Song of a Story-Teller: Patient-Focused Coding

Have we lost the art of telling the patient’s story?

Coming off of two weeks of health information management (HIM) conferences and listening to presentations on incorrectly reporting combination codes and the importance of coded data for quality and data analytics, in addition to speaking on the topic of ICD-10-CM diagnosis coding in the outpatient setting, it appears to me that we’ve lost the art of telling the patient’s story.

Coders are pressured to meet strict productivity quotas while maintaining a 95 percent accuracy rate, and I think we’re losing sight of the fact that, first and foremost, we’re storytellers who convey each patient’s medical story through codes. In a world where chart counts and reimbursement seem to be the driving forces, the patient story is often an afterthought. The healthcare industry is full of articles about patient-focused care, so why aren’t articles about patient-focused coding just as prevalent?

I think any coding professional would agree that coding is not black and white. You can invoke the “if this, then that” rule up to a point, but what lies behind the documentation is the patient – a living, breathing person – who is unique and has a unique history. Quite often I hear someone ask how to code something to get the claim paid – and the short answer is, you don’t. We don’t code to get claims paid; we code to tell the patient’s story. In a perfect world, the documentation fully conveys the patient’s reason for visit, chronic and other conditions that impact patient care, and treatments provided. We code what is documented, the insurance company reimburses providers for covered diagnoses and treatment, and the data goes to a repository where it can be aggregated with other patient data for trending and reporting.

I can hear the cries of coders across the nation already. “But there’s productivity,” they say. “But it’s too hard to keep up on all the existing coding guidelines while learning about new ones,” they insist. I agree that it’s tough to keep up with frequent coding and reimbursement changes, but along with solid training and certification, continuing education is part of the core of the career coder. I argue that we spend so much time focusing on the transactional component of coding (i.e., number of cases coded) that we are quickly losing our ability to think of coding in relational terms. And in a time when we are seeing an uptick in reporting patient severity, clinical validation, and risk adjustment audits and claims denials, we can’t afford to think of coding as a transaction anymore. We are storytellers, and we have a commitment to patients to accurately translate their clinical accounts.

The Productivity Paradox
Does telling the patient’s story just tick away time on the clock, or does it make you more productive? My argument is for the latter. In the coding audits my team and I have performed, the number one variance is incorrect secondary diagnoses. Sometimes we see missed diagnoses, but more often we see overcoding of diagnoses that fall into what I like call the “who cares?” category. For example, say a 16-year-old patient presents to the emergency department with a fracture of the distal radius and also has a family history of colon cancer, personal history of appendectomy two years ago, and is allergic to penicillin. The patient is x-rayed and splinted, and told to follow up with an orthopedic surgeon. While there are Z codes for the family history of cancer and personal history of appendectomy and penicillin allergy, do we really care? What is nice to know, and what do we really need to know, about this patient? Precious time is wasted assigning these extra codes just because “there’s a code for that,” as seen in industry memes posted on social media. There are also a lot of words in the dictionary, but we don’t use all of them!

What about failure to refer to local coverage determinations (LCDs) to check for medical necessity because the coder doesn’t have time? I once had a manager tell me that checking for medical necessity should not be the coder’s responsibility, so they advised their staff to code signs and symptoms separately from related established diagnoses, “just in case” it was needed to get the claim paid, even though that is a blatant violation of coding guidelines. I refer you back to my introduction, and my statement that we don’t code for reimbursement, we code to tell the patient’s story.

Checking Your Work
In analyzing the results of coding audits, it’s easy to point the finger at coders for a knowledge gap or for coding too quickly, but with more organizations utilizing computer-assisted coding (CAC) technology, the issue may be more about retraining coders to check their work by reading the codes. CAC software assigns codes based on documentation throughout the record, but if coders aren’t validating each code, it’s them who will be “dinged” from coding audits, not the software. Since we’re trained to tell the patient’s story in codes, we are also skilled at reading the codes, and that should be the final step in any coding process before finalizing the account. 

The final codes on a claim should include all the “need to know” information about the case, and nothing more. As an auditor, I read the codes before I read the chart – much like reading the jacket cover of a book before buying it. It’s pretty disappointing when the jacket cover doesn’t adequately describe the book. The same can be said for codes that don’t match the story contained in the patient’s medical record. 

If you’re a coder and someone asks you what your job is all about, you can give a complex description of code sets, guidelines, and healthcare reimbursement. Or you can tell them what I do: I’m a storyteller who relates the patient’s encounter in secret code. Let’s face it, that sounds way cooler than droning on about documentation and ICD-10 anyway!

Programming Note:

Listen to Kristi Pollard report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.