Remote coding takes every piece of information from an outpatient’s visit to the doctor, codes it and makes the information easy to assess. The coded information gives Landstuhl Regional Medical Center the ability to increase manpower or equipment based on workload.
“Coding is necessary to validate the manpower, budget and equipment needs to maintain the hospital at optimal level,” said Lt. Col. Aaron Tucker, LRMC chief of medical records. “If a doctor is doing a whole lot of one particular procedure (brain trauma), the code will represent that in the report and a decision like, ‘We may need another physician,’ can be made based on the empirical data.”
Due to the location of LRMC, it is not easy to recruit and hire qualified coders. The most viable solution is to outsource the work to a company in the states. In LRMC’s case, that company is Standard Technology Incorporated, located in Falls Church, Va.
The coding works in conjunction with the Composite Health Care System II, the program responsible for the electronic medical record. The primary health care provider will input all information into system, which will automatically code the outpatient visit. Information for which there is no pre-existing code, such as a doctor’s notes, must be deciphered and coded by the online coders.
The stateside company has access to CHCS II and all documents are securely extracted from it. It audits and validates the codes, thus ensuring maximum credit to the respective clinics and health care providers. This will ensure correct billing to the patients and proper payment to the hospital, said the colonel.
For example, say a patient has a foot ailment. While in the doctor’s office, the patient brings up another complaint – getting more cholesterol medication – for which the doctor orders lab work. However, the doctor doesn’t include this in the report because the patient was there for a foot problem and this was just a concern brought up toward the end of the visit. All is well until it comes time for the insurance company to pay, which it can refuse to do based on no documentation of the lab work.
“It’s about capturing all of the money owed to this facility and being able to staff it according to the workload,” said Colonel Tucker. “This coding process is how we communicate with insurance companies. It makes sure that doctors get credit for everything they do.”
Having empirical data to justify increases in workload makes it much easier for LRMC to maintain its high-quality patient care, he said.