The Importance of Understanding Disease ProcessesPRESENTED BY

GAIL GORDON, MSHA/EDUCATION, CPC,SSGB

Who I am

My name is Gail Gordon, MSHA/Education, CPC, SSGB

I am ICD 10 proficient

HCC Coding proficient

I am the HCC Coding/Education Account Manager for Innovare Health Advocates

I am the Population Health Mgr for 3 IPAs covering 30+ clinicians.

What is a disease?

Per www.Dictionary.com A Disease is: a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sickness; ailment.

What is a process?

Obesity

Too little exercise

Too man

y calories

According to www.Dictionary.com a process is a systematic series of actions directed to some end.

AND:

a continuous action, operation, or series of changes taking place in a definite manner

I.e. The process of decaying.

What then is a disease process?

A disease process then is the progression of a symptom, ailment, and or disease to it’s conclusion. I.e. Cured, Progression, Chronic, and/or Death of the patient.

For example:

Long time smoker complains of cough, phlegm in morning. Doctor orders CXR, which is WNL. Patient continues to complain about productive cough in the AM. Doctor diagnoses patient with Smoker’s Cough and prescribes a Rescue Inhaler and goes over Tobacco cessation program. What is the next step in the disease process? And why is it important to know?

Why it’s important

Code selection

Documentation

Data mining

Communication with clinician

Learning opportunities

Code Selection& DocumentationDisease process drives code selection in ICD 10

The clinician will be required to document the disease process to its highest form in order to ensure optimal code selection

As coders we will need to understand disease processes in order to assist our clinicians in code selection at least in the beginning

Data Mining for Risk AdjustmentRisk Management is the wave of the future of medical reimbursement and patient care

Understanding disease process will help the Risk Adjustment coder to help their clinician maximize revenue and ensure optimal patient care

Communication & Learning OpportunitiesClinicians love to teach

By asking questions we as coders learn

Creates a dialogue between coder and clinician

Opportunity to be seen as a colleague and not simply as a employee

Example of Disease Process

ObesityDifficulty Breathing upon lying down

Pickwickian Syndrome?

Questions to ask

There are no stupid/silly questions

We learn by taking risks and asking the question

Its all in how you ask

Making Connections

Hypertension

Heart Disease

Congestive Heart Failure

Myocardial Infarct

Chronic Kidney Disease

Renal Failure

Code Selection

ICD 10

Clinically driven code set

Drilled down to specificity

In many cases we need to be list the cause of the disease, disorder, condition

ICD 10

In some cases ICD 10 guidelines require that the coder or clinician code also the reason for the progression

I25 Chronic Ischemic Heart Disease: use additional code to identify: chronic total occlusion of coronary artery (I25.82); exposure to environmental tobacco smoke (Z77.22); hx of tobacco use (Z87.891); occupational exposure to environmental tobacco smoke (Z57.31); tobacco dependence (F17.-); tobacco use (Z72.0)

As coders we will need to pour over these notes to find the clues that lead to greater specificity, all inclusive coding and the reporting of casual relationships

ICD 10 cont’dZ87.891

History of tobacco use. Leads to:

I25.10

Atheroscleroic heart disease of native coronary artery w/o angina pectoris. Leads to:

I25.110

Atheroscleroic heart disease of native coronary artery with angina pectoris. Leads to:

I25.2

Old myocardial infarction.Healed.Dx by ECG w/ no symptoms

What you can do as a CPC

Some ways to acquaint ourselves with disease processes is through review of the patient’s chart. Quite often this is the best way to follow the patient’s progression.

2013 patient was diagnosed with a cough and was counseled on smoking cessation.

2014 patient still has cough, and CXR indicates emphysematous changes in the lung tissue.

2015 patient still has cough, and now Spirometry indicates COPD.

The disease has progressed through its processes.

2016 May find the patient requiring O2

2017+ May find the patient in Chronic Respiratory Failure.

What you can do

Take anatomy and physiology through the AAPC and obtain 20 CEU credits.

I do this every other year and it keeps me comfortable discussing disease processes with coders and clinicians alike.

Likewise Ahima also offers an Anatomy and Physiology class.

Data Mining for Risk Adjustment

Essence

AARP Secure Horizons

Coventry Health Care

HCC Coding—Diagnosis Coding

Why it’s important for Risk Adjustment

So why is this important?

In the world of HCC coding choosing the correct code which fully describes the patient’s condition can make the difference in the following year’s out of pocket costs for the patient. And affect your clinician’s revenue cycle.

Additionally understanding anatomy and physiology is part our coding skillset. We should be the subject matter expert regarding how A & P affects code choices and drives documentation.

HCC Coding and Data Mining

Quite often as HCC Coders we are asked to not only code the encounter but also data mine the patient chart to ensure revenue optimization AND comprehensive patient care and documentation.

I am always telling my clinicians document what you code and code what you do. Often our clinicians are documenting the encounter in their head. They know that the patient needs a refill of their thyroid medication but they forget to diagnose the patient with hypothyroid disease; which is an HCC.

They also read the radiologist report and see that the patient has aortic atherosclerosis but fail to mention it in their note and fail to record the diagnosis because the patient may already be taking a statin and/or a heart medication.

It is important for an HCC coder who has been charged with data mining a clinician’s panel to familiarize herself with disease process and medical terminology.

Often a CXR report will state: emphysemic changes or emphymatous changes within the lung; But fails to out right say emphysema.

Understanding terminology and disease process will help you communicate to the clinician that the patient appears to have emphysema based on CXR report.

Disease ProcessCKD

What are the causes of CKD?

Hypertension and Diabetes are the most common.

Understanding disease process will help as you data mine the lab reports for evidence of CKD. (over a 3 month period)

Disease Process Osteoporosis

Post-menopausal woman with osteoporosis based on DEXA and BMD reports 733.01

Pt is on Boniva etc for osteoporosis

Patient is evaluated for back pain and sent for L-spine.

Pathological fx is seen both old and new 733.13; pathological fx of vertebrae

Communicating w/ clinician

Face to face

Phone calls

Within the EMR (Dashboard)

Emails

Roadblocks to effective communication

Coders and clinicians speak two different languages.

Ours is a language of numbers & letters and the business side of Health Care.

The clinicians speak the language of medicine.

Any questions?

Let’s discuss