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Anecdotes are no way to make (or complain about) policy. But they can be instructive, almost like case reports. Therefore, to start the conversation about coding, I’ll share two of my favorite gems that demonstrate how coding (and coders) have run amok.
Both examples were used by compliance officers to provide instruction on ways to document in the medical record, in order to minimize the risk of "fraud" and maximize billing.
The details have been modified to protect the innocent.
Example 1: A previously healthy patient was flown in by helicopter to our cardiac care unit after suffering a cardiac arrest. Nearly 3 hours of bedside care, resuscitation, imaging, intervention, and discussions with the family led to a diagnosis of malignant pericardial effusion. The patient survived the day and was eventually moved out of the CCU to the care of my oncology colleagues. The initial care on the day of admission was deemed to be at level 4 because neither attending physician (me) nor house staff had documented family history. I asked "What does family history have to do with a malignant pericardial effusion?"
Example 2: In the outpatient setting, a complex 77-year-old with advanced heart failure and coronary artery disease under consideration for a destination ventricular assist device was likewise recoded as a level 4 (from a level 5) because I had failed to document family history. I asked "What does family history have to do with a patient of that age who already has documented coronary disease?" After all, family history is relevant only to the extent that it informs the probability of finding disease in a given patient. It’s Baynes' theorem at work.
So what do these experiences tell us?
First, the coding rules are capricious, and coding criteria are often divorced from patient complexity and decision making. Second, family history matters, even when it doesn’t.
Of course, I could opt to fight the coding system, the coders, and the policies underlying the coding. Or, I can now list family history in my progress notes on centenarians. Guess which option I picked?
Dr. Paul J. Hauptman is Professor of Internal Medicine and Associate Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.
Anecdotes are no way to make (or complain about) policy. But they can be instructive, almost like case reports. Therefore, to start the conversation about coding, I’ll share two of my favorite gems that demonstrate how coding (and coders) have run amok.
Both examples were used by compliance officers to provide instruction on ways to document in the medical record, in order to minimize the risk of "fraud" and maximize billing.
The details have been modified to protect the innocent.
Example 1: A previously healthy patient was flown in by helicopter to our cardiac care unit after suffering a cardiac arrest. Nearly 3 hours of bedside care, resuscitation, imaging, intervention, and discussions with the family led to a diagnosis of malignant pericardial effusion. The patient survived the day and was eventually moved out of the CCU to the care of my oncology colleagues. The initial care on the day of admission was deemed to be at level 4 because neither attending physician (me) nor house staff had documented family history. I asked "What does family history have to do with a malignant pericardial effusion?"
Example 2: In the outpatient setting, a complex 77-year-old with advanced heart failure and coronary artery disease under consideration for a destination ventricular assist device was likewise recoded as a level 4 (from a level 5) because I had failed to document family history. I asked "What does family history have to do with a patient of that age who already has documented coronary disease?" After all, family history is relevant only to the extent that it informs the probability of finding disease in a given patient. It’s Baynes' theorem at work.
So what do these experiences tell us?
First, the coding rules are capricious, and coding criteria are often divorced from patient complexity and decision making. Second, family history matters, even when it doesn’t.
Of course, I could opt to fight the coding system, the coders, and the policies underlying the coding. Or, I can now list family history in my progress notes on centenarians. Guess which option I picked?
Dr. Paul J. Hauptman is Professor of Internal Medicine and Associate Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.
Anecdotes are no way to make (or complain about) policy. But they can be instructive, almost like case reports. Therefore, to start the conversation about coding, I’ll share two of my favorite gems that demonstrate how coding (and coders) have run amok.
Both examples were used by compliance officers to provide instruction on ways to document in the medical record, in order to minimize the risk of "fraud" and maximize billing.
The details have been modified to protect the innocent.
Example 1: A previously healthy patient was flown in by helicopter to our cardiac care unit after suffering a cardiac arrest. Nearly 3 hours of bedside care, resuscitation, imaging, intervention, and discussions with the family led to a diagnosis of malignant pericardial effusion. The patient survived the day and was eventually moved out of the CCU to the care of my oncology colleagues. The initial care on the day of admission was deemed to be at level 4 because neither attending physician (me) nor house staff had documented family history. I asked "What does family history have to do with a malignant pericardial effusion?"
Example 2: In the outpatient setting, a complex 77-year-old with advanced heart failure and coronary artery disease under consideration for a destination ventricular assist device was likewise recoded as a level 4 (from a level 5) because I had failed to document family history. I asked "What does family history have to do with a patient of that age who already has documented coronary disease?" After all, family history is relevant only to the extent that it informs the probability of finding disease in a given patient. It’s Baynes' theorem at work.
So what do these experiences tell us?
First, the coding rules are capricious, and coding criteria are often divorced from patient complexity and decision making. Second, family history matters, even when it doesn’t.
Of course, I could opt to fight the coding system, the coders, and the policies underlying the coding. Or, I can now list family history in my progress notes on centenarians. Guess which option I picked?
Dr. Paul J. Hauptman is Professor of Internal Medicine and Associate Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.
