Albany Med is in the midst of a major initiative to improve its clinical, financial and administrative operations — all by changing the codes used to describe interactions between physicians and patients.
“The codes, referred to as ICD-10 codes, describe a patient’s condition and help determine reimbursement, quality measures, and clinical responses to changing conditions,” said Medical Director Dennis P. McKenna, MD, ’92. “With more specific data, we will have improved care and appropriate reimbursement for the vast array of conditions we treat.”
Every hospital in the country will be required to adopt new codes by next October. The challenge is that the number of codes used is increasing by almost five times — from 14,000 codes to approximately 70,000.
Teams of people from throughout the Medical Center are preparing to implement the new changes, including a new team of highly trained Clinical Documentation Specialists, nurses who have received additional training and certification. They will work closely with physicians to translate the language used at the bedside to the codes used for data collection and reimbursement.
“Words matter in coding,” said Esther Brown, head of the new Clinical Documentation Initiative (CDI) unit. “If a physician writes, ‘left lower lobe infiltrate’ in the record rather than ‘left lower lobe pneumonia,’ it could mean a difference in how we get reimbursed."
By doing rounds with the physicians, Brown’s team will help ensure that the coders have the information they need to code the interaction correctly.
The transition will involve significant collaboration between multiple facets of the institution, said Janis Leonard, director of Health Information Services (HIS). “We’re all working very closely to make this go as smoothly as possible,” she said.