Dear Doctor: You Can’t Code This

First, let me say that I understand. My nursing life was spent in busy emergency departments as a trauma nurse. I understand distracting injuries. I understand the need to rule out occult injuries. That being said, far too many emergency department orders for diagnostic imaging have zero indications other than mechanism of injury. In my experience, this is not due to the above challenges. It is due to failure to capture valid reasons for diagnostic testing and valid signs, symptoms, and/or diagnoses. 

I also understand the payer perspective on this. Mechanism of injury is the explanation of what happened, not the definitive diagnosis (i.e. the “why we are performing this service.”) How should they adjudicate a claim for any service with no reason? Is every ED exam really a screening for suspected conditions or to rule out occult injury after an accident? I think most coders and physicians would agree that is just not reasonable. Those patients are the subset of emergency department trauma patients, not every patient.

As a coder/auditor, I pulled the emergency department records for every patient with only a mechanism of injury as the indication for a diagnostic radiology study. The vast majority had an obvious injury, complaint, sign, or symptom documented as present on arrival. However, the indication on the order was listed as MVA, fall, altercation, etc. That finding raised more questions that I think merit a big-picture perspective. Healthcare providers need to be cognizant of the downstream effects of their documentation on other physicians. In addition, they need to be aware of how their documentation determines how other providers will or will not be paid. Should necessity criteria for advanced imaging be expanded to emergency departments, this could become an additional burden on already financially stretched hospitals.

Contingent on contractual provisions and access to medical records, the diagnostic specialties are at the mercy of the physician ordering the testing. Assuming the testing is negative, and if only a mechanism of injury is the reason for testing, there is nothing to code except a screening exam. Most payers will not allow payment for those claims or will require medical record documentation supporting the medical necessity. Those records may not be available to the diagnostician. As a result, the claims will not be paid or extensive labor will be required to obtain the needed supporting documentation.

Assuming the coders for the diagnostic specialty can access the emergency department records, again, significant manual labor and time may be required to review the documentation to verify the real reason the testing was ordered.

So why is this a problem for so many?

It appears that there are some very common excuses. The emergency department physician is not the one entering the order, and there is an information deficit between those providing clinical care and those entering orders. The physicians have electronic health record (EHR) overload frustration when trying to wade through the myriad diagnostic possibilities in “pick lists” and look-up files. They are busy and patients are waiting. Electronic and other order entry systems permit “mechanism” as the primary diagnosis with no requirement for signs, symptoms, or diagnostic indications. In some cases, the number one diagnosis choice is “other.” The radiology staffs are loathe to question an order and delay treatment or incur the wrath of the emergency department. The radiologist is already interpreting the exam before the lack of indication is identified. 

Lastly, this is also a care issue. Every diagnostician of every specialty I have ever spoken with says they can do a better job if they know exactly what the referring physician is worried about or for what they are looking. Clear and accurate indications could resolve this challenge. 

So let’s all get on the same page and on the same team. Quality care is a continuum. Physicians need to look at who comes next in providing care to their patients. Do they have the information they need? Can they be paid for legitimate services? Does the payer know why the exam was medically necessary? 

To collect the most accurate morbidity, mortality, injury, and other diagnostic information, accurate diagnoses must be documented. Let’s work with our emergency departments to find a solution that works for them, for the patient, and for the radiologists and other diagnosticians.