Coding Notes Improving Diagnosis By Jacquie zegan, CCS, wC Specificity in ICD-IO Coding VALID ICD-IO-CM/PCS (ICD-IO) codes have been required for claims reporting since October 1, 2015. But ICD-IO diagnosis coding to the correct level of specificity—a more recent requirement—continues to be a problem for many in the healthcare industry. While diagnosis code specificity has always been the goal, providers were granted a reprieve in order to facilitate implementation of ICD-IO. For the first 12 months of ICD-IO use, the Centers for Medicare and Medicaid Services (CMS) promised that Medicare review contractors would not deny claims "based solely on the specificity of the ICD-IO diagnosis code as long as the physician/practitioner used a valid code from the right family."l Commonly referred to as the "grace period," this flexibility was intended to help providers implement the ICD-IO-CM code set and was never intended to continue on in perpetuity. In fact, this CMS-granted grace period expired on October 1, 2016.2 Unfortunately, nonspecific documentation and coding persists. This is an ongoing problem, even though the official guidelines for coding and reporting require coding to the highest degree of specificity. Third-party payers are making payment determinations based on the specificity of reported codes, and payment reform efforts are formulating policies based on coded data. The significance of overreporting unspecified diagnosis codes cannot be understated. In the short term, it will increase claim denials, and in the long term it may adversely impact emerging payment models.3•4 Calculating and monitoring unspecified diagnosis code rates is critical to successfully leverage specificity 44/Journal of AHIMA April 18 in the ICD-IO-CM code set. An ICD-IO-CM code is considered unspecified if either of the terms "unspecified" or "NOS" are used in the code description. The unspecified diagnosis code rate is calculated by dividing the number of unspecified diagnosis codes by the total number of diagnosis codes assigned. Health information management (HIM) professionals should be tracking and trending unspecified diagnosis code rates across the continuum of care.5 Acceptable use of Unspecified Diagnosis Codes Unspecified diagnosis codes have acceptable, even necessary, uses. The unspecified code rate is not an error rate, but rather an indicator of the quality of clinical documentation and a qualitative measure of coder performance and coding results. Even CMS explicitly recognizes that unspecified codes are sometimes necessary. "When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code."6 It's also important that coding professionals use good judgment to avoid unnecessary queries for clarification of unspecified diagnoses. The official coding guidelines provide explicit guidance for appropriate uses of unspec.

1. Coding Notes
Improving
Diagnosis
By Jacquie zegan, CCS, wC
Specificity in ICD-IO Coding
VALID ICD-IO-CM/PCS (ICD-IO) codes have been required for
claims reporting since October 1, 2015. But ICD-IO diagnosis
coding to the correct level of specificity—a more recent
requirement—continues to be a problem for many in the
healthcare industry. While diagnosis code specificity has always
been the goal, providers were granted a reprieve in order to
facilitate implementation of ICD-IO. For the first 12 months of
ICD-IO use, the Centers for Medicare and Medicaid Services
(CMS) promised that Medicare review contractors would not
deny claims "based solely on the specificity of the ICD-IO
diagnosis code as long as the physician/practitioner used a valid
code from the right family."l Commonly referred to as the
"grace period," this flexibility was intended to help providers
implement the ICD-IO-CM code set and was never intended to
continue on in perpetuity. In fact, this CMS-granted grace
period expired on October 1, 2016.2
Unfortunately, nonspecific documentation and coding persists.
This is an ongoing problem, even though the official guidelines
for coding and reporting require coding to the highest degree of
specificity. Third-party payers are making payment
determinations based on the specificity of reported codes, and
payment reform efforts are formulating policies based on coded

2. data. The significance of overreporting unspecified diagnosis
codes cannot be understated. In the short term, it will increase
claim denials, and in the long term it may adversely impact
emerging payment models.3•4 Calculating and monitoring
unspecified diagnosis code rates is critical to successfully
leverage specificity
44/Journal of AHIMA April 18
in the ICD-IO-CM code set.
An ICD-IO-CM code is considered unspecified if either of the
terms "unspecified" or "NOS" are used in the code description.
The unspecified diagnosis code rate is calculated by dividing
the number of unspecified diagnosis codes by the total number
of diagnosis codes assigned. Health information management
(HIM) professionals should be tracking and trending
unspecified diagnosis code rates across the continuum of care.5
Acceptable use of Unspecified Diagnosis Codes Unspecified
diagnosis codes have acceptable, even necessary, uses. The
unspecified code rate is not an error rate, but rather an indicator
of the quality of clinical documentation and a qualitative
measure of coder performance and coding results. Even CMS
explicitly recognizes that unspecified codes are sometimes
necessary. "When sufficient clinical information is not known
or available about a particular health condition to assign a more
specific code, it is acceptable to report the appropriate
unspecified code."6 It's also important that coding professionals
use good judgment to avoid unnecessary queries for
clarification of unspecified diagnoses. The official coding
guidelines provide explicit guidance for appropriate uses of
unspecific diagnosis codes.7Overuse of Unspecified Diagnosis
Codes
Coding Notes
Conditions Commonly Reported with Unspecified Diagnosis
Codes

3. Alcohol and drug use, abuse, and dependence
· Alzheimer's disease
Arthritis
· Asthma
· Atrial fibrillation
· Atrial flutter
· Cardiomyopathy
Cerebral palsy
· Congestive heart failure (CHF) Depression
Epilepsy
· Intestinal obstruction Migraines
Neoplasms
Non-pressure ulcers
· Pneumonia
Pressure ulcers
· Respiratory failure
Sepsis
· Strokes
· Traumatic injuries
Overuse of unspecified diagnosis codes is a problematic trend.
Use of unspecified ICD-IO-CM codes, ignored during the first
year following implementation of the code set, is not improving.
In this author's experience, unspecified diagnosis code rates can
range anywhere from 20 percent, on the low end, to over 40
percent. A diagnosis code rate over 30 percent requires
investigation and appropriate corrective actions.
Widespread use of unspecified codes should be the exception,
not the rule. 8 High unspecified diagnosis code rates may be
due to either clinical documentation or coding practices. One
strategy to ensure unspecified codes are used appropriately is to
monitor unspecified code rates and address any upward trends
or outliers. HIM professionals should spot check the most
commonly reported unspecified codes. Review the clinical
documentation on a targeted sample to confirm that the reported
codes align with the degree of specificity in the health record.

4. Examples of some conditions most commonly reported with
unspecified diagnosis codes are listed in the sidebar above.
HIM professionals should identify the most commonly reported
unspecified diagnosis codes in their facility and review a
sample of related encounters to confirm that unspecified codes
were used appropriately. When overuse of unspecified codes is
identified, solutions may involve improvements in the
specificity of clinical documentation or process improvement to
ensure coding professionals are coding to the highest degree of
specificity that is available.Specificity in Physician
Documentation
Coding specificity is a shared responsibility between the
provider and the coding professional to create a clear clinical
picture of the encounter. Providers have an obligation to
document conditions to the full extent oftheir clinical
knowledge of the patient's health. Toward this aim, providers
may need assistance—in the form of provider education or
clinical queries—to recognize relevant clinical details that may
impact the specificity of code assignment. Inpatient and
outpatient clinical documentation improvement (CDI) efforts
should address documentation specificity to leverage the details
available in ICD-10-CM.Coding to the Highest Degree of
Specificity
While physicians are expected to document the most specific
clinical diagnosis, it is equally important that coding
professionals assign diagnosis codes to the highest degree of
specificity documented. There is a disturbing amount of
unspecified diagnosis code reporting when more specific
diagnoses are documented in the health record. Cod ing
professionals must continually train their "coder eye" to look
for specificity in provider documentation. A finely tuned "coder
eye" and attention to the level of specificity available in the
ICD-IO-CM code set will ensure the highest degree of
specificity of the codes assigned and reported.
As a final step in the coding process, coding professionals
should perform a final review of the diagnosis codes on an

5. encounter. Diagnosis codes ending in the numbers zero or nine
are often indications that an unspecified diagnosis code was
assigned. A quick second review of the clinical documentation
associated with these codes may reveal clinical details needed
to derive a more specific diagnosis code. Supporting
documentation, particularly imaging reports, may be used to
code to the highest degree of specificity when the physician has
already documented a condition. AHA Coding Clinic for ICD-
IO-CM and ICD10-PCS, from the American Hospital
Association, provides guidance for using documentation from
imaging reports when a physician has already documented a
condition, such as a fracture, stroke, or pain. 9' 10' 11 The
following coding examples demonstrate appropriate coding to
the highest degree of specificity.
Coding Example A
For this example, the documentation in the outpatient setting is
as follows: the emergency department provider
Journal of AHIMA April 18/45
Coding Notes
A finely tuned "coder eye" and attention to the level of
specificity available in the ICD-IO-CM code set will ensure the
highest degree of specificity of the codes assigned and reported.
documents a "non-displaced right talus fracture." The right
the-July-6-2015-CMS-AMA-Joint-Announcement.pdf.
ankle X-ray documents a "non-displaced avulsion fracture
3.
Eramo, Lisa A. "Don't Deny the Denials: Experts Recom-
of the right talus."
mend Implementing a Strong Claims Denial Strategy to
The code S92.101A, Unspecified fracture of right talus, was

6. Offset ICD-10-based Coder Productivity Loss." Journal of
initially assigned. After a final review, the code S92.154A,
Non-
Al-IIMA 85, no. 6 (June 2014): 30-33.
displaced avulsion fracture of right talus, is assigned based on
4.
Fernandez, Valerie. "Ins and Outs of HCCs." Journal of
the greater specificity found in the imaging report.
AHIMA 88, no. 6 (June 2017):54-56.
5.
Stanfill, Mary H. "Call for Additional Coding Metrics."
Coding Example B
Journal ofAHIMA 86, no. 4 (April 2015):56-57.
For this example, the documentation in the inpatient setting
6.
Department of Health and Human Services. "Infor-
is as follows: the history and physical and discharge summa-
mation and Resources for Submitting Correct ICD-IO
ry document that the patient suffered an "embolic cerebral
Codes to Medicare." MLN Matters. 2014. www.cms.gov/
infarction with residuals." The brain CAT scan report docu-
Outreach-and-Education/Medicare-Learning-Network-
ments a "large embolus in the right middle cerebral artery
MLN/MLNMattersArticIes/Downloads/SE1518.pdf.
(MCA) territory."
7.
Department of Health and Human Services. "ICD-IO-CM
The code 163.40, Embolic cerebral infarction of unspecified

7. Official Guidelines for Coding and Reporting FY 2017." wvvw.
artery, was initially assigned. After a final review, 163.411, Ce-
cdc.gov/nchs/data/icd/
rebral infarction due to embolism of right middle cerebral ar-
8.
Lee, Christine. "Nothing Lasts Forever: How Physicians
tery, should be assigned based on greater specificity found in
Can Prepare for the End of the One-year Amnesty from
the brain CT report.
Post Payment Reviews Due to Unspecified Codes." ICDTEN.
May 2016. http://bok.ahima.org/doc?oid=301570.
Addressing Nonspecific Documentation and Coding
9.
American Hospital Association. "Using the X-ray Report
Despite the importance of specific documentation and di-
for Specificity." AHA Coding Clinic for ICD-IO-CM and
agnosis code reporting, nonspecific documentation and
ICD-IO-PCS (First Quarter 2013). Chicago, IL: AHA cen-
coding persists. The solution lies in addressing both im-
tral Office, 2013: 28.
provements in the specificity of clinical documentation
10. American Hospital Association. "Use of Imaging Reports
and process improvement to ensure medical coding profes-
for Greater Specificity." AHA Coding Clinicfor ICD-IO-CM
sionals are coding to the highest degree of specificity that is
and ICD-IO-PCS (Third Quarter 2014). Chicago, IL: AHA
available. The challenge for medical coders is to achieve a
Central Office, 2014:5.
balance in productivity and quality to ensure that reported

8. 11. American Hospital Association. "Use of X-ray to Deter-
codes align with clinical documentation. The goal is to re-
mine Site of Pain." AHA Coding Clinic for ICD-IO-CM
port specific diagnosis codes when they are supported by
and ICD-IO-PCS (Fourth Quarter 2016). Chicago, IL: AHA
the available medical record documentation and clinical
Central Office, 2016: 143.
knowledge of the patient's health condition—and use
unspecified codes only when they are the best choice to
accurately reflect the healthcare encounter. ONotes
1. Centers for Medicare and Medicaid Services. "CMS and AMA
Announce Efforts to Help Providers Get Ready For ICD-IO
Frequently Asked Questions." www.cms.gov/
Medicare/Coding/ICDIO/Downloads/ICD-IO-guidance.pdf.
2. Centers for Medicare and Medicaid Services. "Clarifying
Questions and Answers Related to the July 6, 2015, CMS/ AMA
Joint Announcement and Guidance Regarding ICD-IO
Flexibilities." www.cms.gov/Medicare/Coding/
ICDIO/Clarifying-Questions-and-Answers-ReIated-to-
46/Journal of AHIMA April 18
Tough Cases: How tb
Critical Tlinking and
Coding Notes
Tackling
Empower Temper
By Sarah Htmbert,
Productivity Goals
of
of AHIMA
BY THE YEAR 2020, new technological advancemenc are
predicted to occur evety 30 seconds.I This explosion of

9. technology includes the healthcare industry—and with it,
clinical coding.
The healthcare industry is already witnessing rapid development
ofcutüng-edge medical procedures using disruptive technologies
and processes. Most common in academic medical centers,
experimental surgical procedures raise ICD-IO-CM/ PCS-related
questions for coding professionals and their management teams.
Coding professionals often are foced to choose between fully
researching complex cases or cutting comers to meet
productivity
ICD-IO affords the flexibility to code diese complec cases, but
it also requires that coding professionals apply cridcal thinking
skills and that coding managers adjust producdvity ecpectations.
The Critical Thinking Mindset
According to the World Economic Forum's report entitled "Tie
Future of Jobs," critical üiinking is listed as die number two top
SEII required in all areas by2020. Encouragng
codingprofessionals to engage their critical thinking skills is
pammountwhen coding complex cases or
newexperimentalprocedures. Accordingto Critical Thinking
Web, a website maintained by Joe Izu, PhD, of tie philosophy
department at the University ofHong Kong:
VA üiinker is able to deduce consequences fromwhat he knows,
and hehows howto use ofinformadontosolve problems, and to
seek relevant sources of information to inform himselE„ Critical
thinking help us acquireknowledge, improve our theories, and
strenghen arguments. We can use criücal thinkng to
enhancework processes andimprove social institutions."2
56/Journal AHIMAJanuary 18
For coding professionals, critical thinking skills must be
coupled widl a solid punding in anatomy/physiolow and
pharmacology. This foundadon ensures coding pmfessionals
understand the enäre clinical picture painted through ancillary
and clinical documentation.
Coding professionals also benefit from having an investigator

10. menulity and the ability to think outside the box when
performing research. For example, instead ofrelying only on
"typical" codEng resources, a critical thinker may use to find a
YouTube video ofa new procedure and go to the manumcturers
website br anyrecommended codß sucested for the device or
procedue
Empowering Critical Thinkers
How can a coding manager identify coding professionals who
possess critical thinking skills and encourage their
development? Tie best way is to use a different coding exam—
one that includes several new procedures not already explained
in the coding book Coders who aren't afraid to ask for
clarificadon are usually the best candidates, especially if they
seek input via dioughtful and referenced questions.
Generallyspeakng codingandidateswho don't dar&don tend to be
more focused on producti%ity rather ülan aczuraw. They tend to
forego die drne needed to perform research or quBtionsWhile
the lack ofquestions maybe an attnptto appar knowledgeable, it
does notsucætastrongaitiæl tfrlkingmin&et Consider the
following strategies to encourage a critical thinking mindset
among coding teams:
· Foster an environmentofcuriosity, leaming and sharing. Staff
should feel comfortable asking quætions with impunity.
· Routinely share knowledge of new experimental procedures,
ideally once per week
· Create a queue for secondary review holds that coding
professionals can use when they have questions.
· Reach out to a coding outsourcing company for guidance on
diffcult cases or new procedures.
· Post questions on AHIMA message boards, or even groups on
social media.
It is better for coding professionals to take time, conduct
research, ask questions, and code complex cases right the first
time versus repeating efforts when a claim is denied or rejected
by the payer. A few extra minutes on the front end saves time

11. and money on the back end. This is especially true for new
experimental procedures. However, coding managers must
factor in the additional time needed for these cases.
Resetting Productivity Expectations
Again, it is important for coding professionals working in
organizations with progressive technology to have the skill set
required to research the best way to code a new procedure. If
professional coders are taking time to research cutting-edge
medicine, how can coding managers balance productivity
expectations with accuracy—while also maintaining discharged-
not-final-coded goals?
A proven strategy is to flex productivity benchmarks for com-
Coding Notes
plex cases. Here are three tactics to consider:
1. Base coding productivity goals for complex cases on length
of stay (LOS), allotting more time for records with a higher
LOS.
2. Factor in total charges to accommodate for new, high-
complexity surgical procedures that may have a much lower
LOS than anticipated.
3. Use a combination of LOS and total charges to account for
complexity in coding productivity standards.
As medical technology continues to advance, coding
professionals will be pushed to code complex, new, and
experimental cases. The critical thinking mindset, combined
with flexibility in productivity expectations, ensures coding
professionals and managers collaborate to tackle new horizons
and learn new skills that advance the coding profession. O
Notes
l. Emerging Future. "Disruptive Technology Riding the
Emerging Wave of the Future." www.theemergingfuture.
com/disruptive-technology.htm.
2. Lau, Joe. "[COII What is critical thinking?" Critical Thinking
Web. http://philosophy.hku.hk/think/critical/ct.php.

12. Sarah Humbert ([email protected]) is corporate coding and
compliance manager at Kiwi-Tek.
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Journal Of AHIMAJanuary 18/57
Coding Notes
[CD-IO
A Dynamic
By Lau MIA CCS
and Quality Measures: fo
Relationship
hot ant tek the in
inl of:

14. thi
sic su
CODING PROFESSIONALS ARE the guardians of the pa-
of the metrics associated with quality measures. Coding
tient's story; they translate the language of medicine into
portrays the severity level of the patient and is used in part
it)
coded data. The accuracy of this translation is essential for
to assess quality ofcare and patient outcomes. The dangers
wi
many reasons beyond today's reimbursement. Coded data
of poor documentation and coding include an inaccurate
(G
is used for clinical decision making, healthcare policy, pub-
representation of the severity of the patient and care ren-
th
lic health tracking, research, and quality initiatives. Coded
dered to a patient as well as skewed quality data. Accurate
data helps shape the public's perception of healthcare pro-
and complete coding is also necessary for survival in to-
viders and institutions through ready access to a plethora
day's climate of value-based models with flnancial incen-
in
of public data and rankings for physicians, hospitals, and
tives tied to quality of care and ramifications of accurate
healthcare providers. Coded data contributes significantly
hospital-acquired condition (HAC) and patient safety indi-
a!
to the US healthcare system's ranking and position on the
cator (PSI) reporting.
dc
world stage. A coding professional's daily work has global

15. The patient's story is linked to a wide variety ofinitiatives
significance. This article will explore the far-reaching effects
related to healthcare quality, effective patient care, health-
by
ofcoding through the dynamic relationship between ICD-IO
care economics, policy, and reform. It is important to take
and quality measures.
full advantage of the specificity that ICD-IO provides in or-
The Centers for Medicare and Medicaid Services (CMS)
der to capture robust data that is used in assessing patient
a
"implements quality initiatives to [enlsure quality health
severity, the quality of care received, and patient outcomes.
care for Medicare Beneficiaries through accountability and
The continued evolution of ICD-IO will necessitate the
u
public disclosure. CMS uses quality measures in its vari-
growth and development of quality measures.
ous quality initiatives that include quality improvement,
c
pay for reporting, and public reporting. Quality measures
Sepsis Mortality Study
are tools that help us measure or quantify healthcare pro•
A recent study by the Ohio Hospital Association (OHA) il-
cesses, outcomes, patient perceptions, and organizational
lustrates the effect coding has on quality outcomes. Ace
s

16. structure and/or systems that are associated with the ability to
provide high-quality health care and/or that relate to one or
more quality goals for health care. These goals include:
effective, safe, efficient, patient-centered, equitable, and timely
care."'
Accurate and complete coding is a foundational element
70/Journal October 17
cording to the Centers for Disease Control and Prevention,
sepsis is responsible for roughly 258,000 deaths in the United
States each year and represents 6.2 percent of all hospital costs
across the nation. The federal government's Healthcare Cost and
Utilization Project identified sepsis as the costliest condition in
the nation's healthcare sys-
Coding Notes
ICD-10 and quality measures are inseparable, which places
coding professionals at the center of the healthcare quality
conversation. Coding professionals must ask if provider
documentation and codes reported for an encounter are wholly
reflective of the patient at that place in time.
of AHIMA
of AHIMA
of AHIMA
tem. Mike Abrams, OHA president and CEO, says Ohio's
hospitals in 2015 decided to "confront the brutal truths" and
begin a campaign to reduce sepsis encounters and related deaths
by 30 percent by 2018. Nine months into the initiative, OHA
reported an eight percent reduction in mortality with 353 lives
saved. The study asserts that "ICD-IO has improved the ability
to accurately report the infections, especially upon admission,
which is where 80% of sepsis cases are traced.•a
Ultimately, Abrams says OHA "wants to do for sepsis what we
did for ventilator-associated pneumonia: Make them rare."3
Clean data, which is derived from accurate provider
documentation, coding, and present on admission reporting, is

17. foundational to life-saving initiatives such as this one.
'CD-IO Interwoven with Quality Measures
ICD-IO and quality measures are inseparable, which places
coding professionals at the center of the healthcare qualtrt ity
conversation. CMS predicts that US healthcare spending will
account for 19.9 percent of the gross domestic product te (GDP)
by 2025, due in part to the aging of a large portion of the
population. And yet a recent report from the Commonte wealth
Fund revealed •the United States ranks last in health care
system performance among the Il countries included n- in the
study. The U.S. ranks last in Access, Equity, and Health te Care
Outcomes, and next to last in Administrative Effciency, as
reported by patients and providers. Only in Care Process does
the US. perform better, ranking fifth among the Il es
countries.D4 In light ofthe fact that quality ofcare is measured
h- by outcomes that are reflected by documentation and codke
ing, this ranking begs the question: Was the data correct?
Coding professionals must continue to think strategically nt and
globally about their role in better healthcare for our population.
Coding professionals must ask if provider documentation and
codes reported for an encounter are wholly reflective of the
patient at that place in time. Consistent coding reviews,
performed through the dual lens of reimbursement and quality,
will help ensure that coded data is reliable for the purpose of
quality measures. The APR-DRG C- system offers a
sophisticated method ofassessing both codn, ing quality and
reimbursement simultaneously.
Grace Whiting Myers, the founder of AHIMA, wrote her
autobiography in 1948 and shared her professional credo: "Give
ofyour best to anything you attempt to do." Her words inspire is
and inform today's health information management and cods-
ing professionals as they work to ensure quality documentation
and coding with 10-10. O
Notes

18. l. CentersforMedicare and MedicaidServices.
"QualltyMeasures." CMS.gov. www.cms.gov/Medicare/Quality-
Iniäatives-Patient-Assessment-lnstrumenc/QualiWMeasures/
index.html?redirect=/quaIitymeasures/05_ehrincentiveprograma
ppeals.asp.
2. Commins, John. "Sepsis: Ohio Provides Hospitals with a
Battle Plan." HealthLeaders Media. June 26, 2017. www.
healthleadersmedia.com/technology/sepsis-ohio-provides-
hospitals-battle-plan.
3. Ibid.
4. Schneider, Eric C. et al. "Mirror, Mirror 2017: International
Comparison Reflects Flaws and Opportunities for Better US.
Health Care.' The Commonwealth Fund.
www.commonwealü1fund.org/imetactives/2017/july/mirror-
mirror/.
References
Advisory Board. "CMS: US health care spending to reach nearly
20% ofGDP by 2025." February 16, 2017. www.advisory.com/
daily-briefing/2017102/ 16/spending-growüi.
Centers for Medicare and Medicaid Services. "ICD-IO and
Quality Measures.' CMS.gov. www.cms.gov/Medicare/ Quality-
initiatives-Patient-Assessment-Instruments/
QualityMeasures/ICD-lO-and-Quality-Measures.htmI.
Giannangelo, Kathy and Linda A. Hyde. ØICD-IO's Impact on
Quality Measures." Joumal ofAHIMA 83, no. 4 (April 2012):
46-47.
Leon-Chisen, Nelly. "Coding and Quality Reporting: Resolving
the Discrepancies, Finding Opportunities." Journal ofAHIMA
78, no. 7 (July
Potyraj, Julie. "The Quality of US Healthcare Compared With
the World." AJMC.com. February Il, 2016. www.ajmc.
com/contributor/julie-potyraj/2016/02/the-quaIity-of-us•
healthcare-compared-with-the-world/.
Rangachari, Pavani. "Coding for Quality Measurement; the
Relationship between Hospital Structural Characterisäcs and

19. Coding Accuracy from the Perspective of Quality
Measurement." Perspectivß in Health Information
Managernent4, no. 3 (Spring2007). http://perspecäves.ahima.
org/coding-for-quality-measurement-the-relationshipbetween-
hospital-structural-characteristics-and-codingaccuracy-from-
the-perspective-of-quality-measurement/.
Daniel Land ([email protected]) ts director ofcompliance
reviewservicßatMedPartners
Journal October 17/71
Coding Notes
Data of Coded
By Felicia A. Thomas, RHIT, CCS, CPC, Analytics: The Power
Data
CIC, CPC-I, CCDS, and Wahiyda Harding, MSA, RHIA, CCS
TO UNDERSTAND THE power of coded data, let's first take a
look at its definition. Data analytics is the science of examining
raw data with the purpose of drawing conclusions about that
information. Data analytics is used in many industries to allow
companies and organizations to make better business decisions
and in the sciences to verify or disprove existing models or
theories.l The purpose of analytics is to take existing data
collected from either a single source or multiple sources and use
it to arrive at the optimal decision. Essentially, analytics can be
best defined as a science of analysis. This is most commonly
used in situations where realistic judgements are necessary.2
Healthcare analytics is a term used to describe healthcare
analysis activities that can be undertaken as a result of data
collected from four areas within healthcare:
· Claims and cost data

20. · Pharmaceutical and research and development (R&D) data
· Clinical data (collected from electronic health records
(EHRs))
· Patient behavior and sentiment data (patient behaviors and
preferences)
In health information management (HIM)—and in coding,
specifically—the health information professional must
understand the importance of their role in interpreting and
abstracting this data to be collected and analyzed. While this
data is used primarily in reimbursement and claims activities, it
also plays a much larger role in clini-
48/Journal October 18
cal data analysis performed in facilities for quality of care
reporting, disease management, and best care practices. Let's
take a brief look at the power of coded data in each of these
areas.
Reimbursement and Claims
The reimbursement models in the United States are very
complex, but the underlying constant is the coded data
abstracted from the health record. Coding and clinical
documentation professionals play a pivotal role in the
abstracting and reporting of this information. "Iheir
understanding of the disease process, the Official Guidelines for
Coding and Reporting, and any official guidance from the
American Hospital Association's Coding Clinic for ICD-IO-CM
and ICD-IO-PCS publication helps ensure the accuracy of the
abstracted data. The data needs to represent the true clinical
picture of that encounter; it has to tell the story.
For example, consider a scenario where a 28-year-old man
presents to the emergency department with an open fracture to
his left thumb. He was returning from the break room to his area
in the warehouse when several large boxes fell off of the
conveyor belt. He held up his hands to block the boxes from
striking his head and sustained an open fracture to his left
thumb. How this encounter is coded and abstracted can not only

21. impact the reimbursement made to the facility, but also plays a
part in how this employee can recover from his injuries.
Coding Notes
The power of coded data transcends far beyond the doors of the
health information management department.
It is important that not only the place of occurrence is reported
correctly, but what this employee was doing at the time of
injury as well. ICD-IO-CM Chapter 20: External Causes of
Morbidity codes play an important role in telling this story. The
code used could literally be the difference between whether this
employee receives workers' compensation or not.
Quality Care Reporting
A 37-year-old female with Crohn's disease presents to the
facility with intense abdominal pain. After work-up it is
determined that she is experiencing a flare-up of her Crohn's
disease and will require a partial large bowel resection due to
the extensive damage to the lining of her colon. During her
recovery in the hospital she starts experiencing abdominal pain
and is taken to radiology. It is determined that she is
experiencing a post-procedural ileus.
How these types of encounters are coded and abstracted can
have an impact on the quality of care scores for a facility. If
these types of cases are coded as complications of care without
confirmation from the provider, it can and will negatively
impact the complication rates of the facility through the
Potentially Preventable Complications (PPCs) data reported.
There are many post-procedural occurrences that are all but
expected after certain surgical procedures due to the inherent
nature of the disease process.
In another example, a 59-year-old partially bedbound functional
quadriplegic is admitted to a facility due to lethargy and altered
mental status. It is determined that this patient has a severe
urinary tract infection and will require several days of
hospitalization before they are stable enough to go back to their
nursing home. After 10 days the patient is discharged and this

22. encounter is sent down to coding and is billed out to the payer.
Upon auditor review it is discovered that this encounter went
out with Present on Admission (POA) indicators of "N" on a
stage 3 pressure ulcer that was documented by the nursing staff
and reported on the history and physical by the attending
provider. This type of error in abstracting can again negatively
impact the quality scores of a facility. HIM professionals must
pay close attention to the data they report and recognize the
implications their errors may have.
Disease Surveillance and Monitoring
According to the Centers for Medicare and Medicaid Services'
Official Guidelines for Coding and Reporting, there are certain
conditions that may not be abstracted and reported without
confirmation by the provider. HIV/AIDS and the Zika virus are
the two exceptions to the Section Il. H. guideline for inpatient
encounters for uncertain diagnoses. These two conditions must
be confirmed by the provider.
With this guideline in place, the Centers for Disease Control
and Prevention (CDC) can track and monitor these outbreaks via
the coded data.
Through the CDC's National Vital Statistics System, states
collect and disseminate statistics on births and deaths. In this
manner, the public and healthcare professionals are able to learn
more about tuberculosis, HIV, influenza, and hospital
infections.3
HIM professionals need to understand how erroneously coded
data can have far-reaching implications throughout the
healthcare continuum. Facilities need to have policies and
protocols in place to ensure the accuracy of coded data involved
in data mining activities. The power of coded data transcends
far bevond the doors of the HIM department. O
Notes
1. Rouse, Margaret. "data analytics (DA)." TechTarget.
December 2016.

23. https://searchdatamanagement.techtarget.com/definition/data-
analytics.
2. wiseGEEK. "What is Data Analytics?" www.wisegeek.
com/what-is-data-analvtics.htm.
3. Centers for Disease Control and Prevention. "Disease
Surveillance and Monitoring." 2016. www.cdc.gov/
about/facts/cdcfastfactsßurveillance.html.
References
Centers for Disease Control and Prevention. International
Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-IO-CM). www.cdc.gov/nchs/icd/
icdl()cm.htm.
Centers for Medicare and Medicaid Services. ICD-IO web page.
www.cms.gov/Medicare/Coding/ICDIO/index.html.
Felicia A. Thomas ([email protected]) is inpatient quality
auditor and Wahiyda A. Harding ([email protected]) is DRG
team coach atAccuity Delivery Systems, LLC.
'JoumaIöfAHlM4ContiNJing EducatidnQuit
Quiz ID: Q1838909 1 EXPIRATION DATE: OCTOBER 1, 2019
HIM Domain Area: Clinical Data Management
Article—"Data Analytics: The Power of Coded Data"
Review Quiz Questions and Take the Quiz Online at
https://my.ahima.org/store
Note: AHIMA CE quizzes have moved to an online-only format.
Journal October 18/49
Coding Notes
Effectively Coding
By Clark Chaffin, MBA, RHIA, CCSManaging a Growing
Workforce

24. HEALTH INFORMATION MANAGEMENT (HIM) departments
across the United States, whether small or large, are
experiencing a multitude of challenges and growing pains in
todays healthcare landscape. As more experienced members of
the worldorce are retiring, an increasing number of workforce
members are training for expanded areas of HIM not focused
solely on coding. And HIM professionals are also navigating
constant demands of lowering current discharged not final
billed (DNFB) with simultaneous scrutiny aimed at achieving
and maintaining high quality coding despite incomplete
documentation. This article will discuss how the HIM
department at one healthcare organization—CoxHealth, a six-
hospital system in the Midwest region of the US—has
approached the task of managing a growing coding workforce
while meeting all organization expectations for the department.
In the past five years, the coding department at CoxHealth in
Springfield, MO has almost doubled its staffing due to the
addition of new hospitals, increased inpatient volumes, and
growth in outpatient markets. To successfully manage the
demands of this changing environment, the deparment
developed a coding project plan to address all aspects ofcoding,
including DNFB, to manage not only employee retention but
also recruitment, coding productivity, and internal/external
coding audits.
Healthcare is a business and just like other successful
businesses there must be a project plan in place in order to
achieve goals and successes. As such, it is important for HIM
departments to have goals in place as well, and the
implementation of a clearly defined coding project plan has
proven key to CoxHealth's HIM department achieving success.
48/Journal February 19
What Should the Coding Project Plan Address?
The coding project plan should address all areas that affect the
management of coding-related activities. eme coding project
plan at CoxHeaIth addresses the following:
· Coding education (How often should it be done? What topics

25. should be covered?)
· Coding productivity (How is it measured for inpatient and
outpatient?)
· Coding quality (How often is it checked? What are steps for
improvement?)
· Coding recruitment/retention (What is the best way to attract
and retain coding staff?)
· Coding training programs (What is being covered in training?
What professional organization will provide the best foundation
to train future coders?)
'lhe following sections of this article take a closer look at each
of these elements.
Coding Education
The type of education approach that works best can vary widely
for individual employees. Keeping this in mind, CoxHealth
provides coding education in various forms, including quarterly
coding audits/training meetings, online training tools, webinars,
email communications like the "Monthly Coder Notes"
newsletter, and a monthly department-wide newsletter.
Coding Productivity
Although there are coding productivity standards in the
industry, the set coding productivity measures should be based
on the systems/functionality of the electronic health record
(EHR) within each health system. assessment of coding
productivity at 10 different hospitals would yield widely varied
results.
CoxHealth conducted extensive measurements ofwhat codes are
captured, how the EHR is set up, and clinical documentation in
order to set the standards across the system. Using available
industry standards as a foundation, CoxHealth customized their
standards based on coding productivity studies conducted at the
organization after ICD-IO-CM implementation. Consistent
monitoring of coding productivity is necessary for all
organizations in order to maintain adequate staffing and meet

26. goals, such as those related to DNFB directives.
Coding Quality
Ihe CoxHealth standard for coding quality is greater than 95
percent accuracy, which is the common industry standard.
Primary focus on coding quality should be emphasized over
coding productivity. The accuracy of coding is a top priority
and affects reimbursement, quality outcomes for patients, and
hierarchical
condition category coding on the physician's side.
Coding Recruitment/Retention
As the "Baby Boomer" generation gets older, hospital coding
departments are seeing their seasoned coding professionals
either retiring or nearing retirement. It is important to plan
ahead now and craft succession plans for those coding
professionals exiting the field. Ihe HIM profession should be
utilizing these seasoned coders to provide the training for new
incoming coding professionals. They are the best source
ofknowledge ofwhat it takes for a solid foundation in the
complexities ofcoding. This is an emerging issue that must be
on the radar of any coding project plan in order to avoid the
necessity of using additional coding resources to aid with the
potential staffing shortage.
Thinking outside the box is fundamental for the most effective
recruitment techniques to attract new coding professionals to an
organization. Coders working remotelywant autonomywith their
work schedules, less traveling to the office for meetings, and
the ability to advance within the coding department. Coding
professionals want the opportunity to learn everything very
quickly, and keeping up with that demand means leveraging
experienced/ seasoned coders to become auditors or trainers to
aid in successfully moving the next generation of coders into
the workforce.
CoxHealth decided to undertake recruitment efforts beyond the
usual tactics in order to find and recruit new coders. For

27. example, internally, document imaging and discharge analysis
assistants were sent to online and in-person training on
outpatient coding to get a foundation on the basics of such
concepts as coding guidelines, how to use code books, and code
assignment. CoxHealth invested in this group of clerical staff in
order to grow the outpatient coding program internally.
Retention of current coders is also constantlv on the radar in the
coding project plan. It is costly for any organization to
effectively train coders in-house. Organizations must have
outside-the-box coder retention tools. For example, coder
retention bonuses that are separate from the employees' annual
salary is one way to re
Coding Notes
1'
ward coders. Quality bonuses are a great incentive to reward
coders for their quality of coding and meeting established
standards. Providing ongoing continuing education
opportunities is a must in today's coding environmentto ensure
coders are staying abreast of current coding trends. Lastly, look
at the current workforce and see what it is that makes sense for
your particular market. Not every worker is incentivized solely
by monetary measures.
Coding Training Programs
CoxHealth currently has two training programs in place—an
inpatient and outpatient coding training program. The inpatient
training program was put in place prior to the implementation of
ICD-IO-CM/PCS and started in January 2015. It was set up to
internally train more inpatient coders to reduce the need for
long-term contract coding. Ihere was a growing need to bring
some of that coding back in-house and internally move coders
from outpatient coding to inpatient coding to achieve proper
coverage of inpatient coding needs.
The inpatient coding program began with Ovo inpatient coding
auditors and nine inpatient coder trainees. The program started

28. with dividing those nine inpatient coder trainees into medical
service line training so they were learning at different levels
and distributing the worldoad out evenly amongst the nine
trainees and five seasoned inpatient coders. The goal of the
program is to graduate inpatient coders within a two-year period
so that all medical service lines are covered. New inpatient
coders start in January each year with the goal to complete the
training period within two years. There was a delay with ICD-
10-CM implementation, which prolonged the first group of
graduates. Additionally, an inpatient coding auditor/trainer was
added during this process to assist with further training.
The outpatient coding program began in spring 2017. Online/
in-person training for new coders with no hands-on experience
taught basic skills and then moved to teaching outpatient coding
at a designated coding level, such as ancillary and/or emergency
department coding, to build a strong foundation of coding a
variety of different types of cases. Under the direction of the
coding auditor/trainer, the coder is assigned cases to code and
coding is reviewed for a period of time and then released when
the coding meets 95 percent accuracy or greater. Ihe coder
progresses to monthly quality review by the assigned coding
auditor. O
Clark Chaffin ([email protected]) is system director, coding and
health information management at CoxHeaIth.
e
Journal
February
19
/49
Quiz ID: 01939002 l EXPIRATION DATE: FEBRUARY 1,2020
HIM Domain Area: ClinicalData Management
Article—"EffectiveIy Managinga Growing Coding Workforce"
on