Monday, September 25, 2023

The Crucial Role of Medical Coding in Accurate Quality Measure Reporting and Reimbursement

by Lindsey Lanning, RHIA

In the complex landscape of modern healthcare, accurate and detailed information is not only vital for patient care but also for the financial stability of healthcare organizations. One of the cornerstones of this information ecosystem is medical coding, a process that involves translating complex medical diagnoses, procedures, and services into standardized codes. This coding, based on systems such as Current Procedural Terminology (CPT) and the International Classification of Diseases, 10th Edition (ICD-10), plays a pivotal role in quality measure reporting, which directly impacts the performance and reimbursement of healthcare providers. In this article, we'll delve into why medical coding is integral to quality measure reporting and how it influences reimbursement.

Precision and Accuracy: The Foundation of Quality Measure Reporting
Quality measures are standardized metrics used to assess the quality of healthcare services provided by medical facilities. They range from patient outcomes and safety measures to efficiency and patient satisfaction. Accurate quality measure reporting depends on the correct representation of medical services and conditions, and this is where medical coding comes into play.

CPT codes, developed and maintained by the American Medical Association, are used to document medical procedures and services. ICD-10 codes, on the other hand, provide a standardized way of recording diagnoses and conditions. Proper coding ensures that the medical information documented is not only accurate but also consistent across the healthcare industry. This consistency allows for meaningful comparisons of care quality between different facilities and providers.

Impact on Performance Measures
Medical coding influences the calculation of performance measures in various ways. For instance, coding determines the severity of illnesses, the complexity of procedures, and the resources required for treatment. These factors are directly linked to how well a healthcare provider performs in quality assessments. Inaccurate coding could lead to skewed performance data, potentially misrepresenting the quality of care provided.

Moreover, quality measure reporting often involves tracking patient outcomes over time. Accurate coding allows healthcare organizations to identify trends, analyze the effectiveness of interventions, and make data-driven decisions to improve patient care. Incorrect coding could compromise these efforts and hinder the ability to implement targeted improvements.

Navigating the Reimbursement Maze
In the ever-evolving landscape of healthcare reimbursement, accurate medical coding is essential. Government programs, private insurance companies, and other payers rely on coded data to determine the appropriate level of reimbursement for medical services. Proper coding not only ensures that healthcare providers receive fair compensation for their services but also helps prevent overbilling and fraud.

Additionally, the relationship between quality measure reporting and reimbursement is becoming increasingly intertwined. Many value-based reimbursement models tie financial incentives to a provider's performance on quality measures. Inaccurate coding could lead to erroneous reporting, which, in turn, might impact a provider's reimbursement. Therefore, accurate coding not only preserves financial stability but also supports the transition toward outcome-based reimbursement systems that emphasize high-quality care.

The Human Factor and Continuous Learning
While medical coding may seem like a straightforward process, it's worth noting that it requires a deep understanding of medical terminology, anatomy, and procedures. Coders must stay up-to-date with the latest developments in healthcare, as codes are periodically updated to reflect advancements in medical knowledge and technology.

Continuing education and professional development are crucial for medical coders to maintain their proficiency and adapt to changes. Quality measure reporting and reimbursement accuracy are heavily reliant on coders' expertise, attention to detail, and commitment to continuous learning.

In the intricate world of healthcare, accurate quality measure reporting and reimbursement depend on the foundation of precise and consistent medical coding. CPT and ICD-10 codes serve as the common language that connects patient care with meaningful data analysis and financial stability. The integrity of this system not only reflects the true quality of healthcare services but also supports the fair compensation of providers and the ongoing improvement of patient care. As the healthcare landscape continues to evolve, the importance of medical coding in accurate reporting and reimbursement will remain an integral aspect of the industry's progress.

About the Author 

Lindsey Lanning, RHIA,
is the Co-Chair of the Blog Committee
on the OHIMA FY 2023-24 Board of Directors. Lindsey is a Healthcare Compliance Consultant.

Monday, September 18, 2023

Unlocking the Power of Social Determinants of Health

by Ronda Dun, RHIA

Social Determinants of Health. Do you know what it is? Do you know the importance of Social Determinants of Health and capturing data to improve the quality of healthcare that is provided to you and your family? Social Determinants of Health as defined by The World Health Organization are a person's birth, growth, work, lifestyle, aging, and anything that affects everyday living. 

Data on Social Determinants of Health enable healthcare practitioners to treat the patient as a whole, rather than just their symptoms.  To put things into perspective, suppose a patient visits his primary care physician and the practitioner asks no questions about the patient's lifestyle or employment, only about the symptoms or problems for which the patient is being treated. The doctor prescribes antidepressants and anxiety medicine. The provider blew a chance to figure out what was causing the problem. Interaction with the patient would have led to gaining insight into what is causing the patient's depression or anxiety. The provider may have discovered that the patient is distressed and nervous as a result of a loss of hours at work and the concern of not being able to care for the family. The provider might have given the patient information on food assistance or referred the patient to the Department of Human Services. The Department of Human Services gives access to programs that can help you earn extra training and education to advance your profession. So many aspects of the things that occur in our daily lives affect our health.

Any healthcare provider that treats a patient has the ability to collect socioeconomic determinants of health data. This data can be obtained over the phone or in person before each appointment. During office visits, the provider can collect the data, which can then be included in the record. The data that is collected by healthcare professionals must be kept, processed, and disposed of properly. It is important that healthcare facilities develop and implement rules and standards to control how data is gathered, kept, processed, and disposed of in order to observe the social determinants of health. Healthcare professionals must collect information on social determinants of health in order to identify populations afflicted by certain illnesses. Z codes from ICD-10-CM, which range from Z55 to Z65 and are utilized for Social Determinants of Health data, are used by medical record coders to interpret the information in the electronic health record. The collection of data for socioeconomic determinants of health Z codes aids in the improvement of healthcare quality, service connection, and patient satisfaction. With this knowledge, healthcare providers will be able to send patients to other specialists who can better meet their individual needs. More information regarding the Z codes for social determinants of health can be found on the website.

Data governance for socioeconomic determinants of health involves more than just gathering data. For the purpose of delivering the appropriate clinical decision-support treatments, it is critical that the data is actually used. It is also necessary for accurate data accumulation across practices, EHR systems, and communities. In order to record the determinants in a form that is suitable for clinical treatment, quality improvement, and research, medical standards will need to decide on appropriate methods.

As a medical coding auditor, I've seen that it is not coded if a socioeconomic variable does not demand or impact the patient's care during a visit. It is not coded if the ICD-10-CM guidelines do not state that a Z code should be used. Documentation of socioeconomic determinants of health is most prevalent in mental health services but is uncommon in primary care visits. Unlocking the Power of Social Determinants is crucial to promote health and reducing health imbalances brought on by social and economic disadvantages. Improvements cannot be made until data is collected to illustrate what the public needs to improve treatment quality. It is critical to establish best practices and methods for collecting data on socioeconomic determinants of health.


About the Author

Ronda Dun, RHIA, graduated August 4, 2023, earning a bachelor's degree in health information management from the University of Cincinnati, and she is currently enrolled in the master's program in health informatics. Ronda has been working for the Consolidated Coding Unit at the VA Medical Center in Huntington, West Virginia, for little over five years. She is currently an Outpatient Medical Record Technician (MRT) Auditor ensuring the coding accuracy of ICD-CM, CPT and HCPCS code assignment as well as provides continuing education to the coders. She strives to find a role in Information Governance or Data Analytics.