You will be NOT be judged (and paid) on how well you performed, but on how well you were coded

Did you ever play the game of telephone at a party? A person tells a story to another, who then in turn tells the story to the next person, and on down the line. The last person recites that story back to the group. It is amazing how different that story was from the original. Sometimes the final story is even unrecognizable.

Ironically, the process of Pay for Performance for remuneration and quality outcome determinations is not dissimilar to this old party game.

First of all, what is the original story? What actually happened to the patient? The fact is, no one really knows what actually happened to the patient. No one really knows the “truth” of the original story. The best we can discover is what was documented in the medical record by physicians, nurses and other health care providers. We have all been taught that if it wasn’t documented, it wasn’t done. Lawyers thrive in this interface. Yet as medical professionals, we know very well, that the medical record never completely represents what actually happened to the patient. Something is inevitably lost in the translation of “truth” onto the medical record. But there is no other source to learn that “truth”. In reality, documentation is like the first conversation in the telephone game.

It goes further. A group of health professionals known as “coders” review that medical record and assign various numerical codes based upon what is specifically documented in that record. These reviewers are NOT physicians and can NOT make a diagnosis. Nor can they interpret that record. Based upon the literal language in that medical record, they are obligated to assign specific diagnostic and procedural codes for that patient encounter. There is virtually no flexibility in this process. Specific language leads to specific codes. Specific codes lead to specific DRG’s. It is completely linear and not subject to discussion.

It is these series of codes that are then placed into software programs that ultimately determine the final DRG or CPT code that drives the billing and the reimbursements. Similarly, these codes now populate into the public databases that ultimately determine quality outcome score for that hospital or that physician. This billing system was never intended to be used for quality outcome assessment. It was specifically designed to determine a payment for a service rendered. It has been “jury-rigged” into becoming a quality/ outcome database. And specific codes define specific medical complications.

So now we have a two step telephone game. We will never know the “truth”. The closest we can get is to review what is “documented”. What is “documented” will then be used to determine what is “coded”. What is “coded” then determines what is billed and also what is used by the pay for performance systems to provide quality outcomes ratings. Obviously, there can be information lost in any of these steps. Just as in the telephone game, the ultimate story can sound very different from the original story. But those are the rules; that is the present playing field.

Bottom line, in the present Value-based system, we are not remunerated or judged on the basis of what actually occurred or did. Instead we are rewarded on how those events were ultimately coded.

Frustration or opportunity? I suppose that is for all of us to decide.

The reality is that all health care providers need to be more aware of this process and more involved in determining the ultimate outcome of the codes that are assigned. Physicians get very upset when they are queried by coders for clarification of the record. The proper response to that caller should be “Thank you and what can I do to more accurately represent what happened to the patient.” Physicians and hospitals should be aware of the most common clinical situations that occur in their specialties and learn specific ways to most accurately document the “truth”.

It is more important than ever that all health care providers get involved with this process to ensure its maximal accuracy. Our reimbursements and our evaluations depend upon it.

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