Coding diabetes care

[Guest guest]

A good friend of mine sent this to a colleague. I find the email

rich in coding resource.

Gordon and I are close friends from medical school. He forwarded

your email to me to see if I can help you.

I am a med-peds physician in Portland, OR. Currently I work in a free

standing Emergicenter and am the coding training lead for Northwest

Permanente. We will roll out a four hour full scale compliance/coding

and billing training for all of our 1,100 clinicians. I've been doing

coding training work for about three years , with an emphasis on

diagnosis coding for Medicare Risk adjustment for both medicine and

mental health. We are finally moving to full scale integrated training.

This was my preference but was not a priority for NWP until now.

Previously I created the first documentation and coding training

materials for the OHSU IM residency program.

There are several very good commercial websites to get information. CMS

also as good information but it is very boring to read. None of this

is proprietary though you may decide that you want to hire a consultant

to do the teaching. See the list below.

Here are a few thoughts which may help

1. The key to good coding is excellent documentation --knowing how

much to put in a note, reflecting on chart review and the past history

and discussing medical decision making w/ an emphasis on diagnostic

plan, therapeutic plan, contingency plans and coordination of care.

If you have charting gaps you will have coding gaps.

2. You must align your incentive/reinforcement systems to make

documentation and correct charting a priority. If the leadership

doesn't believe that and agree to what the front line doctors should be

doing you will not make any headway.

3. Physicians should be doing the diagnosis, level of service and

procedure coding. Coders audit for accuracy. Only the treating doctor

knows which services s/he performed. Billing sheets/superbills/EMRs

must have accurate data

4. Contrary to popular belief there hasn't been too much revolution in

the documentation and coding requirements since 1997. Some codes have

been added or deleted and this changes every October. But the general

requirements are exactly the same.

5. Consider a " high touch " small group training if you want to make a

cultural change in your medical group. Don't assume everyone will get

in on the web

6. Make sure that you have followup -- rapid cycle chart

audit/feedback is probably the best way to instruct doctors and change

behavior.

7. The diabetes coding can make you absolutely crazy. It is

frustrating for everyone.

Doctors need to understand the difference between " vanilla DM --

250.0 " and DM w/ complications. A dialysis dependent diabetic w/

retinopathy, amputation, old CVA, skin ulcer can have 10 codes

describing the diabetes.

My best analogy is to use the " mix it in " ice cream store. You can

have uncomplicated " vanilla " DM but once a patient has complications

you start mixing in the new flavors and the DM is never vanilla again.

As a physician if you are managing the DM you are also managing the

complications.

If you use a paper superbill you can require this paired coding. If

you use an EMR you have to have a prompt to pair the codes.

Here are some web sites you can look at

CMS: www.cms.gov -- look at Medlearn. There is a book you can have

delivered or download geared at new Medicare providers. It's a federal

government document but has all the information you need. It is not

clinical enough for most clinicians.

Hill and Associates -- www.complianceandcoding.com -- Hill is a

Physician's assistant who teaches coding nationally. I met her this

year a the Kaiser coding summit. She is a very clear, straightforward

speaker and a delightful person. Her website is very informative.

EM University -- www.emuniversity.com - This site is run by a New

Hampshire based family doctor. This is probably the best site I've

found for an approach to teaching coding from a clinical perspective.

This is how I think about coding and the materials are well written and

clear.

HCCS -- major vendor of web based compliance/coding materials.

Other good sites include the professional academies. Almost all have

some practice management tools. Several universities have put their

coding materials on line.

Hope this helps. I'm happy to speak w/ you if you have questions.

Incidentally I'll be in NYC staying at the Chelsea Hotel from 4/9-4/11

and will be free on 4/10. I am visiting my sister and her family after

the ACP meetings.

Ellen Singer, M.D.