Evolution of Medical Coding

By Aimee Wilcox, MA, CST, CCS-P

In today’s ever changing and evolving technological world, medical coding professionals face major challenges.

Within the past 20 years, medical coding has evolved in a significant way. In the 80’s most documentation was either handwritten or transcribed and sometimes typed on an electric typewriter. As advances in technology became more affordable to the public in general, personal computers were used to type documents and save them onto floppy disks or print forms using the old dot-matrix printers.

Those who worked in medical offices were trained as medical assistants, which was a general title to cover all aspects of work within a medical office including patient care, reception, transcription, coding and billing, filing, insurance verification, etc. Medical coders, as a specific job title, were a rare commodity, as the CPT codes were still evolving significantly.

Rooms filled with numerous, large file cabinets held patient’s medical charts. These were pulled each day for the patients being seen and filed again after each use. These charts contained labs, tests, office notes, hospital notes, and all information pertaining to a patient’s care, as well as personal information such as name, date of birth, and social security numbers. This information was protected under lock and key.

Coding was done through the use of a superbill or chargemaster, marked by the physician. Surgical services and procedures were entered into computer software billing systems and claims printed and mailed to insurance companies. Insurance and patient payments received via mail (snail mail) were entered into the same software program and monthly statements, showing a patient's balance, were printed and mailed.

Paper was everywhere until it became more affordable and feasible to use personal computers to manage information more efficiently.

The technology boom from the 1980s to the present has brought about enormous changes to how we manage information.

Although there are still some providers who use the paper medical chart, there has been a surge in providers who have progressed to the electronic medical record and soon paper charts will be a way of the past. Specialized software programs have been designed to meet the specific needs of the medical office and facility.

Information is rarely transferred via facsimile (fax) anymore but instead is transmitted electronically via computer networks. Instead of physical locks protecting information, secured passwords and private networks protect confidential patient information.

Almost all patient information can be gathered electronically prior to an appointment and those who are unable to do so fill out information sheets that are then entered into the computer billing programs at the office or facility in which treatment will be rendered.

Coding, which was previously done manually using the large and rather cumbersome ICD-9-CM diagnostic and CPT procedural coding manuals, is now performed via encoding software programs. These programs allow a simple search of specific terms which allow the program to go through a process of elimination to get to the correct code faster and more efficiently.

Where dot-matrix printers once ruled and all claim follow-up was done by pulling the carbon copy of the original paper HCFA mailed to the insurance company, electronic transfer of data via internet to clearinghouses are used with a report of received and accepted claims reported electronically as well almost instantaneously.

Even claims that still must be printed and mailed are completed with ease with new laser printers and the use of carbon copies eliminated through the advancement of computer systems that enable a claim to be printed multiples of times and stored in the software program until needed again.

Insurance payments are still received in the mail, but once again, technological advances have made is less expensive and quicker for some insurance carriers to direct deposit payments into your bank account at the same time they submit an electronic explanation of benefits. Some programs even allow the payments and adjustments to be entered into the billing software automatically, avoiding excess hands-on work by an employee. This frees up employee time to verify correct payments and adjustments as well as spend their valuable time pursuing claims that remain unpaid or that need to be appealed.

As you can see, technological advancements have changed the way coders and billers perform their job duties. As such, they can perform tasks faster and more efficiently and allow for greater productivity.

Aside from all the high-tech HIPAA laws that have been put into effect to secure patient information from falling into the wrong hands, additional computer system requirements have been put into effect to allow for better transfer and receipt of data between facilities and providers, providers and insurance companies, and government agencies. Some facilities and providers have such advanced systems that in situations where you are out of town or in the emergency room on the weekend, the provider taking care of you may have access to your medical records from your physician; even though their office if closed.

Above all, right now the largest change to the healthcare industry as a whole, is the change from ICD-9-CM diagnostic data set to ICD-10-CM diagnostic data set taking place in October of 2014.

This change will require coders to have a greater knowledge of anatomy and organ systems and providers to document in greater detail so accurate and more detailed codes can be assigned to patient services.

With greater specificity in diagnostic coding and reporting, medical necessity will be more readily able to be proven.

Proving a service or procedure is medically necessary has become a fundamental requirement of many insurance companies, especially CMS (Centers for Medicare and Medicaid Services). The pre-authorization process is centered around the demonstration through medical documentation that an ordered service or procedure is medically necessary. Additionally, CMS has developed a system that lists specific procedure codes and the criteria that must be met within medical documentation in order for a patient to qualify for that service.

For example, a common procedure performed for chronic back pain, associated with arthritis of the facet joint resulting in irritation of the spinal nerves surrounding the area where the arthritis has developed, is radio-frequency ablation of a spinal nerve. This is where the doctor places electrodes on a specific spinal nerve(s) and burns them to destroy them. They don’t grow back for approximately a year, providing pain relief to the patient and many times a reduction or complete discontinuance of the need for chronic pain medications.

In order to have this procedure approved, your insurance generally requires your medical documentation to show imaging that indicates you have this diagnosis, a physical examination that also indicates pain over the facet joints (among other things), and notation that physical therapy and medication management failed to provide significant or long-term relief. Additionally, they want to see that the targeted nerves the physician intends to burn are indeed the nerves being effected so they require a facet joint nerve block that, when injected with an anesthetic, provides adequate relief (of at least 80%) for a specified period time.

Once these options have been exhausted and has been documented, pre-authorization may be granted to proceed to the radio-frequency ablation of the specified spinal nerves.

Enough data has been gathered from patients having had this procedure that it has now been determined that patients with a specific diagnosis of facet joint arthritis or spondylosis experience relief from their chronic back pain symptoms when they undergo this procedure.

Due to technological advancements making data mining and data gathering much easier, we will begin to see more and more procedures that have a requirement for documentation by the provider to prove medical necessity or the claim will not be paid.

This puts a great demand on medical coders to know and understand how to locate what information must be documented and properly disseminated to their providers. When claims are denied for medical necessity, the medical coder can then return to the provider and show them the information that was not documented. If the provider can show that the information was gathered, then an appeals process can begin and possible payment received.

The ability for medical coders to have immediate access to information is vital to the success of a medical practice and facility. There are many companies that provide educational information to medical coders and medical practices to aid them in the coding and billing process. This information comes in many forms: electronic, CD, individual websites, books, etc. As you can imagine, navigating so much information in search for the correct code or documentation requirements can become a daunting process.

FindACode.com, has created a fantastic product that provides immediate access to all of this information in a comprehensive and searchable database. It also contains all the upcoming diagnosis codes and crosswalks for ICD-10-CM that will be put into effect in October of 2014.

FindACode.com provides a plethora of information that supports medical coders and billers in their careers. It is customizable, so any facility or medical practice can determine what information they would like to use and pay for; a type of buffet-style service of information. Simply look up findacode.com and get started making your job easier and more productive today.

Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.

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