September 4 , 2007

Juggling Today’s Coding Demands
By George T. Schwend
For The Record
Vol. 19 No. 18 P. 8

The skillful art of juggling has enjoyed waves of popularity throughout the ages, mostly as a form of entertainment. But today’s healthcare organizations are quickly learning that juggling coding standards, including vocabularies, classifications, messaging, and more, is serious business—a business where professionals are capable of keeping multiple objects in the air, but amateurs frequently drop the ball, wasting valuable resources, compromising care, and jeopardizing timely reimbursement.

The current healthcare regulatory environment, including the government’s interoperability mandate and national adoption of standards, is driving widespread change in healthcare around the world. There is a strong impetus to adopt standardized clinical terminology because it is the key component to ensuring interoperability in electronic health records (EHRs), reducing the variability in how data are captured, encoded, and used in patient care and medical research.

Therefore, healthcare organizations, IT vendors, and government agencies are now engaged in a precarious balancing act to effectively localize, update, and disseminate more than 70 controlled, accepted, and usually licensed healthcare terminologies, mappings, and other terminology-related content issued by national and international standards bodies.

How Many Jugglers in the Act?
As if it were not challenging enough to “toss and catch” all these variant terminologies, including those related to billing and coding, there are a growing number of active participants in this juggling act. Distinct sectors within each healthcare enterprise and different professionals working in these facilities rely on a wide array of codes and standards provided by different organizations, sources, and standards bodies, and even some that have been “homegrown.”

This type of juggling is definitely not a spectator sport. It requires input from innumerable sources; demands continuous, regular updates to maintain accuracy; and provides critical information essential to the medical well-being of patients and the financial well-being of healthcare organizations.

We’ve all enjoyed watching the swift pace and dexterity of a good juggling act—when a cascade of balls flows through the air with apparent ease—whether handled by one or several jugglers. Today’s healthcare stakeholders should demand similar fluidity and ease as they seek to address the dilemma of variant terminologies and codes and the increasing demands for enhanced analyses and reporting.

Medical Terminologies: Who Is Saying What and Why?
With input from so many reputable but disparate sources, there are inevitably issues related to the content or semantics of healthcare information. In fact, medical terminologies exist for a range of purposes. For example, terminologies are utilized to report clinical data and findings. A number of specialized terminologies comprise billing, auditing, and reimbursement operations. Various medical vocabularies are used for classification and statistical analyses, while others initiate automated decision support functionality. Any or all of these medical terminologies and/or coding systems may be used by one or more segments of a healthcare organization.

It is important to note that despite the challenge presented by multiple standards, including terminologies, each plays a significant role in clarifying and enriching data. Some healthcare organizations and vendors employ sleight of hand by reducing or limiting the number of standards and vocabularies addressed. This is certainly a case of the juggler “dropping the ball.” Although it is difficult to rely on such an extensive collection of standards and terminologies, each element needs to be embraced because it complements the collective good.

Today’s healthcare entities commonly depend on a host of medical terminologies including, but not limited to, the following:

• Systemized Nomenclature of Medicine (SNOMED);

• International Classification of Diseases (ICD-9, ICD-10);

• Logical Observation Identifiers, Names and Codes (LOINC);

• Current Procedural Terminology (CPT);

• World Health Organization Adverse Drug Reaction Terminology; and

• National Drug Codes (NDC) in the United States and many other drug terminologies used around the world.

The inability to efficiently manage these multiple terminologies on a real-time basis often poses difficulties for those healthcare professionals who use and/or interpret these codes and standards, sometimes causing misreading or confusion that may lead to delayed or compromised care, billing errors, or misinterpretation of data for outcomes reporting. This situation presents a strong case for sophisticated technology tools to not only manage but also address and resolve potential terminology and coding conflicts.

A Numbers Game
Given the quantity of balls in the air and jugglers involved, medical care, billing, and reporting is a complex numbers game that can potentially hobble healthcare organizations. CPT codes govern physician payment, and ICD-9 codes are now the backbone of U.S. hospital billing systems. Soon, however, the United States will be transitioning to the ICD-10 model. Today’s medical coders, who have been trained on the ICD-9 model using approximately 15,000 codes, will have to decisively broaden their skill set to recognize the estimated 100,000 ICD-10 codes now used globally. (And, with ICD-11 already on the drawing board, it’s a reality that will be with us for many years to come.)

Another barrier posed by divergent coding standards is the instability of the assigned numbers. CPT, ICD-9, ICD-10, and a host of additional pharmaceutical, laboratory, and imaging codes are updated and changed on unrelated frequency schedules. New codes are added; old codes are dropped. To complicate an already difficult situation, some old codes are periodically reassigned, and one system often uses a code bearing a strong resemblance to another.

For professional coders, each time a coding conflict is confronted, another seems to pop up in its place. At face value, it is an overwhelming task to juggle not only multiple standards, terminologies, and codes but also the frequent changes that must be implemented on variant timetables. Each time a conflict arises, a terminology or coding discrepancy may require hours, days, or weeks to pull and examine the patient and/or hospital records, verify data from all sources, resolve the conflict, and resubmit “corrected” information.

Failure to resolve coding discrepancies can postpone accurate payment for up to six months as precious facility resources are wasted on manually tracking down the proper code for reimbursement. On the medical side, disparate standards and vocabularies can delay proper diagnoses and treatment protocols, putting patients at increased risk.

Despite these inherent barriers to the timely resolution of terminology or coding conflicts, there should be a high degree of confidence at the healthcare organization in the semantic integration of its clinical, financial, and administrative data.

Semantic alignment is the ultimate goal, and critical to this success are standards that must be mapped together. These maps must be automated and maintained on an ongoing basis to keep the data comparable—not doing so would risk compromising data integrity. Whose Job Is It, Anyway?

While the goal is clear, responsibility for achieving that goal is ambiguous in some healthcare organizations. Many hospitals rely on their system application vendors to recommend or supply the requisite technology to address variant terminologies and codes. Some facilities directly contract with HIT/terminology specialty companies, while others opt to manually handle—or mishandle—this task in-house.

As the exchange, integration, sharing, and retrieval of healthcare data become more technologically sophisticated and highly regulated by government entities here and abroad, juggling variant billing and coding terminologies will command plenty of time and resources. Some healthcare stakeholders may consider partnering with a technology/terminology specialty vendor with a long-term commitment not only to terminology but also the tools to make it both efficient and effective.

Juggling for Today and Tomorrow
Since all solutions are not equal, healthcare executives should establish stringent criteria before implementing a technology solution. Selecting an inadequate technology tool to address and resolve standards, vocabulary, and code variants can seriously impact revenue and quality treatment and possibly endanger patient safety. The selected technology solution should include the following capabilities:

• easy to use;

• fully automated;

• accurate;

• timely;

• reliable; and

• analytic.

Innovative software infrastructure technology and expertise are essential to not only simplify access to controlled vocabularies, code sets, and maps but also to ease the management of such content in the long term. Today’s healthcare regulations will certainly morph over time, and healthcare organizations recognize that “getting a bill out” is only one ball they need to juggle. They require a terminology/coding technology solution that can also juggle the following capabilities:

• real-time updating;

• enriched clinical data;

• fraud, abuse, and misuse information; and

• patient safety measures.

The terminology/coding technology tool of choice needs to quickly and efficiently integrate health-related terminologies into a single, manageable environment that facilitates local changes and mappings. It also must allow these changes and mappings to be seamlessly merged with scheduled and unscheduled periodic releases and updates from all pertinent standards bodies.

A strong asset of a highly sophisticated terminology and coding technology solution is its ability to provide healthcare organizations with complex analytical tools that can examine retrospective and prospective data. Since, in reality, a medical record cannot be “changed,” there needs to be a mechanism in place allowing the healthcare organization to manage code changes. This is essential when an existing medical record is underpinned by a previously unacceptable code but is now either changed or eliminated. Historical maps are increasingly more important to healthcare entities as a viable means of minimizing date/time code dependency and providing thorough and accurate outcomes analyses.

Medical terminology/coding technology can juggle an additional ball for today’s healthcare organizations: pay-for-performance (P4P) metrics. Managed care payers are demanding—and healthcare entities are seeking—a reliable method to measure P4P. With best-of-breed technology, all pertinent information is permanently captured and accurately codified. The patient’s medical record then offers complete data detailing the event, clinical treatment, and outcomes, virtually eliminating subjective interpretation from the metrics equation.

— George T. Schwend is president and CEO of Aurora, Colo.-based Health Language, Inc., a supplier of language engine technology for medical language vocabulary.