Guest post: Clinical Truth™️ versus SOI/ROM

By Cesar M. Limjoco, MD

Coding versus the true nature of patient’s condition can be enigmatic. In order to parse out the difference between the two, we need to understand the ultimate goal of CDI. It’s not in following the severity of illness (SOI)/risk of mortality (ROM), the resource consumption or, to be blunt, the “money;” the ultimate goal of CDI is to capture the true nature of the patient’s condition.

When we relegate what is true to what is advantageous for the organization rather than the patient, we step onto a slippery slope off the ground of justifying resource consumption and onto the muck of putting patients in higher levels of care and on costlier treatments/procedures for the sake of increased revenue.

This is partly the reason for concerns like methicillin-resistant staphylococcus aureus, hospital acquired conditions, etc., as patients receive treatments and/or levels of care they do not need which exposes them to higher risks. The treatments must be based on what the patient’s actual condition requires.

Think back to the late 1980s and early 1990s. It was an uphill battle to educate physicians that a sepsis diagnosis does not rest on positive blood cultures. The pendulum has now swung to situations where all patients who are admitted with an infection are considered septic and placed on sepsis protocol. There has to be a middle ground.

From the physician to the CDI specialist to the coding professional — everyone needs to assess for themselves what their North Star is. Choose wisely and there will be fewer problems going forward. Fewer denials, fraud, and abuse allegations, plus accurate and complete information and data that improves our healthcare system and improves patient care. After all, that’s what it’s all about! Long term outcomes should not be supplanted with short term gains.

Editor’s Note: Limjoco is the chief medical officer for T-Medicus, LLC, based in Las Vegas. He has more than 25 years of consulting experience. Limjoco is also a member of the ACDIS Regulatory Committee. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. Contact him at dr_cesar_limjoco@me.com.