Discuss the coding process, the relevance of coding sequence and the importance of assigning the appropriate diagnosis and procedures
The medical coding process needs reviewing patients record documentation to identify diagnosis, procedures, and services for the purpose of assigning ICD-9-CM, HCPCS level II and or CPT codes (Green, 2013). Each health care entry for example hospital, medical clinic and or physician office implements a unique medical coding process, which requires adherence to the following
Coed of ethics
Steps to accurate coding
Avoid assumption coding
Physical query process
Coding compliance system
Coed of ethics
According to Green 2013, professional associations establish a code of ethics to help members understand how to differentiate between the “right” and the “wrong” and apply that understanding to decisions making. The AAPC publishers codes of ethics and AHIMA publishes standards of ethics coding, both serve as guidance for ethical coding conduct, and they demonstrate commitment to coding integrity.
Steps of accurate coding
Regardless of health care setting. The steps to accurate coding begin with a review of the entire patient record be it manual or electronic record before selecting diagnosis, procedures, and services to which codes are assigned. Depending on the setting, coders perform retrospective coding, concurrent coding, or a combination of the two (Green, 2013).
Retrospective coding is the review of records to assign codes after the patient is discharged from the health care facility for instance hospitals and other medical centers or released from same-day outpatient care for instance outpatient surgery. It is most commonly associated with impatient hospitals stays because accurate coding requires verification of diagnosis and procedures by reviewing completed face sheets, discharge summaries, operative reports, pathology report, and progress notes in the patient records (Green, 2013).
According to Green 2013, Concurrent coding is the review of records and or the use of encounter forms and charge master to assign codes during an inpatient safety for example hospital or an outpatient encounter for example hospital outpatient visit for laboratory testing or X-says. It is typically performance for outpatient encounters because encounters for and charge master are completed in real times by health care providers as part of the charge-capture process.
Encounter forms are used to record encounter data about office procedures and services provided to patients
Charge master contain a computer-generated list of procedures, services, and supplies and corresponding revenue codes along with charges for each.
In your own words explain DRGs and MDC giving examples and their relevance to healthcare funding
As stated by Holloway 2004, Medicare’s prospective payment system (PPS) dramatically altered the U.S health care system. Diagnosis-related groups of DRGs provide the basis for payments to hospital for the care of Medicare, Medicaid, and many commercial insured patients. According to Holloway 2004, the federal government adopted DGRs system to curb rising health care costs and to put a more measurable system of care versus cost in place. Faced with these restrictions and regulations affecting the delivery of health care, nurses are increasingly confronted with sicker patients and shorter allowable and paid hospital stays. Nurses play a key role in maintaining a hospital’s financial violability on our competitive, market-driven health care environment. Documentation is crucial (Holloway, 2004). Hospital executives closely evaluate case-mix because the nature and severity of overall patient illness plays a heavily in budget projections. Nurses must continually find ways to improve the quality of care and care outcomes while working within the ever-0narrowing constraints of reimbursement (Holloway, 2004).
How DRGs are assigned
After discharge of a patient, DRG is assigned based on the following factors
Principal diagnosis. This is diagnosis that necessitated admission to the hospital
Secondary diagnosis- all secondary conditions that exist at the time of admission or that develop during hospitalization and affect the treatment or LOS
Operative procedures- any surgical procedures performed for definitive treatment rather than for diagnostic or exploratory purposes
Age- for some conditions, a different reimbursement rate for patient younger that age 17 than of those age 17 and older
Discharge status-whether the patient was discharged home or transferred to another hospital
Complications- any conditions arising during hospitalization that may prolong the LOS at least a day in approximately 75% of the patients for example diabetes
Co morbidity – a preexisting condition that will increase the LOS at least one day about 75& of patients.
All these factors need to be considered and the presences or absence of each factor determined to indentify the correct DRG.
Once the DRG has been determined, the administrator can identify further statistical measures affecting reimbursement, such as geometric mean LOS, relative weight, and outliers (Holloway, 2004).
According to the American Hospital Association’s Coding Clinic of ICD-9-CM, the importance of understanding and following the basic coding system is essential (Green, 2013). The coding principles cannot be overemphasized in the training of coders and in quality control activities undertaken to improve the accuracy of data reported for internal and external hospital use. The measures for coding accuracy include
Adherence to ICD-9-CM coding principles and instructions
Attention to specificity in code terminology
Absence of clerical-type errors such as those due to carelessness in reading or in transporting numbers.
An auditing of coded diagnostic and procedural information for accuracy should not be confused with the review for relevancy in sequencing of the codes at hand, they are separate tasks linked together in the data reporting process.
The underlined statement is important since it means that coders are expected to review the entire record when assigning codes to diagnose and procedures documented on the face sheet and in the discharge summary (Green, 2013). Thus, coders should review the face sheet, discharge summary, and other documentation for instance notes, reports to assign the most specific codes possible.
In your own word explain “casemix’ and its roles in healthcare funding. Give examples to support your answer
Casemix is responsible for assigning accurate costs and prices through jurisdiction and for reconsidering the prices of health care centers. Controlling the way hospital performance and its stability as far as consists and weights are concerned is essential in ensuring that the health care has confidence in its operations and the way it is run.
The availability of healthcare that is affordable to citizens is a dream of every nation. The issue of healthcare spending has been a topic for debate over the past few years. Today, there is a lot of concern on healthcare issues one of them being the healthcare spending. The cost of healthcare has been going up and it is still projected to rise. Presently it is about a fifth of the economic activity of the U.S. There are many factors that contribute to the rising costs of healthcare. This include first the fact that many people in America lack health insurance at any costs and they cannot even manage to afford what is termed as the most basic health coverage.
There has been a rise of people who are not insured due to the fact that the per capita healthcare spending has gone up. It can also be attributed to the fact that many people have lost their jobs and the fact that the economy is poor. Rise in healthcare spending can also be attributed to the use of improved technology, vaccine improvement, antibiotics, introduction of heart disease care as well as advances in surgery. There have also been improved medical devices like CT scanners, MRI, ultrasounds and defibrillators that can be implanted. At the same time there are developments in pharmaceuticals and administration costs have also contributed to the rise in costs of healthcare. Mostly the heath care costs are due to medical technology which is approximately over 200 billion per year (Wayne, 2012). The lifestyles of people in America also impact the health care industry in a big way almost sixty percent of the population is over weight and childhood obesity is a very rampant issue in today’s health. Other factors that have an impact on the healthcare spending are; poor diets, high blood pressure, smoking, lack of exercise, drugs and drinking. It is the people themselves who have pushed the costs of health care up. The high healthcare spending ahs effects not only to families but also to businesses and public budgets. Expenditure on healthcare is seen to rise at a rate that is fast even faster than the state of the economy entirely and the wages of the working people.
In 2011 spending on medications, hospital visits as well as other medical care went up with an estimated percentage of 3.9 this consumed about 17.9% of the GDP. This is more than three times the deficit. Much of the money is considered to be spent appropriately which is keeping people alive and healthy but of course this is a very big problem. If only the health care spending can be reduced to a certain level then the deficit will be offset and free by almost half-trillion dollars in a year which can be used to invest in other areas of the economy particularly economic growth. These increases in the expenditure will continue outpacing the projections of economic growth. It is projected that by 2020 healthcare spending will be about $4.64 trillion which is a representation of close to 20% of the GDP. This therefore means that health care spending commands a great percentage of the overall GDP. GDP will therefore continue to go up as long as the spending in healthcare goes up or continues to rise. If the trends that have been seen for the previous years go on then health care spending will eat up the GDP in the lifetime of the future generation. Health care spending will use up the federal government budget which is the root cause of the debt problem in the U.S. With health care spending eating too much into the GDP will mean that there will be no room for spending on security, defense or any other roles by the government (Hixon, 2012).
Discuss the relationship between diagnosis, procedures, ICD-10, DRGs?
Charges for services and procedures are generally classified and coded using standardized systems. As discussed above, the prospective payment system of Medicare hospital reimbursement established diagnosis-related groups, revised in 2008 as MS-SRGs. The MS-DRGs are based on major diagnosis category (MDC) classifications of illness and standardized expected length of inpatient care (Susan, 2013). Beside their utility in prospective payment systems which are now extended beyond acute care to home health and long-term care setting, MDCs and MS-DRGs enable the identification of average patient resource consumption by diagnosis. All the four are used in healthcare settings.
Green M., 2013. 3,2,1 Code It! 4th Edition, Publisher Cengage Learning.
Holloway M., 2004. Medical-surgical Care Planning. Publisher Lippincott Williams & Wilkins.
Susan J. Penner 2013.Economics and Financial Management for Nurses and Nurse Leaders: Second Edition. Publisher Springer Publishing Company.
Wayne, A. (2012). -Care appending to reach 20% of U.S Economy by 202 BloombergBusinessweek.Health 1.Retrieved march 28,2013 from http://www.businessweek.com/news/2012-06-13/health-care-spending-to-reach-20-percent-of-u-dot-s-dot-economy-by-2021Hixon,T.(2012).The U.S Does Not Have A Debt problem….It has a Health Care Cost problem.retrieved march 28,2013 from http://www.forbes.com/sites/toddhixon/2012/02/09/the-u-s-does-not-have-a-debt-problem-it-has-a-health-care-cost-problem/