Health Information Management

Crossing the divide: Closing the language gap between coders and physicians

JustCoding News: Outpatient, May 16, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

 Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder.

This language barrier looms even larger as ICD-10 implementation draws closer. As specificity increases, so does the need for more detailed documentation.

Improving documentation should not be about coders versus clinicians. “At the end of the day, good documentation is really about good patient care,” says Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of ICD-10 education and training for the AAPC in Salt Lake City, Utah.

A patient’s record is used for more than just coding, Buckholtz says. It is also used for:

  • Quality measures
  • Decision support
  • Risk prediction
  • Policy development

So coders, clinicians, and payers need to be able to look at the record and know exactly what is happening with the patient, Buckholtz says.

ICD-10 also has the potential to change the way coders and physicians interact, she says. The level of specificity will present challenges for both clinicians and coders, so teamwork is essential.

It’s critically important to have better communication,” adds Joseph Nichols, MD, a board-certified orthopedic surgeon and medical director for healthcare informatics with ViPS, based in Baltimore.

Change coming with ICD-10
ICD-10-CM introduces new concepts and requires greater specificity, while ICD-10-PCS procedure coding represents a completely new system. The changes and new concepts in ICD-10 include:

  • More specific anatomical locations
  • Laterality
  • Classifications
  • Functional impairments
  • Sequelae
  • Complications
  • Etiology
  • Environmental impacts

“Specific anatomic locations make a big difference in clinical care,” says Nichols. A three-inch difference in the location of a fracture can change the patient’s risk and mortality. If physicians don’t document the location with enough specificity, the coders won’t be able to assign the most detailed, accurate code. As a result, the documentation and coding don’t represent a true picture of the patient’s condition.

The increased specificity in ICD-10-CM will also show up when physicians treat a Salter-Harris fracture of the bone plate. Salter-Harris fractures are classified by location and severity. For example, a level I Salter-Harris fracture indicates a break through the bone at the growth plate, separating the bone end from the bone shaft and completely disrupting the growth plate. A level IV Salter-Harris fracture breaks through the bone shaft, the growth plate, and the end of the bone.

The level of Salter-Harris fracture makes a big difference in how the physician treats the patient and what outcome the physician expects, Nichols says. In ICD-10-CM, coders will be able to report exactly what level of Salter-Harris fracture a patient suffered and which bone is involved, provided the clinician documents the information.

For example, a patient may suffer a Salter-Harris fracture of the arm. In ICD-10-CM, coders need to know:

  • Laterality—which side of the body
  • Specific bone—humerous, radius, or ulna
  • Location of break—upper or lower end
  • Level of Salter-Harris fracture—I through IV

So if a patient suffered Salter Harris Level III physeal fracture of lower end of the humerus of the right arm and is seen for an initial visit, coders would report S49.131A. However, they can only do that if the clinician documents all of the necessary information.

In ICD-10-CM, physicians will also need to alter the way they document some conditions, such as diabetes. In ICD-9-CM, coders need to know if the diabetes is controlled or uncontrolled. That distinction disappears in ICD-10-CM.

In ICD-10-CM, the diabetes mellitus codes are combination codes that include the:

  • Type of diabetes
  • Body system affected
  • Complications affecting that body system

These combination codes make coding diabetes mellitus less confusing and decrease the number of codes necessary to describe diabetic complications, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro Inc., in Danvers, Mass. Coders may report as many combination codes as needed to fully describe all complications. Coders should sequence the codes based on the reason for a particular encounter.

If provider documentation includes words such as uncontrolled, out of control, or poorly controlled, coders should report the type of diabetes with hyperglycemia.

Problems from a coder’s perspective
Coders and clinician see the language barrier and its associated problems from different perspectives. Coders are sometimes reluctant to interact with physicians, Buckholtz says. “They don’t feel qualified to tell the physician what he or she should be documenting.”

Coders are also often removed from the day-to-day operations, which makes it harder for them to interact with physicians.

In addition, coders may also think they are consistently asking for the same information over and over. They may also be afraid to take a stand because they fear retribution from an unhappy provider.

Problems from a physician’s perspective
Clinicians don’t always understand what coders do. They may view coders as a necessary part of the business, but not as partners in taking care of patients, says Nichols.

Clinicians often view coding as an administrative task, Nichols says. It doesn’t help them take care of patients. They know it influences payment, but may assume someone else is taking care of coding.
Clinicians are often bothered by repeated queries from coders and don’t know why the coder keeps asking them for certain information, Nichols says. “They wonder why others want to know about their interactions with patients. They view patient interaction as private.”

Physicians can also become frustrated because what is obvious to them isn’t obvious to everyone else, Nichols adds.

Physicians are also struggling with the financial impact of various healthcare initiatives, such as ICD-10 and HIPAA version 5010, combined with decreased reimbursement.

Physicians also need to remember that it’s not all about them, Nichols adds. A lot of people are involved in healthcare. “[Physicians] are a part of it, but we aren’t the center of the universe,” he says. That should be the patient. “We want the best information possible about the patient.”

Solution: Define a common goal
Closing the distance between coders and clinicians is about changing the mindset, Nichols says. “It’s not about coding. It’s about patient care.”

Coders and clinicians already share values, Nichols says, but don’t communicate well.

Coders know they need to assign the code with the highest level of specificity, Buckholtz says. The number of additional codes in ICD-10 isn’t overwhelming, she says. “Coders need to work with clinicians to be able to get the best quality data.”

The goal for both clinicians and coders is to “represent as accurately as possible the patient’s clinical condition,” Buckholtz says.

Physicians understand the importance of good documentation, but just don’t document well, Nichols says. Physicians are going to take a productivity hit after the switch to ICD-10, just like coders, he adds. “They have to go back and document better, which is what they should have been doing all along.”

One way coders can help physicians improve documentation for ICD-10-CM is to provide physicians with a list of information coders need in order to assign codes for a certain condition, Nichols says.

Coders and physicians also need to create an open dialogue, Nichols says. Talk to the other group and say, here’s what our problems are, here’s what we think your problems are, then work to find middle ground.

Clinicians can educate coders about the medical conditions, while coders can educate clinicians about coding.

“Nobody can be an expert overnight,” Buckholtz says. “We need to exercise a little bit of patience.”

Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Most Popular