The challenge for coders is not so much that there is no physician documentation; it’s that the documentation they have does not provide them with what they need to assign an accurate and specific code.
This article orginally appeared on JustCoding.The coding function would not exist if there were no physician documentation from which to code. Some say that’s true today—yet we continue to code! The challenge for coders is not so much that there is no physician documentation; it’s that the documentation they have does not provide them with what they need to assign an accurate and specific code.
The reason for this is that the physician is capturing the clinical nuggets he or she needs. “The physician mind is focused on the associated process of evaluating, treating and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language, and [that language] certainly is not about codes” (Insights from the HCC, n.d.).
Many hospitals have implemented clinical documentation programs to coach physicians on the documentation elements required for the hospital to optimize its coding efforts. However, when physicians don’t feel they or their patients benefit from efforts to alter documentation practices, they are quick to disengage. Physicians are accustomed to being paid by their evaluation and management level, not their diagnoses.
Thus, the lack of precision of documented conditions, such as pancreatitis without specifying whether acute, idiopathic, alcohol-induced, sclerotic, or not indicating length of laceration or use of anesthetic or even providing details without a diagnosis (e.g., glomerular filtration range provided to indicate stage of kidney disease) is not unexpected according to Lucyk et. al. from the University of Calgary (Lucyk, Tang, & Quan, 2016). No, it’s not just a United States problem.
At the office
For the physician practice, the superbill, or encounter form, often contributes to incomplete, unspecified, and inaccurate coding. The superbill often lists the most common diagnoses seen in the practice.
Conditions treated may be forced into those listed on the form or not captured at all. If the physician documents the condition, it may be generic (e.g., asthma, without indication of whether it’s intermittent, persistent, mild, moderate, or severe). In preparation for ICD-10, many practices took the convenient route and selected the unspecified code for each of their most common diagnoses. Therefore, the more specific ones are not on the form to be selected. Even if the physician uses the electronic health record (EHR) for diagnosis selection, when a long list of choices appears for the condition, it is unlikely that the physician will take the 30–60 seconds to glance down the list to find the specific one; worse yet, the condition that previously had a code may no longer have one (e.g., accelerated hypertension). The physician may believe that for the current state, diagnoses may not be needed for reimbursement purposes, but that’s short term, with the advent of risk-adjusted reimbursement. Additionally, the specificity may be short term as well, with CMS’ stated intent to deny many unspecified codes.
Helping the physician help us
For the physician practice, if we desire details, we need to push some of the responsibility out to others in the practice. It should start at the front desk when the appointment is made and the health questionnaire is returned from the patient. That is when, at minimum, duration or date of onset can be obtained.
I recently spoke about the value of using the medical assistant (MA) to help with securing some of the diagnosis details needed for ICD-10 and augmenting the physician’s efforts. Physicians can benefit from the talents of their MAs and possibly in areas other than ICD-10.
MAs are typically members of the physician office team. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes.
They are one of the first clinical team members to speak with the patient, often collecting the patient’s initial history information, capturing specimens for lab tests, and in some states placing, initiating an IV, and administering IV medications. Since organizations are struggling with capturing start and stop times for IV infusions, perhaps the MA may be another option for capturing start and stop times.
Given their understanding of medical terminology, and with an orientation to ICD-10 code requirements, MAs can quiz the patient and capture some of the details often overlooked by physicians. MAs can save physicians time, supplement the physician’s documentation, and help the physician select a more specific code.
If we look at the ICD-10 injury code elements, most of the elements can be captured in whole or in part by the MA in a short interview with the patient:
- What was the injury? The MA can query the patient for this information and capture “upper/lower” and laterality, as well.
- When did it happen? The MA can help the physician establish whether this is an initial encounter for active treatment, whether the patient is in the healing stage, or if the condition is sequela.
- Where did it happen? Knowing the patient fell at home will not get us to the most specific code.
- We need to know where in the home, and sometimes even need to ask for the type of home.
- What was the patient status and what was the patient doing when the injury happened? If the patient has been bitten by a cat, it may be attributed to a patient status of other, but if the person bitten by the cat was a vet tech when she was holding the cat for the vet to give it an injection, the status leads to an activity for income. Assigning the code for the activity of “holding a cat” would lead to the Y code for animal care.
This example shows us that with a little bit of prodding from the MA, we can get the additional information we need for a specified code.
How about hierarchical condition categories? We know that these are driven by chronic conditions, and our physicians occasionally miss documenting all the conditions. The MA may be able to preview the patient’s health questionnaire and highlight conditions that the patient notes. The MA may be able to prompt the patient for some additional amplification on the condition, like how long has the patient had the condition or whether another physician is treating the patient for it, or what medications the patient is taking for the condition.
The MA may transcribe dictation for the practice already. Perhaps the MA could serve as a scribe and enter the physician’s findings into the EHR as the physician dictates them while the physician examines the patient. This will save the physician time and may provide for a more comprehensive progress note in the EHR.
Finally, medical necessity. The MA often is the individual who performs in-office testing. Medical assistants with a knowledge of national and local coverage determinations can prompt the physician to properly link the diagnosis with the test to avoid medical necessity denials.
Editor’s note: Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management (HIM) consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article is excerpted from JustCoding's Practical Guide to Coding Management.