An interesting paper in CMAJ Open reports on a series of interviews with coders concerning their perceptions of their interactions with doctors. The study was done in Canada but it rings true to what we experience in the US. The fundamental objective of coding is the same: to translate information about the patient’s story into a series of numeric ICD 10 codes for various administrative purposes. Several themes emerged from these interviews. Form the abstract of the paper:
Five themes emerged regarding physician-related barriers in coding of high-quality administrative data: 1) coders are limited in their ability to add to, modify or interpret physician documentation, which supersedes all other chart documentation, 2) physician documentation is incomplete and nonspecific, 3) chart information tends to be replete with errors and discrepancies, 4) physicians and coders use different terminology to describe clinical diagnoses and 5) there is a communication divide between coders and physicians, such that questions and issues regarding physician documentation cannot be reconciled.
Physicians play a major role in influencing the quality of administrative data. There is a need for physicians to advocate for culture change in physicians' attitudes toward coders and chart documentation, in recognition of the importance of accurate chart information.
So the bottom line is that there is a significant divide between physicians and coders and it's all the physicians’ fault.
But let's unpack this. The coders perceive that physician documentation is "replete with errors and discrepancies.” We are repeatedly admonished by coders to "document correctly". But what does that really mean? In the coding world it means using terms that align with administrative language. A nuanced account by the physician detailing all the complexities and uncertainties in the patient’s diagnosis and treatment is unlikely to pass muster.
The coders also complained that doctors are often not specific enough. What they fail to realize is that often we don’t have enough information to make a specific diagnosis in which case we must simply state the patient’s problem at the level of resolution we have, and not attempt to go beyond that. To do so, to be too specific too early, increases the risk of real diagnostic error. It’s a fundamental principle that Lawrence Weed, the originator of the problem oriented medical record, taught us decades ago.
The authors of the cited paper got one thing right though. Coders and doctors are operating with two separate languages: clinical language and administrative language. Clinical language tells the patient’s story and acknowledges all the uncertainty in the clinician’s reasoning process. You lose a large piece of that when you try to reduce that story to a list of codes. Doctors need to stand up for meaningful clinical documentation. Tension invariably results. Don’t expect medical record chaos to end any time soon. Remember above all: words are supposed to mean things.