The Clinical – Coding Disconnect!

By Andrew B. Maigur, MD, system director, Premier Physician Advisor Program

During our clinical practice as providers, we often receive queries from CDI (Clinical Documentation Integrity) specialists and coding specialists about our electronic medical record (EMR) documentation. Often from a clinician’s point of view, I felt the answers to these questions were obvious or at least implied. They occasionally left me scratching my head as to “WHY”I was being asked these questions. Having worked as a CDI Physician Advisor, I have come to appreciate the complexities in the world of CDI/coding and the clinical disconnect it can create. With the dawn of the ICD-10 (International Classification of Diseases), the coding system came with specificity, coding rules, and hierarchies that affected our clinical documentation requirements. I also realized that as a clinician, my thought process or reasoning was often in my head but never translated or documented in the EMR. Let me give you two examples to highlight the clinical coding disconnect.

“History off….”: a term that is embedded into our vocabulary from medical school. Often you find “History off….” documented in the HPI (History of Presenting Illness) or past medical/surgical history sections of the EMR. In a clinician’s mind, it denotes the presence of a medical condition diagnosed in the past but concurrently contributes to the patient’s medical complexity. However, in the coding world, “History off…” describes a medical/surgical condition that occurred in the past and is now inactive, not being treated or monitored, and does not contribute to the concurrent severity of illness (SOI); risk of mortality (ROM) or medical complexity of the patient. “History off…” when documented in your assessment and plan leads to ineffective documentation.

• “History of Hypertension” and the patient is on three blood pressure medications-not OK, instead document “Chronic/Essential Hypertension”
• “History of Chronic Kidney Disease” not OK when an active medical condition, instead document “Chronic Kidney Disease”
• “History of breast cancer s/p mastectomy and chemotherapy” is OK because it is resolved and not currently being treated

Another example is the term “post-op”, often used by clinicians to denote a time frame, the “post-operative period.” In a clinician’s mind, any condition that occurs within this period is frequently documented as a “post-op” condition, e.g., post-op respiratory failure or post-op anemia. However, in the coding world, the term “post-op” denotes a complication directly caused by the surgical procedure. It often leads to assignment of “complication” codes, negatively impacting quality metrics for the surgeon and the facility. The term “post-op” should only describe the number of days since the operation was performed. Alternatively, document the new condition but that it was expected after the surgical procedure-when clinically appropriate.

• Example: “Post-op Ileus,” which leads to a complication code (K91.89) versus “Expected ileus after colectomy,” which allows the coder to code the ileus, accurately portraying the patient’s SOI/ROM but without using the complication code and without querying the provider

In conclusion, remember to capture (within the EMR) your rationale when making a diagnosis, ordering investigatory tests, and determining an appropriate treatment plan. “Think in Ink,” or in today’s world of the EMR, “Think in Clicks.” Answer your CDI and Coding queries promptly; they have a good reason to ask the question. The “I” in CDI stands for Integrity; we owe our patients an accurate medical record. Happy Documentation!

Back to the September 2022 issue of Premier Pulse