A DAY in the LIFE of an INPATIENT CODER
A Typical Workday in my Life as an Inpatient Coder
Alyssa J. Keeley, CCS, CPC
A little background: I’ve been coding (facility) since early 2010 and although I learned to code all types of hospital charts, I fell in love with inpatient coding from the get go. I currently work full time as a remote inpatient coder for Bon Secours Virginia Health System. Our team of 60-65 coders codes for all the Bon Secours hospitals in Virginia.
Setting the scene: I typically get up between 6:00 and 6:30am, let the dog out, have some quiet time with my Bible/prayer, work out or do yoga, get ready for the day. Having this time to myself in the morning is wonderful and really sets a calm, positive tone for my work day. I used to lounge in my pajamas in my desk chair all day but I’ve found that getting dressed and doing my hair/makeup helps me feel totally prepared for the work day and more productive.
I have a dedicated home office per my employer’s requirements. My employer provides my computer – a desktop computer with 2 monitors, and reimburses my monthly internet. My husband built me a large L shaped desk so I have lots of room to spread out. My desk faces the window so I can enjoy as much sunlight as possible (I live in cloudy Michigan). I keep my code books (provided by my employer) on my desk. My certifications, diploma, and proof of memberships hang on the wall to remind me to always take pride in my work and accomplishments. I decorated the walls to make it cheery and home-y since I spend a lot of time in there. My favorite thing about my office is the bulletin board hanging over my desk at eye level where I put inspirational quotes in fun, fancy script.
Starting my work day: I try to start work around 8:00am. I boot my computer up, log in to the VPN, clock in via Citrix, open the Excel spreadsheet that I use to track my daily productivity, open Outlook, and open Epic (EHR). I catch up on emails and glance at my Outlook calendar to see if there are any meetings scheduled for the day.
Epic/work queues: Our coding team has various work queues that we pull our charts from. All the IP charts from all Bon Secours Virginia hospitals go into the same queue. The work queue gets sorted in a specific way so that the oldest charts get coded first, and the highest dollar charts from each day get coded before the lower dollar charts. Sorting the queue this way keeps the work load evenly distributed among the inpatient coders so that one coder isn’t stuck coding high dollars while another coder is floating along on easy newborn charts. Cherry picking is discouraged.
CAC: We use 3M Computer Assisted Coding, which has its pros and cons. I feel like it has really helped increase my productivity and for the most part it’s pretty accurate. My favorite feature is the capability to search for words or phrases within the medical record, which is very handy when formulating a query. But one can’t depend on CAC totally since it doesn’t always auto-suggest the right code, and sometimes it doesn’t auto-suggest a code at all! So it’s important to read the chart in its entirety so that all appropriate codes are assigned.
The process of coding an inpatient chart:
-When I click on a chart in the Epic work queue, it opens the patient’s chart.
-I cross check the arrival date/time, IP admit date/time, discharge date/time, discharge disposition, financial class, admit order.
-I do a quick preliminary check to make sure there is at least a discharge summary and H&P on the chart, and enter an account note if they are missing. If I feel confident to complete the chart without the discharge summary, having an account note in place stating “no discharge summary on chart at the time of coding” will cover my back in case the discharge summary comes through later and has any extra diagnoses that weren’t mentioned in the rest of the record (eg., hypokalemia that developed on the last day, etc). Important side note: if there is any doubt in my mind as to what the DC summary might say compared to the rest of the record, I send the chart over to HIM asking for one. Auditors jump all over DC summaries and will try to deny diagnoses based on their presence or absence in the DC summary, which can be rather frustrating. I want to make sure the chart’s documentation backs up every single code I select.
-I check the working DRG calculated by CDI, and look to see if the CDI team queried on the patient and if so, review the query and the physician response.
-At that point I open 3M CAC and start by reviewing the discharge summary, if it’s available. This gives me a good overview of what was going on with the patient so I know the outcome as I go back and read/code the rest of the chart: the H&P, ED note, consults, procedures, progress notes, radiology reports, etc. Side note: if you aren’t sure which diagnosis codes to pick up, a review of the UHDDS guidelines will be very helpful.
-I pick up all applicable procedures like PICC lines, transfusions, thoracentesis, etc., as outlined in our facility’s policy. Each facility might vary slightly as to what procedures they pick up outside of the OR. I check the charges and flowsheets in Epic to make sure I haven’t missed a procedure code (eg., mechanical ventilator and bipap times).
-I look for any unsigned physician reports in Epic since those, along with other items in the EHR, do not flow into CAC. Side note: facilities can pick and choose what they want loaded into CAC. Huge amounts of information/documentation in CAC can really slow down its processing speed.
-I go through my list of codes and verify all my POA indicators, which often requires checking lab values in case the record isn’t clear whether the hyponatremia and hyperkalemia were present on admit or not.
-I look over the medication list that the patient came in with / is discharged with to make sure I have medications for chronic conditions like GERD, HTN, hypercholesterolemia and have assigned all the appropriate long-term use of medication Z codes.
-If my final MS-DRG is different than the CDI working DRG, I double check my rationale for choosing the DRG I calculated and enter a note in Epic stating my reasoning. I do this in case CDI, an auditor, or management wants to know how I arrived at a different DRG – I can just quickly look at the account note instead of having to review the chart again and try to remember what my train of thought was. If the CDI working DRG is 871 (sepsis), my account note might look something like this: “Final DRG 853 due to Px performed – excisional debridement.”
-Once I finish working in CAC, I submit the codes and everything crosses over into Epic. I enter the procedure information: date of the procedure, the surgeon’s name/ID, anesthesiologist’s name, the type of anesthesia used.
-Once this is done, I’m ready to hit “complete” and move to the next chart in the queue!
Querying: Querying is such an important part of inpatient coding. I was lucky to get hands-on CDI experience at my first coding job, and I’ve continued to expand that knowledge whenever possible. Becoming familiar with clinical indicators and common treatments for conditions such as sepsis, respiratory failure, CHF, pneumonia, encephalopathy, malnutrition, etc., is key. Why do you think I have so many folders everywhere? When I have a brain fart and can’t remember what an ABG level should look like for acute respiratory failure I am able to quickly refer to documents I bookmarked and move on. Having trustworthy resources at your fingertips will empower you and help you grow your skillset as a coder.
My favorite tip to share on querying is this. Compile the query as you go. As I go through the record, if I see conflicting documentation or see a diagnosis that suddenly drops off the record or is only mentioned once or any other scenario that might make me pause and go “hmm, I might need to query about this”, I bring up a blank document and start copying and pasting pertinent documentation, clinical indicators, treatment, etc., into the document so that by the time I finish going through the chart I have everything I need to compile my query.
Querying takes a lot of practice and attention, and I firmly believe that the coding department and CDI (Clinical Documentation Integrity) department should work hand in hand. Our CDI team at Bon Secours Virginia is wonderful and I reach out to them if I need a second opinion on anything or help wording a specific question. When you work together you are combining a coder’s expertise with coding guidelines and rules and a CDI specialist’s level of expertise that most coders do not have (which is ok!). Most CDI specialists have at the least an RN degree, many also have a BSN degree, and many also hold the CCDS certification through ACDIS and/or the CDIP certification through AHIMA.
Researching: Google is a coder’s best friend. I would caution you to go to reputable sources like MayoClinic, MedlinePlus, the Merck Manual website, etc, when looking for things like clinical indicators and treatment. Not all medical websites are trustworthy. Manufacturer’s websites are a wonderful tool. Make use of sites like HCPro, SuperCoder, JustCoding, AHIMA, AAPC, and more. If I get stuck I’ll just Google something like “symptoms of ______” or “ICD10 code for ______” – you might be surprised at how much information you will find.
I would encourage you to make use of all the coding resources that your facility offers. Know the ICD10 guidelines backwards and forwards. Study the AHA Coding Clinics and ICD10 Handbook. Familiarize yourself with a good drug reference, anatomy diagrams (Google is great for this, too), and a medical acronyms tool. Make use of the device key and body part key in the ICD-10-PCS electronic codebook in 3M (or whatever encoder you use). To access those keys you just open the encoder, go to the top of that page, and find the “help” tab. There is a whole list of reference keys/tables there. The device key will help you pick the right device when you’re not sure if the heart valve is zooplastic or nonautologous. The body part key will help you discern whether the trapezius muscle is coded as part of the shoulder or upper back.
Productivity: Our inpatient productivity is calculated by length of stay rather than by number of charts. We have to code 60 LOS per day. For example, I would meet productivity if I coded 12 5-day stays (12 x 5 = 60), or 6 10-day stays (6 x 10 = 60), or any number of LOS combinations to equal 60.
My productivity spreadsheet: I keep track of the LOS of each IP chart I code so I can calculate throughout the day how many more LOS I need to reach 60. I make a note on the spreadsheet if place the chart on hold I note the reason why (holding for a report, manager review, query, question for CDI, mortality review, etc). I have a section to list any time lost due to computer/system issues, a section for time spent in meetings, and an area to track my education modules.
Email organization: I primarily use folders in Outlook to save emails from auditors, educational ICD10/CPT coding information that management sends out on a daily/weekly basis, and tricky/interesting chart scenarios that I discuss with my manager in case I need to refer back to the discussion – which happens quite a bit when I encounter similar scenarios.
Hard drive organization: I have folders on my work computer for time sheets, productivity spreadsheets, webinar handouts, CEU certificates, ICD-10-CM/PCS guidance/tricks/tips, company/coding policies, auditing and compliance information, CPT, Word documents or PDFs with clinical indicator information/cheat sheets for diagnoses like respiratory failure, malnutrition, etc.
Internet browser organization: I mostly use my browser favorites folders for clinical indicators and coding guidance (eg, coding articles from HCPro, a joint implant manufacturer’s website to make sure I assign the correct device code). I organize the folders similarly to how the ICD10CM book is laid out, by body system. I have folders for infectious diseases, the respiratory system, musculoskeletal, etc., etc. Clinical indicators, coding guidance, and PCS information all go in one appropriate body system folder so everything is in one place.
If you have any questions, feel free to reach out via Facebook messenger and I will do my best to answer!