called me not a coder or an uneducated coder so many times it has lost all meaning to me. Apologies -- we aren't all like that. Best luck if you decide to go the coding route -- or even if you don't!

LOL!!! Now they will think you and I are the same - SM

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I just posted a response in this thread that said dang, calm down. I am a non-coder too who got caught up in the MM threads. I called myself rooting for the coders too, as I thought there were a lot of perpetrators faking to be coders...LOL!!!

Sorry - Sigh

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I am just really irritated. I wrote that post above this morning, couldn't get it to show the paragraphs, worked 10 hours, and came home to hear that the person who asked the question couldn't be bothered. Ugh.

Well, at least with this being on the coding board, we are spared the attentions of the troll.

Oh DANG. I hate when my other personality - slips up and replies back to myself

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At least I guess I must have a multiple personality disorder because I have been involved in several threads where "we" were accused of being all one person responding.

Yup, I see you in there sometimes! - lol

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NM

Whatever...this is getting really childish. - Not taking the bait.

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But gotta wonder, which person are you? Now that you mention it, you sound like you're one in the same.

Actually, the 2 posters who used the word dang both - posted at 8:24 sharp. It is

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Impossible for one person to post a response to 2 different people at the same time. Look at both posts and you will see what I'm talking about.

Yes, I was one of the dang's - multiple personality post was facetious

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I am tired of the accusation of one person posting. It is just a way for superior-thinking people to shut others down. It is annoying.

You're one of the superior thinkers, you by no means - sounded like a dummy &

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Stated your case very well.

You all look like a bunch of bullies ganging up on Coder. - Who just will not listen.

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A large lot of you are not coders, but yet you make statements like the OP: "a true coder knows there are no gray areas in coding" - really and how on earth would you "know" that? You can't possibly "know" that because it patently is not true.

Coder tries to speak reason, you will not listen, and these message boards look a mess because a bunch of people want to proclaim things that they know nothing about. Aaaaaand that is all. I am out. Not adding any more to the mess than I admittedly now have with this post.

This is getting confusing. - shaking my head.

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Will the real coders please stand up?

Wait, wait, wait - You just spent all of this time

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Saying that MModal would teach the AAPC program because they HAD to, there was nothing else for them to teach, that as long as you were able to get your certification that that was all that mattered, and now you are going to call a coder "poorly trained?" How is that possible? You said that certification is required, so you know she is certified -- how can she be poorly trained if there are no differences between training between coders?

What you are missing here is that this stemmed from - the MM board and that was

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Indeed posted by someone in a thread over there. This thread was moved here and I think the coder you are responding to is speaking on her own experience.

Dang, calm down. Like we knew you were the original - poster.

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NM

I do not agree that 95 percent is industry standard - Yes, a coder

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Our facility is 97 percent. Of course that is minimum. I have nothing else to say, as nothing else on this convoluted thread made enough sense to argue with. Yes, I do outpatient coding, by the way and while there are no "low level coders" you sure treat everyone you come into contact with as lower than you. As for me, personally, I don't code "gray". It's my a$$ on the line. Take the risk if you want.

Now that's what I'm talking about. - You said a mouth full.

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Done with this thread.

What an interesting group of people. - nm

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