Don’t Forget the Patients behind the Codes!

Don’t Forget the Patients behind the Codes!

There are people back there! So often, in our struggle with productivity and accuracy expectations, I’m afraid we’ve lost sight of the real people to whom our code assignments will be permanently attached. Patients have lives, families, employment and financial interests that could all possibly be negatively impacted by these codes. I want to let that sink in before I place that debatable code on the claim.

What is your motivation for assigning those codes? Why are you querying? Is it strictly for an increase in reimbursement or are you driven by the ethical coding principle that the encounter should be an accurate reflection of the severity of the patient’s condition and the intensity of the services rendered for that episode of care? These may seem like strange questions, but they are some we should not ignore.

Their significance was driven home to me at a meeting of the ICD-10 Coordination and Maintenance Committee, when a physician presenter stated these very foundational concepts as he told of a patient whose claim was given coded data that did not accurately depict his condition. This particular error was two-fold: the lack of a specific code for his condition and the error in the nomenclature describing this particular classification of disease, neither of which was the fault of the patient – but the outcome was the same! The young man now has a diagnosis on his health record, thanks to a code, that will be very difficult to change and it could negatively impact his future!

Here are some questions to consider when coding or formulating a query:

  1. Does the condition meet criteria for reporting? The rules for assigning additional diagnoses are clearly laid out for us in the ICD-10-CMOfficial Guidelines for Coding and Reporting.
  2. Is the condition an exception to the inpatient “Uncertain Diagnosis” guideline? HIV is one of those.
  3. Has the clinical significance of the condition been established by the physician and supported in the documentation?
  4. Is there agreement in the record among providers as to this diagnosis? If not, the attending physician will have to resolve that issue.
  5. Has the entire record been reviewed? Coding data comes from much more than just the discharge summary!
  6. Will this code assignment have negative implications for the patient? (This answer will not be the determining factor in whether to assign the code or not, but it does give us pause to consider those impacts.)

In our zeal for reimbursement, we dare not forget the human element of our work! Not that our job isn’t stressful enough already, but this is another dimension that certainly deserves our consideration every time we code an encounter. As an auditor, I’ve seen many instances where inappropriate queries were placed due to the lack of clinical evidence. I wonder how we would feel if that query were on our own record? One instance that stands out in my memory was a query for opioid dependence on the record of an elderly patient suffering from severe osteoarthritis of the spine. As it turned out, the medication had been prescribed PRN, and the patient had not even taken any of it! All that information was contained in the record, but either was disregarded or overlooked.

In the larger picture, these same codes on the individual claims will be the means of determining the incidence of disease, population-wide; and therefore, the necessity for coding accuracy can’t be overemphasized. The validity of our statistical data depends on it, and there are lots of dominoes attached to that. My students know that I am a stickler for coding every encounter comprehensively and accurately, according to the conventions of the Classification and the ICD-10-CM Official Guidelines for Coding and Reporting. If we do that, there will be those times when the codes will have an unavoidable negative impact, but at least we will have given the human element the consideration that it is due.


Katherine Isbell, RHIA, CDIP, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer

LexiCode Education Services Manager

“We recommend LexiCode without hesitation. For many years, LexiCode’s has provided high quality audit services to support our compliance program. The formal audit deliverables and reports far surpass any I have seen in the industry; they translate all of the audit data into meaningful and useful information. All other aspects of the audit process demonstrate a commitment to excellent customer service. We also love the annual coding education modules that LexiCode offers!”

Rachel C. Sherksnas, RHIA, VP Health Information Management
Post Acute Medical