She says that in addition to the threat of audits, hospitals and health systems must be conscious of the fact that their quality and safety scores are generated directly from the codes applied to patients' medical records.
Inaccurate coding can mean hospitals get penalized once for not recording accurately the complexity of the treatment given, which may negatively affect quality scores, and they get penalized under fee-for-service payment by serial undercoding. Much of this undercoding stems from poor communication between physicians and coders, she says, and she works to fix that.
"Sometimes physicians feel they've told coders the story, but they do it in clinical and technical language," she says, meaning coders won't, and shouldn't, try to bridge the communication gap between what the physician knows he or she is treating but hasn't communicated. "The coder is very literal. If you think you've [implied] something to them, they won't code it. If you haven't said it in black and white, they don't assume anything. They can't. They can't put down something they think you mean."
It's a communication and education problem that when resolved, not only cuts down on the likelihood that hospitals will have to repay some of their reimbursement, but also increases their profitability—and the cost of healthcare.
"Sometimes multiple diagnoses aren't mentioned, but have been treated," she says. "We teach clinicians and coders how you document in a medical record to make sure you capture all diagnoses."