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MUSC ranks 5th in hospital coding practices by Cindy Abole Public Relations Managing patient data with health information technology is an important contribution in the health care delivery process.   The hospital's coding staff join the Health Information Services staff. At hospitals, clinics, physician practices and health care facilities, skilled coding professionals have the extraordinary job of sorting through and reviewing medical documentation from patient records. More specifically, they classify information and assign specific codes for each patient’s diagnosis and medical procedure during every hospital or doctor’s visit.     MUSC’s team of coding specialists are among the best in its field. In September, Health Information Service’s (HIS) Coding Department ranked fifth out of 239 major teaching hospitals across the country for its coding practices and excellence by the American Health Information Management Association (AHIMA) and HIS. MUSC was the only major teaching hospital in North and South Carolina recognized with this distinction.   An award plaque was formally presented to MUSC coding manager Christine Lewis on behalf of her 20-member team on Oct. 17 at the AHIMA National Convention in San Diego. This award coincides with the hospital's celebration of Health Information Services Week, Nov. 7 - 11.   “This is an extraordinary honor for us,” said Sue Pletcher, Patient Access Services and HIS director. “Our coding staff succeeds through teamwork among themselves and other Health Information Services staff. They share a dedication towards excellence in their work, credentialed staff and professional growth through training and education.”      The award appraised MUSC’s 2004 coding performance in a national study of inpatient coding practices using Medicare data gathered by Hospital Insight, a Web-based analytical tool sponsored by AHIMA. A year earlier, MUSC was listed among the top 50 national hospitals for coding performance.   “We are extremely proud of our coding staff for such a remarkable achievement,” said Lisa Montgomery, vice president for MUSC Finance and Administration. “To be ranked in the top five out of all major teaching hospitals is quite an accomplishment. The staff and management team have always been committed to quality and accuracy. This recognition confirms that.”   MUSC coding professionals are trained specialists who conduct their jobs 24/7. Each day their knowledge and experience are tested in areas including medical terminology, anatomy, pharmacology and understanding the clinical disease process. They interpret health record documentation, while referring to clinical information or references to provide a code assignment for in-patient and out-patient services. They embrace the complexity of their job by upholding the standards, ethics and legal responsibilities that correspond with hospital coding. Most importantly, HIS coders share a vital link to the clinical care team of physicians, residents, nurses, case managers, compliance and financial specialists and other hospital representatives.   According to Pletcher and Lewis, MUSC coders succeed thanks to a focused and cooperative team effort shared within Health Information Services and Patient Access Services, as with other medical center staff. In February, the department added the expertise of nurses as part of the Clinical Documentation Improvement Program (CDIP). CDIP nurses Colleen Gary, Tina Smith and Pam Parris work closely with coding staff to improve communications between clinical staff, thus enhancing documentation and coding efforts.      Other elements of success include an ongoing emphasis on hospital coder training, continuing education and development, plus professional certification. HIS coders must complete an annual self-assessment to keep up their credentials.   In addition to their standardized training, the coding staff also participate in statewide training or coding roundtables involving physicians, quality review specialists and other experts. As part of a clinical institution, coders are regularly invited to attend grand rounds sponsored by different disciplines to explain a new medical technique or introduce a new drug and it’s coding criteria for reimbursement.   For the past few years, HIS coders hosted internships for hospital coding students from Midlands Technical College in Columbia and Trident Technical College in Charleston. Other successful training program involved observing medical procedures taught by the specialists who normally perform them. Coders benefitted from watching a gastric bypass performed by Karl Byrne, M.D., or a coronary artery bypass graft by John Kratz, M.D.   “The staff has a more complete understanding about how specific medical procedures are performed and the accuracy of code assignments,” Lewis said. “It provides a fresh perspective to their jobs which is an improvement to just reading about it in a patient’s record.”   Aside from the awards and recognition, Pletcher is most impressed with the staff’s ability to succeed within an atmosphere of change. For the past decade, the field of health information management expanded to gradually merge health care with today’s latest technology. At MUSC, this progress extends to changes in the way health information travels, is interpreted and documented. Since the millennium, HIS gradually shifted away from their standard of maintaining paper files to providing a faster, multifunctional electronic medical records system.   “I’m impressed with the staff for adjusting and rolling through changes associated with electronic medical records,” Pletcher said. “Change, whether it’s positive or negative, expends a lot of energy. What’s important is how our staff and teams of extended clinicians learned to adjust to this huge transition. Everyone within Health Information Services and Patient Access Services has done a tremendous job converting from working with paper to working online with electronic medical records.”     Friday, Nov. 11, 2005 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.