Friday, May 25, 2018

(Yet another missive from Coding World.  It turns out you can't place a diagnostic code into the medical record from a consultant's report.  Which means that if a consultant writes something on the charts, you have to ask the patient;s personal hospital physician if they agree before you can code it. Get it?  Got it?  Good.)

Memo from the Full Disclosure Department:

Lying behind my confident attitude, my devil-may-care good looks, and my abundant modesty lies a nerd.  I say this knowing full well what that entails, for a nerd is different than a dork or a geek.  According to OKCupid:

“A Nerd is someone who is passionate about learning/being smart/academia. A Geek is someone who is passionate about some particular area or subject, often an obscure or difficult one. A Dork is someone who has difficulty with common social expectations/interactions.”

Remember that OK Cupid is a dating website, designed to find people for people who don’t have people (and may be the unluckiest people in the world).  So they are morally obliged to put a positive, quirky spin on the terms.  Who wouldn’t want to date someone who’s passionate about learning or a master of a particular domain?  In truth, don’t we all have those little social hiccups?  Aren’t we all unique in our own way?  Isn’t that cute and endearing and wouldn’t you like to date me?

(I was actually okay with Nerd, as I thought I had no obsessions to speak of.  That is, before the Dental Empress brought up my thing with buying only hardcover books. And Legos.  And WKRP in Cincinnati.  And the fact that I cannot walk inside the house until I’m sure the interior light in the car is fully off, a trait which has caused the College Student to call me “Captain Paranoid” rather than the warmer epithet of “Dad.”)

I bring this up to indicate that after many years of attempting to be somewhat more normal, I’ve become comfortable with who I am….a middle aged guy who can admit to liking Barry Manilow and girls in the same sentence.  It also means that I can also freely express my admiration for Star Trek in the most unambiguous terms.  Which brings us to a small matter of CDI.

As we know, one of the rules of the coding system is that we cannot code off of anything except what’s written in the chart by the attending physician.  We can find useful information in nursing notes, nutritional consults, radiology reports, and pathology files, but we can’t code it unless it’s been noted by the attending physician.  As a result, we wind up sending queries to physicians asking if they concur with the tissue diagnosis of a pathology report, or agree with a particular finding on a CT scan or an MRI that might affect coding, reimbursement, and measure of illness severity.  These queries usually take the form of “Doctor McCoy, the pathologist noted the presence of Pon Farr in the biopsy sample.  Do you concur?  If you agree, please indicate this in your Progress Notes and Discharge Summary.”  To which in Klingon we most often hear in angry reply  “Im qar’a’ pathologist Qel“ or “Dammit Jim, I’m a doctor ,not a pathologist.” 

(Yes, I know you cannot see Pon Farr on a tissue biopsy.  But ponder the fact that you knew this and what it says about you.)

The simple fact is that doctors understandably don’t want to pass judgement on their peers, especially if it’s about something out of their own area of expertise.  It’s inherent within physicians to greet such a request with caution.  So if you ask them to agree or concur with something out of their ballpark, with medicolegal umpires officiating the game, they are going to eye that request with suspicion and may well let it go unanswered or actively reject the query.  (This is true unless it’s an ER doc, where anyone can level a shot and it’s considered fair game.  This is because most doctors did a month or two of ER during their residency and then went on to be SPECIALISTS…translated as “person smarter than you”…while the ER docs were not bright enough to leave.) 

I am not immune to this reluctance to confirm or deny that which I don’t understand.  This is especially true given that I made it through my pathology lab course in medical school not by detecting differences in the cells I was looking at under the microscope, but because I was able to memorize the shapes and colors on the stained slices of tissue slides we were issued for class.  (There was also this story going ‘round about students crawling through a ceiling in order to get a copy of an exam.  I’m sure it was just a rumor.)

Physicians don’t feel that way just about pathology reports.  We’re likely to encounter the same difficulties given any piece of conflicting or incomplete information in the record, whether it’s a radiology finding or a consultant note.  I’m not in a position to second-guess the other guy, goes the thought process, so why are you asking me to do so?  And yet clinically, we unwittingly do this all the time, in that we generally guide our clinical efforts dependent upon the findings and recommendations from our pathology, radiology, and consultant colleagues.  That certainly implies acceptance and concurrence.  We’re just loath to say so.  (Dr. McCoy told Kirk he was “a doctor, not a bricklayer.”  But he still found a way to patch up the Horta, and it still says something about you if you know what I mean.)

So in the end, it’s a matter of semantics, and there’s got to be a better term to use when we’re trying to get information into the chart.  If “agree” and “concur” won’t work, what can we use?  We need to look for words of agreement that don’t imply judgement but do imply active acceptance and integration into the plan of care.  Simply saying the results are “noted,” I think, doesn’t quite do it.  (I know this from experience; when nurses in the ER tell me that a patient wants more pain meds to go with their turkey sandwich and a bag of Cheetos, I usually say “Noted.”)  So perhaps we can ask, in a yes-or-no query, if the Attending Physician “acknowledges” the pathology report.  The common use of the word implies an active thought process and integration into the plan of care.  Maybe “accept” fills the bill, as it doesn’t imply an additional opinion but implicitly says the information is received, like a gift.  “Recognize” may not be as strong, but the word implies integration of the idea with reference to past events.

In order to improve our responses to these sorts of queries, we’ve got to quit asking doctors to second-guess their peers.  The right wording will help.  Unless it’s an ER doc, of course, in which case it’s all fair game.


Hi!  Lt. Commander Grammar Guy here, just beamed in from Deep Space Station K-7 to cause a little bit of Tribble.  Today’s agitation is with anything that calls itself (insert name of city) Memorial Hospital.  I get that hospitals can be named after important people who have passed on to the Gamma Quadrant.  But how do you name a hospital after an entire city unless that city has been wiped off the face of the earth?  I had a friend in Starfleet Medical College who was a graduate of Joplin Memorial High School in Joplin, Missouri.   We would go to Joplin to visit his parents and as far as I could tell, Joplin was still there.  So who was it named for, anyway?

(The Vulcan High Command, recognizing that that the Grammar Guy’s rant is illogical, has in fact discovered that Joplin was named for the Joplin Creek Valley, which in turn was named for the Reverend Harris G. Joplin, who settled upon its banks around 1840.  It’s my understanding that the Good Reverend has indeed passed on, swept up by the Great Bird of the Galaxy, so he could in fact qualify as a building’s namesake.  The Library-Computer also tells us that the nickname of Joplin is “JoMo” and that the City Motto is “The City that Jack Built.”  Which makes us want to neck pinch you all into unconsciousness.  It would be the logical thing to do.)

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