Taking Coding to the Next Level through Clinical Validation
Health information management (HIM) is a discipline that has rapidly evolved toward roles of increasing complexity and demand in recent years and the coding profession has been one area at the center of this growth. Even though the HIM profession is currently rethinking their coding and clinical processes due to widespread industry changes and initiatives, it has always been essential for coding professionals to have ongoing professional development.
Enhancing clinical knowledge through education and resources is essential. The following is an excerpt from an article developed by the 2013 AHIMA Coding Community Council to discuss approaches to achieving accurate coding/documentation, supported by clinical validation. The full text of the article is available in AHIMA’s HIM Body of Knowledge.
Advancing the Coding Profession: Communication Skills, Clinical Skills, and Credentials
A coding professional must have a solid base of medical terminology, anatomy, pathophysiology, and pharmacology. It’s not enough to see a diagnosis, sign, or symptom documented in the medical record. Coding professionals must take the time to look it up in the book or encoder and add it to the list of codes. Clinical knowledge is put to use continuously along with coding rules and guidelines to make the proper code assignment.
Consider the following scenario for example: a 23-year-old female presents to the emergency room with the sudden onset of severe pelvic pain, vaginal bleeding, and lightheadedness. She has a history of multiple abdominal surgeries. Positive smoker, 1 pack per day. Serum β-hCG levels were elevated. The patient was diagnosed with an ectopic pregnancy and transferred to the OR.
Without knowing the pathophysiology and clinical picture of an ectopic pregnancy, an untrained person may code the pain, bleeding, lightheadedness and abnormal lab values in addition to the ectopic pregnancy, where a trained coder knows all of these are signs and symptoms of the definitive diagnosis and are not coded.
Communication skills, both oral and written, are essential, as well as the ability to effectively interact with all types of clinical staff including physicians, mid-level providers (i.e., physician assistants, nurse practitioners), nurses, technicians, and therapists from many different specialty areas:
- Surgical/Operating Room
- Cardiovascular/Catheterization Lab
- Orthopedics/Physical Therapy
- Critical Care/Respiratory Therapy
- Emergency Department
Where many professionals are well versed in one or two specific areas, a coding professional must be knowledgeable in all body systems and know how to convey the information concisely and in several different styles:
- Face-to-face or written queries
- Coding education to providers and staff
- Appeal letters
- Day-to-day interaction
- Coding questions
The ability to formulate a query with clinical evidence from the medical record will garner the attention of the provider and decrease the likelihood of an unanswered question. The ability to speak with a provider in clinical terms about disease processes and formulate intelligent questions will gain the respect of the provider and increase the likelihood of successes in the future. Providers will also be more likely to listen to those who are clinically knowledgeable when being educated about coding issues, which is of utmost importance as we move closer to the implementation of ICD-10-CM/PCS.
The ability to speak to or query a provider or write an effective appeal letter with the clinical knowledge of a disease process further supports the importance of and the need for a coding professional in the clinical validation process.
In the transition to ICD-10-CM/PCS, coding documentation will be even more important as will the need for coders to translate that clinical documentation to the new code set. Just the sheer volume of added codes will require more analysis and research by coders. This is the time for coders to take the opportunity to expand their skills on the clinical side of coding and strengthen their position in the industry. Most coders are being given the chance to sharpen their clinical knowledge by their employers and they should all take that opportunity to grow their skills. It is a great time to increase their confidence in the very important position that they are in and capitalize on the opportunities that ICD-10-CM/PCS will bring.
One way for coding professionals to demonstrate their advanced clinical knowledge is by attaining the Certified Documentation Improvement Practitioner (CDIP) credential. Professionals earning the CDIP credential will be distinguished as knowledgeable and competent in clinical documentation in patient health records and be positioned as leaders and role models in the HIM community.
Cathy Brownfield, RHIA, CCS
Karen Cole, RHIT, CCS-P, RCC, CPC-H, CGCS
Kathryn DeVault, RHIA, CCS, CCS-P
Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM
Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
Kim Huey, MJ, CPC, CCS-P, CHCC, PCS, CHAP
Tedi Lojewski, RHIA, CCS, CHDA
Pat Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC
Ginny Martin, RHIA, CCS
Donna Wilson, RHIA, CCS, CCDS, CPHM