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Concurrent Coding: The key to comprehensive hospital management

Our company, eICD.com, is founded on the principle that quality healthcare delivery begins with a diagnosis and treatment plan. While this statement may seem trite, it is a truth that remains the foundation for most of our work. The easiest explanation for this may be found when we examine the medical record. As many of you know, the most widely accepted format for a clinical record entry is the Weed SOAP system. SOAP is an acronym for the four elements of the clinical entry; subjective, objective, assessment, and plan. The latter two elements serve as the basis for the entire field of professional service known as healthcare. Simply stated, the expectation of any patient who seeks medical attention is that the physician will make an assessment of his condition and recommend a treatment plan.

We are fortunate in the United States that there are accepted standards for the codification of both the assessment and plan for the purposes of billing. Unfortunately, providers have relegated the process of identifying accurate diagnosis and procedure codes to health information management personnel and billing clerks. This is due to a number of reasons, among them:

    • Rarely is any aspect of billing, let alone coding, ever discussed during graduate medical education.
    • There are a tremendous number of codes, more than 13,000 ICD-9-CM diagnosis codes alone, and the shear volume precludes detailed knowledge of all but small percentage of codes (please note that over 2,000 of those 13,000 codes are non-specific, and thus unusable).
    • Coding texts are cumbersome, their indexes are often incomplete, and the syntax of coding is different from that of standard medical textbooks.

This has led to a critical void in American medicine. Documentation of a patient encounter is discordant. Recordation and review of the clinical record and financial record are performed at distinctly different times, often by different individuals even though they share a common information source. Before our current era of rigorous fiscal accountability in healthcare, this void was not of material concern. Today, complete real time concordance between the clinical and financial records is a necessity. This can only be accomplished if there is a readily available tool that allows for the accurate translation of the free text clinical assessment and plan into diagnostic and procedure codes. The hospital is where there is the greatest need for a fast, easy tool to perform concurrent coding. We designed eICD, Enterprise Edition™ to be such a tool. The eICD bridges the void between a SOAP note assessment and an ICD-9 code by matching free text phrases in the typical syntax of clinical medicine with diagnosis and procedure codes. This is done with such speed and accuracy that it makes the possibility of concurrent coding (even by a physician) a reality.

Probably the greatest benefit of concurrent coding with eICD, Enterprise Edition™ is that it provides for concurrent case management. A daily, running census of the acuity of an inpatient population, a Disease Oriented Census (DOC), in ICD-9 format means that centralized case management may direct resources to meet the needs of the most challenging patients- in real time, when it can best effect clinical outcome and the bottom line. Effective clinical pathways may only be brought to bear if there is a recognized need. The immediate recognition of major clinical trends is easily culled from a list of current inpatient conditions. Length of stay concerns with a particular DRG can only be addressed if managers have access to daily assessments in a format that lends for accurate, objective analysis. The same form of analysis that the clinical record will be subjected to by third party payors prior to reimbursement.

While a Disease Oriented Census can have an impact on inpatient length of stay, it is quite significant the effect the DOC information can bring to the institution’s Quality Assurance program. To ensure quality and manage disease you must have data. To proactively manage disease, you need real time data. Imagine the institutional impact of an abrupt increase in nosocomial pneumonia, wound infection, or drug reactions. With real time identification of institutional-wide trends there is an opportunity to address the clinical, social, and legal implications of these problems within days of diagnosis rather than weeks after the fact in retrospective review.

Peer review may be performed nearly concurrently with a DOC. The day of diagnosis is the best time to assure that a physician is presented with and has access to best practice information. At teaching programs, weekly Mortality & Morbidity conferences will be much more efficient and complete by matching cases discussed to the DOC of the institution.

Almost as exciting is the potential of linking other critical hospital processes to the clinical conditions currently being treated. Medicine may be the only service industry that does not provide middle and upper level management with real-time data on parameters critical to the delivery of service. To run an airline you have to be able to know how many planes you have available, their current operational state, and their locations. It is wholly expected that a manager for one of today’s airlines would be able to tell you the number of their passengers that went into San Diego today. Hospitals provide medical care to the ill. How many hospital administrators or case managers can tell you the number of patient’s that went into congestive heart failure today, or this week, or even this month? How can there be effective management if there is no way of determining, on a daily basis, the institution’s case mix and thus what services need to be provided? The demands of managed care oversight and government regulation mean that hospitals no longer have the luxury of managing through retrospective analysis. Such practice will only result in retrospective denial of payment. The benefits of concurrent coding are seen not only on the revenue side, but also on the expense side of the ledger. Levels of staffing and even the utilization of clinical supplies are directly related to the acuity of the inpatient population. How can a hospital ever expect to take advantage of efficiencies created through e-commerce in the supply sector when it continues to use antiquated methods to project staffing and inventory needs? Admission of three new patients with the diagnosis code 820.8 (hip fracture) should be recognized for what it is. Staff and materials for three hip nailings in the OR, Social Service arrangements for three rehabilitation transfers, and Materials Management should see this diagnosis code as a need to provide three walking assist devices in two days. Concurrent coding has the potential of making all areas of a hospital more immediately responsive to the needs of its patients. But you can not anticipate a need that the relevant clinical departments do not know exists until an order is written, and billing will have no knowledge of until two weeks after discharge.

Lastly, having a networked based application will help strengthen the relationship hospitals have with their physicians. Physicians and hospitals share a unique commonality through their association with the patient. Both are providing services for patients. And both expect payment for those services by providing insurance carriers a codified summary of an assessment and treatment plan. The eICD, Enterprise Edition™ allows hospitals and physicians the ability to share the tools required for this common expense. Hospitals desperately need to forge strong bonds with their physician staff. Indeed, the common fiscal pressures of both speak to the need of leveraging every opportunity to decrease overhead and increase productivity in both the hospital and the physician office. The eICD, Enterprise Edition™ provides that lever by allowing hospitals and private physician’s offices the ability to share a common ICD-9 coding application. What better way to build loyalty than to provide physicians and their staff access to information they would otherwise purchase annually? By placing the eICD, Enterprise Edition™ on their Intranet, hospitals confirm that they understand the problems facing physicians and are ready to help by sharing tools they both already use. Such a relationship could be the start of more robust application sharing and information transfer to the benefit of both. The hospital could deliver daily a physician’s individual Disease Oriented Census. Such a list could be accompanied by case manager’s notes, clinical pathway recommendations, as well as updated literature references. In addition to assisting the physician in case management, the list could be used by his office staff to help with coding for billing, thus eliminating a duplication of work.

These are but a few of the benefits achieved when providers apply the power of eICD, Enterprise Edition™ to perform concurrent coding. It is clear that medicine is no longer exempt from the fundamental precepts of management. To manage effectively, you must have accurate, timely information, in the proper format. eICD, Enterprise Edition™ gives hospital managers the tools they need to manage the bottom line.


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ICD-10 codes, terms, and text World Health Organization, 1992-94