Capturing the true picture of patient complexity

As a former director of clinical documentation integrity (CDI) and health information management (HIM), I know that the need for optimized sequencing of diagnosis codes on a claim within the Centers for Medicare & Medicaid Services (CMS) limit of 25 codes for claims submission is key to ensuring the most appropriate and accurate reporting of a patient’s visit. While a patient’s hospital stay can be fraught with co-morbid conditions that can truly affect the outcome of a patient visit, the only way to accurately report the true picture of a patient’s condition, severity of illness (SOI) and risk of mortality (ROM) is through the capturing of accurate codes and code submission.  

While many inpatient visits can be quite complex with multiple conditions translating into multiple codes, CMS only accepts 25 codes on claims submitted for payment and quality of care assessments. Traditional groupers do not take into account quality indicators as well as risk adjustments due to co-morbid conditions. It is possible that some key codes affecting payment, as well as potential under-reporting of patient safety indicators (PSIs) can fall below the 25th code. These codes would not make it on the claim which ultimately leads to under-reported SOI and ROM, incomplete population reporting, and inaccurate quality rankings to various peer reporting and comparison agencies.  

As health care documentation guidelines and health care reporting become increasingly complex, it is very difficult for a coder to manually ensure all key codes are sequenced in the top 25 codes. With technology and advanced code sequencing, this process can be automated for coders and assist in ensuring optimal sequencing within the complex guidelines. Advanced code sequencing goes beyond the traditional grouping software capabilities and adds additional logic to review and include codes impacting Agency for Healthcare Research and Quality (AHRQ), as well as applicable quality risk adjusted methodologies. 

Technology can assist coders in applying logic in the background to sequence the codes, allowing them to augment their critical thinking skills to manually adjust and override any sequencing they deem appropriate. In my experience, the data that is being reviewed and assessed for penalties is a few years behind, therefore it is essential to stay in front of coding and claims submission reporting to ensure optimal sequencing. 

Optimal code sequencing is a critical component to the ongoing assurance of true, accurate patient population assessment and patient visit reporting. While coder and physician training also play a key role in sequencing and reporting success, ongoing staff turnover as well as resident physician turnover can play a part in past years data assessments for current penalties. Therefore, the need to combine coder critical thinking skills with advanced code sequencing is truly key to ensure the ongoing submission of code sets accurately reflects a patient’s encounter and portrays the complete clinical picture through the elevation of codes that impact quality outcomes and measures.

Chana Feinberg, RHIA, is a CDI product specialist at Solventum.