Better Record Keeping Drives Coding Evolution

Stories from the beginning of coding show us the importance of today’s more efficient electronic era.

By Barbara Fontaine, CPC
Survival demands evolution, and such is the case with the coding. Medical coding has come a long way since paper records and microfiche. The expectation for better record keeping and the trend toward using electronic health records (EHRs) are the driving forces behind upcoming changes. To provide you with a better idea of how far our industry has come, read the following “old time” coding stories from seasoned coding experts. If you haven’t already, I think you’ll quickly realize that evolution is a good thing.

In the Beginning, There Was Paper, No Coding, and No Compliance

“There was no coding, nor was there compliance. If the surgeon performed an appendectomy, we would just type ‘appendectomy’ on a claim form that had a piece of carbon between two sheets. The forms were typed up every day and the physician would sign each one. Then we mailed them out. Everything was documented on a handwritten ledger card. The providers charged according to what the carriers would pay. The idea was to not have any out-of-pocket expenses for those patients with insurance. Insurance was meant for catastrophic, mostly hospital services. There wasn’t obstetrics (OB) coverage unless a patient required a C-section (Patients would stay seven days in the hospital for that!). X-rays and labs had an annual diagnostic benefit (for a good policy) of $50-100 per year.
“When I worked as a claims examiner at Blue Cross in the 1970s, we’d batch claims in groups of 20 and we’d first check a patient’s eligibility via microfiche. If the patient was eligible for benefits, we’d calculate the benefits based on the patient’s plan. The group benefits were listed in large binders on our desks. We flipped through pages in the binder and ‘priced’ the line items. We’d then run a calculator tape on the amount that should be paid to the provider. Claims examiners had a quota to handle 10 claims per hour. When each batch was complete, an auditor would take the batch and randomly pull two claims out to quality check (QC). The expectation was a 90 percent accuracy rate. We had a saying in our group (amazing I still recall this), ‘If in doubt … route.’ If we had a question about a test, procedure or diagnosis, we’d route it to someone in medical review, who’d likely ask for medical records. When we routed a claim, we’d get credit for it as part of our quota of 10 claims per hour.”
Elizabeth Acquistapace, CPC

Handwritten Ledger Cards Were Stored Alphabetically in Metal Trays

“I remember the days when we had to take a ream of paper down and cut it to the size of statements (about half the size of a normal sheet), and then stand at the copy machine with a cassette that would hold them while copying each patient statement from their ledger card for monthly billing. After getting all the statements printed, we then had to sort and place stickers on them, such as ‘past due’, ‘please call,’ etc. Because there was never enough time during the day to stuff the envelopes, we’d take them all home and stuff them for mailing. When we finally got a postage meter, we thought we were in heaven because we could just run the statement envelopes through it and not have to lick each stamp.”
Margie Scalley Vaught, CPC, CPC-H, CPC-I, CCS-P, MCS-P, ACS-EM, ACS-OR

When Physicians Bought Personal Typewriters for Office Staff

“Boy, those were the days! I remember sitting at my desk with a manual typewriter and a stack of continuous claim forms behind my typewriter. I typed out each individual form for a skilled nursing facility (SNF) with Medicare A beds, and billed Medicare B supplies where possible. Make a mistake? Forget it and start over again, because trying to erase and correct mistakes just made a mess of the form and it wasn’t always legible.
“The senior physician’s wife did the coding and billing in the office while I managed the other aspects of the practice. I’ll never forget the day she walked into my office, slammed the CPT®, ICD-9, and HCPCS Level II books and said, ‘I’m outta here! You’re the coder!’ This was before coding was considered a profession. There wasn’t certification, much less classes, workshops, or networks. I’m amazed I managed to learn what I did without any resources at all!”
Linda Martien, CPC, CPC-H, CPC-I, CEDC

Do We Really Need a Book?

“No one taught me to use the ICD-9 book and I couldn’t figure out why there was an alphabetic section and a numeric section. I thought, ‘How silly! How would anyone remember numbers to look up codes that way?’ I didn’t know the chapter guidelines were there until a few years after I had been coding. Gee, they really do tell you how to use the book!”

Carbon Paper Days

“When I started all of this, diagnosis codes were written out and we handwrote or typed the information on forms using carbon paper so we had a copy. I spent a lot of days with blue fingers. I remember hospital charts in those little metal boxes with the flip tops because those were thought to be more sanitary.”
Donna Nugteren, CPC, CEMC

Finally, NCR Paper!

“I remember working in the emergency room (ER) of a small, rural hospital where our records were kept on a four-part, handwritten form. The top layer was the original and the three copies beneath were on no-carbon required (NCR) paper: one copy for the patient’s personal physician, one for any specialist referred to, and a copy for the patient. We thought NCR paper was really wonderful because we finally didn’t have to deal with carbon paper. The only problem was that if you forgot and picked up one of the clip boards and used it to write a note, a shopping list, or a phone number; it came through on the bottom three copies. You would not believe how hard it was to read those copies. One time, a primary care provider’s (PCP) office called our ER doctor to find out what he meant by the diagnosis BLTNM, only to find out it meant bacon lettuce and tomato, no mayonnaise—it was his lunch order.”
Barbara Fontaine, CPC

The Beginning of the “Electronic” Era

“My start began when IBM Selectric typewriters were used; I’m sure at the time they were cutting edge and quite costly. Today, when I Google ‘Selectric typewriter,’ I am directed to the Selectric Typewriter Museum. This shows just how far technology has come. Computers were used to enter patient demographics, charges, and payments back in the early 1980s; calculators were used to run a tape of verification on the total of charges and payments entered. Appointment books were used for scheduling. Insurance claim forms (prehistoric HCFA-1500s) were generated on a giant printer and initialed by a staff member who represented the provider. Secondary claims would get an explanation of benefits (EOB) strip, hand-cut from a copy of the full page (to keep patient privacy). Overtime occurred when the end of the month rolled around. Statements were generated on that same giant printer, hand sorted and separated, and envelopes were manually stuffed for mailing. Coding was much easier back in the day, CPT® codes were not required (Imagine that!). ICD-9 was the only code set to learn. There were no coding classes or any formal training.”
Brenda Edwards, CPC, CPMA, CPC-I, CEMC

The Electronic Revolution Is Here

Billing, coding, and documentation have come a long way and our past has brought us to an efficient, electronic revolution. Today we are looking at patient records on iPhones and other handheld devices. Prescriptions can be sent electronically to a patient’s pharmacy across the city, alleviating errors due to poor handwriting. Insurance policies can be verified immediately with a few keystrokes. The billing and coding world as we know it is changing and it’s changing fast. Where will we go from here?
Barbara Fontaine, CPC, serves on the AAPCCA board of directors and is business office supervisor at Mid County Orthopaedic Surgery and Sports Medicine, a part of Signature Health Services, a large multi-specialty organization. She served on several committees before becoming a local chapter officer. In 2008, she earned the St. Louis West, Mo. local chapter and AAPC’s Coder of the Year awards.

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