Forums » Smalltalk » AMA: Medical Coding/HIT

I'm currently majoring in HIT with a minor focus in inpatient medical coding. HIT refers to health information technology; this covers pretty much all things related to your health information. Databases, electronic and paper records, statistical analysis, confidentiality, security, all things data and electronic related. I also have overlapping knowledge into HIM, which is more of the management field. It's just a bunch of quality performance improvement and administrative policy mumbo-jumbo, really. I am one of few people who can read an health insurance terms agreement and tell you what it means. Yes, health insurance and pharmacology is as much of a scam as you think it is. It's unfortunate.

Medical coding refers to the deciphering of diagnostic documentation into billable coding for insurance reimbursement purposes. It's the coder's job to dig through a hellish amount of poorly written physician documentation and try to make meaning out of it. Primarily, it's broken down into the categories of 'outpatient' and 'inpatient', the latter of which being much more complicated. Think an hour of documentation versus three weeks. Not fun.

My life currently consists of cramming hundreds of organizations, policy and performance improvement steps/decision making paths, insurance guidelines, coding systems, healthcare standards, and compliance rules in preparation for sitting the RHIT exam next fall. I will probably cry. Lots. The RHIT certification is notoriously an absolute pain in the ass to take the exam for, solely because 90% of it is remembering miscellaneous things that hold no actual relevance to the very specific career path you choose. Depending on if you take it in-person or online, it can last anywhere from 3-6 hours. The passing score is a 75%, to tell you how miserable it is.

I eventually plan on continuing education through a masters degree in a RHIA program, but those days are far in the future. College is expensive, bros. And the exams are even more expensive - especially when you factor in CEUs, membership fees, annual books, encoders...I spent $1000 on books for this upcoming spring semester alone.

But yes. I have an ambiguous spread of medical-related knowledge. There are codes for conditions and situations that you've never even fathomed. I know the code for 'sucked into a jet engine'. 'Bitten by a cow.' 'Injury sustained while knitting.' I've had to read and google things that my eyes can never unsee. I'm not really sure what questions people could have about something vague like HIT, but feel free to shoot. I can do a basic breakdown of an admission slip (of just ICD-10-PCS and CM, because nobody likes CPT or HCPCS) if anyone's interested.

Haha, that's so cool! What is the cow bite code? 😂 Health technology/engineering/coding is so damn cool!

The base code itself is W55.21, although technically it would end up being W55.21XA since the guidelines specify that it needs to be seven characters long. X in this situation is used as a 'placeholder' and A refers to this being the 'initial encounter' for cow bite. Amusingly enough, there are also codes for 'struck by cow', 'crushed by cow', and 'other contact'. Whatever that means.

...There's actually a lot of weird animal related encounters in that group. I found raccoons, alligators, and chicken attacks.

So... The code you just mentioned, is that specifically cows, or animal bites in general? Assuming that one is just cows, what would a different animal bite be - for example, maybe a dog, or a snake (and if it would differ for venomous vs non-venomous)?

If "A" is for "initial encounter," would using other letters be a count of how many times it's happened? Or just a "not initial encounter" thing, or possibly a middle ground of a designation for "not the first, but not many" vs "this has happened a number of times" vs "this is a recurring issue" (since I know more "risk" = bigger fees with insurance)?

I'm not surprised that there would be multiple codes for cow-related issues, but I am sort of amused/interested by the fact that "struck by" and "crushed by" are different designations! I'm curious if you're able to define what would qualify for each of those, since I'd expect most "struck by" cases to still have something that got crushed. (I'd probably be more surprised if I hadn't already heard that some pretty weirdly specific ones exist; otherwise I'd expect it just be more vague things like "bitten by animal" or even "bitten by large, non-predatory, non-venomous land animal.")

Definitely not surprised about raccoon, alligator, or chicken attacks. Probably least surprised about chicken attacks of the three, actually. Are there different codes for chickens, geese, ducks, turkeys, and other birds?

From what you can recall offhand, besides ones you'd already mentioned, what do you thing you'd say is the one that has seemed the most weirdly specific to you?

On a more serious note, are there cases where you're required to interpret certain phrasing in a specific way even if the context makes to think it should be interpreted in a different way? As an example, let's say that you can tell an abscess is being described, but instead of "abscess" they wrote down something like "infected cyst" or "cyst that may or may not be infected (plus further notes describing present symptoms of infection)" - would any of that change what code you're supposed to use? I don't know if that example is necessarily a good one, but hopefully it at least illustrates what I mean well enough.

Specifically just for cows. W55 covers the category of 'contact with other mammals', in which the specifics of cats, horses, cows, pigs, and raccoons are listed. Any mammals that don't fall under those named terms are included in W55.3, contact with other hoof stock, or W55.8, contact with other mammal.

Dogs have their own category of W54, and non-venomous snakes fall under W59, contact with other nonvenomous reptiles. Venomous snakes fall under a completely separate group of codes as it would be considered poisoning/toxic effects. T63 and its subcategories cover the toxic effects of contact with venomous animals/and or plants.

Initial encounter means that this is the, well, initial encounter where a patient presents with a particular principal diagnosis - or the chief complaint, main problem, etc for a visit. In this case, think of it as a patient presenting to the emergency room following the bite from the cow.

If they require aftercare or a follow up visit, that would be considered a subsequent encounter, in which case the code W55.21XD is used. 'D' stands for subsequent encounter. Subsequent encounters have no complications and are basically just to check on the healing process, change casts or packing, make sure that everything is fine and spiffy.

If the patient has a complication specifically caused by the cow bite later on down the road that needs treatment, that would be considered a sequela encounter. The code W55.21XS is used, 'S' standing for sequela. Complications could include things like scarring, hematoma, poor wound healing, etc.

There's also the more complicated system of 'present on admission', 'not present on admission', 'not required to specify', but that's sort of complicated and hard to explain. Long story short, the seventh characters A, D, and S cover most of the things relating to encounters for insurance. A lot of chronic conditions will involve coding for 'history of (x)' or 'long term use of (x medical drug/treatment.)'

'Struck by' in ICD-10 typically refers to being hit by a projectile. One can assume from this that someone, somewhere, somehow, managed to be struck by a cow traveling at speeds high enough to be considered a thrown projectile. There is probably a more intelligent explanation than this, but I find it funny so that's what I'm going with. Otherwise, a bite obviously refers to an injury inflicted by an animal's teeth and a crush injury refers to when a substantial force is put on a body part, usually to the point of compression. Other contact includes anything that doesn't meet those definitions.

Place of occurrence codes get really weird. I swear I think there's one that entails injuries sustained at a 'swimming area of a prison' and 'day spa of a prison.' But it's mainly injury codes that make you raise your brows. There's one for falling off Heelies. And being involved in a spacecraft collision. And getting injured because your water skis spontaneously combusted.

Coding guidelines are VERY strict. The general rule is unless it's specifically noted in documentation, it's not your place to assume that that diagnosis was made - mistakes on the coder's part can easily cause massive insurance headaches and lead to conflicting health record information. The textbooks, professors, and experts in the industry beat the words 'QUERY THE PHYSICIAN QUERY THE PHYSICIAN QUERY THE PHYSICIAN' into your head ruthlessly, just in case you forget.

In this case, abscess and cysts are two completely different categories and are not interchangeable. Coding an abscess as a cyst would be incorrect coding and result in improper reimbursement and record information. If there's reason for the coder to believe the physician made a mistake, they would have to query them and double check they meant what they wrote down. 'Querying' just means passive aggressively telling a doctor they suck at writing documentation and they need to clarify their nonsense.

Infections are typically coded as their own separate code. An example of something you might see would be 'acute respiratory distress syndrome due to COVID-19'. ARDS is coded as U07.1 and the infectious agent, COVID-19, is coded as J80. I'm not too familiar with wound infections in particular, but I should assume they follow a similar route: main injury code, infection code (i.e local infection of (x)...), then infectious agent code if applicable. Septicemia and sepsis, however, are a completely different beast to tangle with and it would take me far too many words to go into detail about.

Hello! I work in trauma registry, billing and EMS software! And chances are through the roof that we've all laughed and wondered greatly about the ICD-10 codes while putting together/maintaining our products.

So this question isn't going to be serious at all - but what's the strangest one you've found so far?

Would you believe me if I told you that 'assault by human bite' happens a lot more often than you think it would at the local emergency department? I've not been in a professional setting yet since acquiring internships is particularly difficult at the moment, but I have been in contact with some people who've worked in the area for a long time. That one and R46.7 are probably the oddest ones that pop up the most often around here. Not sure what the correlation is between being bitten by humans and being unwilling to admit to your doctor that you just really want a work note...I'm still working on figuring that out.

Animal stuff sounds like it can be a mess to deal with all itself. The separation of venomous bites from other animal things definitely makes sense, though. As for projectile cows, I'm still not sure how that wouldn't still result in something getting crushed, but that might just be in more detailed intricacies. It's also less weird when thinking about how it's not all that unusual for cows to transported by truck, and I've seen footage of cows being lifted in swings like in rescues and such, so it'd just take an accident during something like that.

I originally thought "initial encounter" referred to the first report/record of a specific patient presenting with a given problem in general, but the way you elaborated on it and the codes associated with that do seem to make a lot more sense! And I can imagine the details of whether something was present or not at the start of the visit could have a pretty big legal impact beyond just insurance - like if a malpractice suit were to come up, it'd be hard to blame a doctor for something that was noted to already be there on the patient's initial arrival.

The prison ones you mention do seem oddly specific and like the "prison" part of those shouldn't even matter? And I'm just... really baffled by the idea of a prison with a day spa. There are certain countries were I could see that being a thing because they seem to have a better focus on rehabilitation, but not anywhere around here. And I'd have figured Heelies would end up grouped in wherever falling in rollerskates/rollerblades is. I imagine spacecraft collision was mostly a "planning for the future" designation. But... combusting water skis? Like, plain ol' water skis, not jet skis (which, having an engine, sure)? Now I'm over here wondering what kind of ridiculous friction that would take. o.o

On the example I gave, upon double-checking, it does look like my understanding of some things had been over-simplified. That was my example because in many cases (but apparently not all!), a cyst becoming infected gets its designation updated to abscess. It does look like that's an area that can get super complicated even for doctors, though, and I can only imagine how much more of a mess that becomes when you have to translate their notes!

As specific as some items are combined with how complex and multi-faceted some issues can be, this would probably be a good time to ask: are you supposed to list out all codes that seem to apply to a given situation, or narrow it down to whichever one or few seem to best encapsulate the situation, or what? I'm sure there's at least sometimes a different set of notes used for records than what gets shared with the patient (the organization I get my healthcare from provides a patient summary, but additionally has a separate "notes" section that can be accessed online and usually has much more detail, and my assumption from presentation is that those notes are still a patient-friendly variant rather than the official record), but I've noticed there are sometimes parts that don't entirely match up (especially between different visits for the same issue), as well as there usually being an "issues addressed" section that just names one or more topics brought up in the visit (and occasionally I'll be a little confused by things entered there, like it's a bit of a stretch). So there's that, there's the acknowledged issue of wounds becoming infected or having other complications develop, so it definitely seems like despite the specificity in the coding, there's still gotta end up being cases of overlaps or stacking or something? (I have no idea how much sense this paragraph is actually managing to make. Brain seems to have decided it's done with this subject for the moment and isn't even letting me properly reread it. >.< Apologies if it just came out a mess.)

I really, truly, cannot make these things up. There's typically the saying that if there's a classification for it, it's happened to someone at least once...

Depends. You don't code symptoms or standard manifestations of a disease/condition; if someone presents with influenza, there's no particular need to code out fever, vomiting, headache, fatigue. That's expected. Now if they were to happen to have syncope at the same time, you would code that because it's not within the standard symptoms of influenza.

ICD-10 contains notes like exclude1, exclude2, NOS and NEC that cover the base of 'should I code this? Can I code this?' That, and the encoders that are more or less standard in the professional setting these days prevent you from doing dumb stuff like coding two conditions that can't be present at the same time or going through 30 codes you don't need just for influenza.

But to answer the tried and trued question everyone has regarding 'bro why is my documentation so bad?' You can blame your physicians and/or medical assistants for that. They're usually the ones who slap together the charts you're able to access. And while I can't put too much fault on them, given that they're expected to plow through an ungodly workload everyday...damn are some of their charts wonky. It's usually because they're not technologically literate enough to operate the charting/notes system or they abuse copy paste. The autofill functions can get horribly messed up if you don't know what you're doing. It's not unusual to see a patient's chart have the same diagnosis like three times and seven different instances of the exact same prescription.