Interview with Richard D. Pinson, M.D., on clinical documentation

You can listen here to the interview, linked in a recent issue of The Hospitalist. Dr. Pinson, who is a coding expert with HCQ Consulting, says there are two different worlds of documentation. There's ordinary clinical language, the terms doctors use to convey meaningful information and another type of language, a set of magic words and phrases which administratively define diseases and enable coding for higher DRG payments. Administrative types want you to translate true clinical documentation into the more lucrative but sometimes less meaningful administrative documentation. That, says Dr. Pinson, is a core skill for hospitalists. Funny.

He goes on to give a few examples. About 3 minutes in he talks about how the coders want us to make the completely meaningless distinction between “simple pneumonia” and “aspiration pneumonia.” I guess they haven't heard that the pathogenesis of all bacterial pneumonia, including ordinary pneumococcal pneumonia, is colonization followed by aspiration.