Guest post: Vocab lessons

By Howard Rodenberg, MD, MPH, CCDS

We’re all about language in the CDI world, which is probably why I fit in. I’ve always been kind of a vocabulary nerd, with an occasional spell of “grammar guy” thrown in for good measure. This is why I don’t like the song “I’ll Be There” by the Jackson Five. If you know the song, you’ll recall that 12-year old Michael Jackson croons in his most plaintive pre-pubescent voice:

“If you should ever find someone new,

I know he’d better be good to you.

‘cause if he doesn’t

I’ll be there.”

It’s a great sentiment, right? Because if your new boyfriend is mean to you, you’ll want to fall back on a guy whose closest companion for years was a chimp named Bubbles (who is, according to Wikipedia, now living a quiet life at the Center for Great Apes in Wachula, Florida, where he is said to “enjoy painting and listening to flute music”). But it’s horrible grammar. There’s no way “doesn’t” is a form of the verb “is” or means “not to be.” If he isn’t good to you, that’s one thing. But if he doesn’t? You should stay away from Michael as well, if he can’t figure out why that sentence is so very wrong.

Language is important a little closer to home as well. As all of us in CDI know, specificity is our friend. That being said, coding rules recognize that things in medicine are not always cut and dried, and that there is significant fuzziness in everything we do. We don’t always know what’s causing a problem, but we can make pretty good guesses. For example, the rules of the game allow a clinician to use words like “probably,” “likely,” and “possibly” to describe what they think underlies and clinical problem even if they don’t know for sure.

There’s a little bit of hair to be split here, however. (Not mine, in which case there’s a lot.) My colleague Douglas Campbell, MD, FAAP, MHA, notes that we really should not use the word “possible.” His contention is that you should have at least a 51% chance of being right before being certain enough to code a clinical diagnosis as being present. So, if “probably” and “most likely” suggests that level of certainty, words like “possible” that suggests less than a 50% chance and shouldn’t be used. After all, anything is possible. There’s a zero point zero, zero, zero, zero, zero, zero, zero, one chance that both Gal Gadot and Ed MacMahon will appear at my front door tomorrow with a check from Publisher’s Clearinghouse. (Probable less now that Ed’s dead.) So, how can you code with certainty anything that’s less than halfway likely? Or, as Dr. Campbell put it: “See that three-day-old taco sitting on your desk? I’d possibly eat it, but I probably wouldn’t.”

The clinical term that always drove me nuts was “appreciate.” In medical school we were told that we appreciated a heart murmur or some other physical finding. But did we really? According to the book definition, if you appreciate something you “recognize the full worth of” or “are grateful for” something. In that case, who really appreciates a murmur? I have heard a lot of heart murmurs, but I have never truly appreciated one. I have never been so moved by the whoosh of some blood fighting its way through a narrowed channel, nor by the splash of plasma thudding back into the chamber from whence it came, that I was overcome by sentiment and fell, weeping, upon a linoleum hospital floor. I have yet to recognize the full worth of a mid-systolic breeze, to completely and utterly envelop myself in the rapture of the moment. I have never called my parents to relate the experience to them, have never pulled a sweetheart aside and, in a tender moment, told her that while I have absorbed the full value of the murmur its significance is nothing compared to my love for her.

Instead, I’m usually just trying to figure out what it is I’m hearing because my cochlea have been poisoned professionally by years of monitors with alarms and bells, and personally by decades of turning up the car stereo way too loud. I’m also trying to figure how just how close I have to be to hear anything if the patient is hygiene-challenged. We should not say we appreciate heart murmurs unless we really mean it.

 The glamorous process of CDI chart review has added another term to my List of Infamy. It’s the word “endorse.” Have you seen this in your shop? Apparently the new trend is to say that “the patient endorses shortness of breath and a history of congestive heart failure (CHF)” instead of saying the patient has or said it. I have no idea where this comes from, because when I look up the definition of “endorse” it goes something like this:

1. To declare one’s public approval or support, or
2. To sign a check or bill of exchange to make it payable, or to accept responsibility for paying for it

According to these definitions, when the patient “endorses” a history of shortness of breath and CHF, we might assume they are showing approval or support. “I LOVE my CHF! Best pulmonary edema ever! I’ve got cardiomegaly! HUGE cardiomegaly! Bigger than China! My ejection fraction is so bad it’s the best of the worst! Admit me for a little dobutamine and we’ll Make My Heart Great Again! You should get some CHF too! And I’m paying my own bill!”

Come to think of it, that sounds familiar. Wish I could place it. Must be somewhere in that chart…

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.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.