Guest post: BS jobs and appropriate rage

By Howard Rodenberg, MD, MPH, CCDS

Several posts ago I mentioned that there was a rant brewing inside of me about clinical validation. Like Dylan Thomas, I often “rage, rage, rage” against many things, including the dying of the light. But this kind of rage is expressed viscerally, without rhyme or reason. So, while I've had these thoughts about clinical validation percolating in my head, I couldn't put them into context.

A recent book has helped me crystallize them. Impolitely titled Bullshit Jobs by David Graeber, (a professor of anthropology at the London School of Economics), the book proposes that 30-40% of jobs fall in the category of bovine excrement, in that they don't produce a net societal good and the people who fill those positions acknowledge the same. In reaching this conclusion, the book draws from studies of mediaeval feudalism, the labor theory of work, and the devaluation of those who do actual labor and the elevation of those who don’t. It’s well worth a read, even if it’s a bit strident and dogmatic in parts.

I am in no way proposing that what we do is equivalent to the output of a feed lot. What we do as CDI professionals not only improves healthcare quality but it also raises revenue, which allows more people to be employed and provide for their families. But the concept of the BS job did help me understand why my gut reaction to the process of clinical validation is so profoundly negative.

Why is this? Let’s take a moment to review why we do clinical validation in the first place. We do this because outside payers question the physician’s diagnosis as an excuse to withhold payment from the hospital. They do this because they are allowed to, and because nobody has the political desire nor willpower to rein them in. And if I was a profit-driven health insurer, I would do the same thing. I would look for ways to deny payments wherever and whenever I could.

But we’re in the business of bringing revenue into the hospital. So when a claim is rejected, we respond. Our clinical validation processes request additional information from the physician to support their documented diagnosis. Even if we can get more information that supports the diagnosis, cite articles supporting our view, and point out errors in the insurance companies’ standards, we really have no leverage. The insurance companies make the rules, and while they have an appeal process, they determine the outcome of the appeal. The hospital’s ultimate recourse is a legal case, which will likely cost more than the amount you might get back from the rejected claims. So no matter what you do, how hard you work, how careful your documentation, or how valid your case, the insurance company wins.

To me, this sounds like lots of effort expended for no particular purpose and no real opportunity to change the result. Doesn’t that strike you as the very essence of a BS job?

There’s a deeper issue here as well, one that is a less visible, but for me a more potent source of rage. The entire process of clinical validation, from insurance companies refusing to accept a clinician’s diagnosis to our questioning of the physician’s judgement (as CDI folks, we can fancy up the language, but that’s essentially what we’re doing) implies that physicians are either unreliable, incompetent, or outright liars. As a physician who does the best he can to meet impossible demands to achieve impossible standards in impossible circumstances, it’s insulting, demeaning, and humiliating. The entire process becomes nothing but a personal affront.

No social problem gets resolved unless someone stands up to fight for what’s right. The Cooperating Parties behind Coding Clinic would seem to be our natural advocates. After all, it’s their guidance that dictates we code what the physician writes down.

Alas, it’s not quite that simple, as evidenced by these statements within Coding Clinic, Fourth Quarter 2016, pp. 147-149:

While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria…Coders should not be disregarding physician documentation and deciding on their own…whether or not a condition should be coded. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.

To summarize, coding professionals are bound by whatever the physician writes down, but others don’t have to follow the same rules. The subtext coming from Mount Olympus is that Coding Clinic can bind us to their guidelines without considering the implications of their advice. It’s an open invitation for outside parties to dispute the diagnosis of the clinician at the bedside.

I understand that Coding Clinic does not want to pick any fights, and certainly the dollars involved in healthcare make everything inherently political. But, in order to make progress, to right a wrong, one needs to be political. Political in this sense does not mean Democrat or Republican, liberal or conservative. It means being willing to stake out a position in the public forum. Non-partisan bodies can have an impact; non-political ones are destined to irrelevance.

So what can we ask Coding Clinic and the Cooperating Parties to do? It’s pretty simple: Issue a position statement that all parties should consider the diagnosis of the attending physician caring for the patient to be definitive. The position statement will not change the behavior of outside payers and other parties. Coding Clinic has no power to do so. But such a statement will lay a moral foundation for what we do, and give us respected authorities to reference when fighting this battle. We can use this statement to support our physicians in the appeals process, and as a basis to ask our hospital partners to advocate on our behalf. There’ll be a lot less rage in the world.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.