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Janet Dillione Headshot

What's Treated, What's Coded -- How It's Changing and Why It Matters

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Health care is complex. When a patient goes into a doctor's office or hospital the process only just begins. In the most simplistic view, symptoms are presented, care is provided and a bill is paid. But what patients don't always realize is the complexity of healthcare reimbursement.

Healthcare reimbursement affects each and every one of us. It impacts how much doctors are paid, how insurance plans are structured and the amount patients are charged. And behind the price tag of healthcare is a highly-intricate billing system that right now, is going through an enormous evolution.

Let's take an example. A patient comes in with a symptom, perhaps a broken arm. The documentation that the patient's doctor uses to describe that broken arm and any other presenting problems is translated from clinical language into "codable" (code-able) language so that a bill can be created for an insurer and the patient. When it's done right, the reimbursement accurately reflects the level of care provided. When information is unclear, however, or detail is missing, reimbursement can be adversely affected.

Today, hospitals and doctors use a system of about 18,000 codes to describe medical services. While that might seem like a lot, the coding ecosystem is in its infancy. A new federally mandated coding initiative will expand the number of medical codes, which are called ICD codes, from 18,000 to around 140,000 -- the purpose of this expansion, from ICD-9 to ICD-10, is to ensure clinical descriptions are precise and accurate. Additionally, with better coding we'll be able to better measure healthcare services, quality and even conduct public health surveillance.

Many issues caused by the lack of specificity in the ICD-9 code sets will be resolved with ICD-10. In the current system, there is only one code to describe a patient with a broken arm. Say the patient broke their right arm, then was seen again weeks later with a break in their left arm. A second claim with the same ICD-9 code would be submitted, requiring additional documentation describing the difference between the two incidents. In the expanded ICD-10 diagnosis code set, characters in the code can identify right versus left, initial encounter versus subsequent encounter, and other clinical information.

This shift, however, from 18,000 codes to 140,000 codes will not come easy or overnight. It has been referred to by many as the "Y2K" of health care and will be enforced beginning Oct. 1, 2013. Though two years may sound like a long time, it is not when you consider how much has to be done. To give you a sense of why this change is so daunting to some, consider our patient example. In addition to the laterality of the fracture, right vs. left, the kind of fracture -- open vs. closed, location on the bone -- distal vs. proximal, and whether this was the initial or a subsequent encounter, doctors will need to be much more explicit when documenting care. While there are many benefits, ICD-10 will require a major change in everyday workflow.

Today, 40 percent of patients' notes, which are coded in correlation to 18,000 codes, require a manual query to the physician typically from a clinical documentation specialist with an extensive clinical background and knowledge of the reimbursement process. This query is to request more information or more specificity from the doctor, hours or even days after the documentation has been signed. These queries are disruptive to the physician and to the continuum of care. And with the coming of 122,000 extra codes, many hospitals and physician offices are asking themselves how to ensure the necessary level of specificity is captured so reimbursement will not be disrupted, while also keeping doctors focused on patients, not the process of billing.

Considering we're all patients, I believe it's important to understand the inner workings of the healthcare system. The 2013 code shift will mean that patients' medical records will be more detailed than ever before; this is a really good thing, not just for reimbursement, but for the wealth of information we can use to improve the performance and quality of our healthcare system. But we must prepare now for what's coming down the road.

At Nuance, we have partnered with 3M to create computer-assisted physician documentation (CAPD) technologies that will support physicians throughout their entire transition to ICD-10. Clinicians will be able to use speech-recognized dictation to document patient encounters in their own words, through automated queries address any missing or unclear information during the process, ultimately preserving the unique patient story and teeing up the detail necessary for appropriate reimbursement.

In closing, when it comes to patient care, no detail should be left out. Hospitals, doctors and even patients should rest assure that this change will be fully supported by enabling technologies that will help caregivers focus on what's most important -- their patients.

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