Find Your Routine: Know Your Client Workflow
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them.
This week, we talked with Tilina Sablan, RHIT, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
Q: Describe in detail your daily routine.
A: First thing in the morning, I check both my client e-mail and HIA e-mail. If there is anything administrative related that needs my attention, I take care of that right away. Next, I look at any pending charts that are outdated and need to be reviewed and I follow up on those. Since I am in touch with CDI a lot at my current client, I also like to check that e-mail first thing.
Finally, it’s time to start coding!
I begin with the discharge disposition in PowerChart, then I abstract the attending and consults. I go through the workflow that the client provides. Every client is different, so I find it important to get to know your client and their workflow. This ensures I don’t miss anything that needs to be coded. From there, I open 3M and review CDI notes to get a glance at what kind of chart I will be coding. After reviewing, I will go through their final notes. From there I go into PowerChart and review entire the H&P to get admitting diagnosis, then ED, discharge summary, consults, op notes, progress notes, etc. After reading all of that, I go back to the discharge summary to make sure I got the correct principle diagnosis and secondary diagnoses – making sure I’ve captured everything. My client uses CAC system that I do use; however, if I’m not sure if it’s the right code, I will use The Coding Tree. If there are some codes that they are suggesting for me, I will look up those codes to verify and be sure that they are appropriate secondary diagnoses to report.
If I know there is a chart that I will have questions on, I open SharePoint and put in the main terms or terms that will help narrow down the search. I read what relates to what I am coding to familiarize myself with the chart I am about to code. This all helps to make sure I am selecting the correct principle diagnoses.
If I still have a question and don’t find a similar tip, I will save all the notes and send my questions to Sharepoint so our HIA Education team can provide that extra help and clarity.
Q: How do you maintain your routine day after day, week after week?
A: I make sure to do things that encourage me to focus. In the beginning of my work day, I like to listen to the radio and morning talk shows until about 10 a.m. – it helps get me motivated for the day. Depending on what charts I get, like new moms and babies, I try to attack those by spending less of my coding time. This allows me to spend longer on those charts that require more time, like longer length of stays
Q: What techniques have you found to minimize distractions?
A: In the morning, I make sure to keep my water and a snack nearby so I don’t have to get up and then get sidetracked. Just being ready for the day and prepared to work is the best tip I can give. I must keep my phone around me for my kids, but I always get in that work mind set and have what I need to attack my work day and prepare to code.
Q: What are the productivity goals that you set for yourself? And how do you track them?
A: I feel that productivity is a never ending challenge and I am always striving to improve. I always want to make the most of my day – finishing that last record or trying to fit in one more chart before the days end. I also found the speed-reading tip and action plan very helpful. Another trick I use is writing down tips and coding shortcuts on digital sticky notes on my desktop (example below). This prevents me from having to go online and research the same thing twice – it’s just right there in front of me.
Q: What motivates you the most? Positive feedback from managers, self-motivation by reaching personal goals, financing incentives? Or other?
A: Positive feedback from managers and self-motivation works best for me. I love getting positive feedback from clients – that motivates me the most. I like to hear that I am doing a good job, and any constructive feedback.
TIP: Use digital sticky notes on your desktop to write down tips and coding shortcuts. Below is an example of Tilina’s:
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.
For Part 2 of this 5-part series, we will look at Chapter 1 within ICD-10-CM—A00-B99—Certain Infectious and Parasitic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 1 of this 5-part series, we will look at Chapter 21 within ICD-10-CM—Z00-Z99—Factors influencing health status and contact with health services. There is no possible way to include every guideline or coding reference for this chapter, but I’ll do my best to touch on some off the most common issues.
The HIM world has been buzzing recently with discussion of “Social Determinants of Health” and coded data. What does this mean for coders and the HIM field?
The Centers for Disease Control and Prevention (CDC) is in process of developing a new code for the COVID-19 (coronavirus) that will be released October 1, 2020. In the meantime, the CDC has provided advice on coding the COVID-19 coronavirus.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #4 is DRG 193—Simple pneumonia & pleurisy with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #5 DRG with the most recommendations during HIA reviews : DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC