Clinical Documentation Improvement and Coding During a Pandemic: Three Lessons Learned on the Front Lines

COVID-19 has prompted a look-back on my experience working as a pulmonary critical care physician for more than three decades, specifically during three infectious disease pandemics: HIV/AIDS, H1N1, and COVID-19.

Although AIDS, H1N1, and COVID-19 were vastly different, one commonality stands out: Physicians create the clinical story. It is their documentation that provides the narrative.

In the clinical story, the plot and themes of the patient’s condition unfold. And, in my experience, it is also where the true nature of a pandemic is exposed.

Increasingly, coding professionals and clinical documentation improvement (CDI) professionals help physicians tell that story by guiding them and ensuring their documentation translates to accurate coded data. The value of these efforts cannot be underestimated. Coding and CDI professionals help physicians become more effective clinical historians.

As I reflect on each pandemic, three lessons come to mind. My hope is that these lessons will help provide insight into the challenges and opportunities inherent in coding and CDI during a pandemic.

1. Information Dissemination Is Paramount

The AIDS epidemic began in 1981, first with reports of previously healthy gay men dying of unusual infections. I was training as a fellow at the University of California, San Francisco, where I treated some of the very first patients diagnosed with AIDS. It was unsettling to see young, recently healthy men come into the hospital and die six weeks later. At that time, the medical community did not understand transmission of AIDS, and healthcare workers in close contact with patients were terrified.

Information transfer was terribly slow in 1981. It took two years to publish information in a peer-reviewed journal and the only rapid source of information was the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report—a 10-page paper report physicians received by mail. Because information moved so slowly, it took the medical community significant time to identify the specific virus that caused AIDS and to better understand transmission methods. It wasn’t until 1983 that we had a study, in the journal Science, reporting on a retrovirus, later named human immunodeficiency virus (HIV) that was the cause of AIDS.

In December 2009, H1N1 came onto the scene. At the time, I was part of Memphis Lung Physicians Foundation, a group of pulmonary critical care physicians who provided 24/7 coverage in an intensive care unit for a 500-bed hospital. By March 2010, H1N1 was gone. During that relatively brief period of time, physicians struggled to understand what was happening and why. Thankfully, information flowed much more quickly than it did during the AIDS epidemic. The medical community soon discovered that this particular strain of the influenza virus was one against which the flu vaccine didn’t offer any protection. People over the age of 60 were more immune to the strain, while younger people tended to have a more severe reaction. Healthy, young people would come into the hospital with the flu. Then they would get pneumonia and adult respiratory distress syndrome. Then they would die.

During the COVID-19 pandemic, information dissemination has been faster than ever before. For example, the Johns Hopkins University of Medicine’s Coronavirus Resource Center provides physicians with critical COVID-19 data updated every 24 hours. The CDC’s website is also updated frequently, providing physicians with near real-time data and clinical care information. In addition, the National Institutes of Health provides timely updates to treatment and management protocols. Access to information has clearly not been a challenge during COVID-19.

What has been challenging is filtering out inaccurate or outdated information. As guidelines and advice evolve—sometimes daily—it is often difficult to stay abreast of the changes. This has been true on the clinical side, and it has also been true for coding professionals and CDI specialists. Managers have had to ensure that staff rely on the most updated and accurate guidance as they query physicians and assign medical codes based on physician documentation. This hasn’t been easy. ICD-10-CM coding guidelines have changed frequently, with the most updated version published for Fiscal Year 2022. New medical codes have also been released throughout the course of the pandemic—six new codes became active on January 1, 2021:

• Z11.52 – Encounter for screening for COVID-19
• Z20.822 – Contact with and (suspected) exposure to COVID-19
• Z86.16 – Personal history of COVID-19
• M35.81 – Multisystem inflammatory syndrome (MIS)
• M35.89 – Other specified systemic involvement of connective tissue
• J12.82 – Pneumonia due to coronavirus disease

There are also more new codes coming in April of this year. To ensure data integrity, everyone must play their part in staying up to date on these changes. Internal resource libraries as well as ongoing education and auditing have become essential.

2. Staffing Shortages Directly Impact Documentation and Coding

Although we saw some healthcare workers withdraw from patient care during the AIDS and H1N1 crises, nothing compares to the staffing shortages hospitals have experienced during COVID-19. I personally was well on my way to retirement when physician shortages began. I decided to work part time as a night intensivist in a 220-bed hospital’s 36-bed ICU to do my part and help out during the crisis, and I continue to serve in this role. Many other physicians have done the same.

Staffing shortages are a serious concern. Today’s healthcare organizations face voluntary turnover rates at nearly 25 percent and rising. A 2021 Washington Post-Kaiser Family Foundation survey found that nearly 30 percent of healthcare workers are considering leaving their profession altogether. Ninety-four percent of healthcare organizations say filling clinical staff vacancies continues to be a challenge.

Staffing shortages, particularly with nursing shortages, can cause a lack of resources available for CDI efforts. Many CDI professionals have been pulled into direct care roles, leaving fewer CDI professionals available to query physicians. Fewer queries potentially lead to data integrity problems that can jeopardize public health surveillance and monitoring. What happens when there is a backlog of patients, many of whom are sicker because they have avoided or delayed preventive care? What will this mean for CDI? What if there are not enough CDI professionals to ensure documentation integrity for this more severe patient population? This could have a negative domino effect on patient care, outcomes, and revenue.

In addition, coding professional shortages affect a healthcare organization’s ability to translate clinical documentation into coded data in a timely manner. When organizations do not have enough coding professionals, cash flow bottlenecks can directly impact the ability to invest in patient care initiatives. Healthcare organizations continue to explore ways to leverage outsource partnerships, refine employee engagement strategies, and pursue automation to address these challenges.

3. Coded Data Is Critical

Those of us who work in coding and CDI already know this, but there is nothing like a pandemic to remind us of the key role we play in supporting public initiatives. At the onset of COVID-19, we did not even have a diagnosis code to record and start tracking the virus. Now we have a code, and as new variants emerge, we may also see new medical codes created to denote those variants specifically. Will physicians be ready to provide necessary documentation for these new variants? Will CDI professionals be ready to query when necessary? And will coding professionals be ready to assign the most specific codes? My hope is that yes, everyone will rise to the occasion. However, only time will tell. Education and ongoing auditing will clearly be necessary.

In addition, as the medical community continues to learn more about COVID-19, it will be critical for physicians to document chronic health conditions associated with COVID-19. These diagnoses, often referred to as post-COVID conditions, must be coded correctly because the information will undoubtedly be used to set future healthcare policy.

The ‘Guardians of Data’

Nothing elevates coding and CDI more than a pandemic. Health information management and coding professionals are what I call the “guardians of the data,” and physicians provide the clinical documentation from which that data is derived. Now is the time to embrace the critical role of coding and CDI and shine a spotlight on the important work we do every day.

Emmel B. Golden Jr. is the chief clinical officer at Enjoin.