The importance of telling a story

Coding has become the language of storytelling in medicine

By Joseph Habig II, MD, Medical Director, Valley Preferred

Growing up, I had an Uncle Francis. He was from North Carolina, and he could tell a story like no one I have ever known. When our families got together – myself, my sisters, and many of our cousins – we would sit on the floor, gathered around him. With his southern drawl, and his way of telling a story, he kept us entranced. He could weave words and phrases that would keep us mesmerized. We would laugh and cry and hang on every word.

Every patient has a story. When they seek us out as their physician, they have a story to tell. It may be an urgent problem, or an ongoing single problem or series of problems for which they seek our guidance. Either way, they look to us to help them with improvement or cure.

We have all been trained to listen to our patient’s stories and ask them proper questions. To paraphrase Sir William Osler, one of the four founding professors of Johns Hopkins Hospital, “If you ask your patients the right questions, they will tell you what is wrong with them.”

We are also trained to know the value in keeping records. Long gone are the 3 x 5 index cards that made up our predecessors’ medical records. For example, such a record may have read: “sore throat,” “PCN x 10 days.”

Now we muddle through – and some say “suffer” – with elaborate electronic technology to record extensive information on our patients. Perhaps at times it seems to be too much information. However, in this day and age, the insurance companies that pay our bills and cover the cost of the patient’s care, demand it.

So, in this time of electronic medical records and value-based health care, we are required to as accurately and as specifically as we can, record the severity of illness and medical conditions for which we are treating our patients.

How we report to contracted payers the severity of the illness of the patients we care for, determines the expected costs incurred in caring for these patients. As you know, this reporting is done through Hierarchical Condition Categories (HCC) codes, encompassed in The International Classification of Disease, Tenth Edition (ICD-10), created by the World Health Organization (WHO), the current book of codes utilized across the vast world of health care.

We all work very hard, as we have been trained, to provide the best care for our patients,

What follows are four key guidelines on HCCs and how to accurately and completely tell the story of the patients we treat.

1. BE AS ACCURATE AND SPECIFIC AS POSSIBLE. The more specific we are in our coding, the more accurately we represent to the payer(s), the true illness and condition of the patients we see. For example, a patient with a diagnosis of “Type 2 Diabetes, uncomplicated,” is fine if there are no complications. However, if the patient has co-existing nephropathy, neuropathy, or another condition related to diabetes, it is important to use the HCC code that includes that co- morbidity.
2. REPORT ALL DIAGNOSES THAT YOU ADDRESS. Coding diagnoses that may be secondary or are complications related to the primary reason for the encounter are very important to mention and include. If you see a patient for a particular problem, even if an acute problem, but you also address an existing chronic problem, it is appropriate to document it and list that existing diagnosis in your note.
3. DON’T DROP THE DROPPED CODES. Every year chronic medical conditions that persist for a patient need to be refreshed and the HCC codes, re-coded. If not, it appears to the payers that these conditions have gone away. The classic example here is a patient who suffered a limb amputation. It is important to document this condition every year in their record. Otherwise, it will appear that that problem no longer exists when it obviously does and is a significant co-morbidity for the patient.
4. CONDUCT ANNUAL WELLNESS VISTS. Doing an annual well visit with your patients provides the best opportunity not only to code accurately, but to capture “dropped codes,” and help close any Care Gaps that the patient may have. If you are a primary care physician, annual well visits are also the best way to maintain attribution of your patient. This means that according to the payer, you are that patient’s physician.

If you are using an EMR, there may be software included that can assist in selecting the most accurate or precise code for your patient encounters. If you are still using paper charts, moving onto an integrated EMR, such as the universally used EPIC system, would not only assist with proper and accurate coding, but enhance vital data collection that is needed in the current value-based practice of medicine.

Physicians and other health care providers have been recording encounters with patients and interpreting them through coding for decades. So, while filling out diagnostic codes my not seem like it, it is in fact an updated and efficient way of telling an important story. Using HCC codes may not be amusing or entertaining, but it is important, and allows us to do a better job at taking care of the patients who entrust their care to us as their physicians.