Note from the Instructor: Silencing the “Silo Storms”

By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC

I’ve never met an experienced coder who wasn’t told at one point or another that they “coded a record wrong.” Usually, by someone with no coding education or experience, typically because he/she doesn’t like the outcome(s) of the codes assignment as related to payment, quality measures, medical necessity, or some other initiative dependent on claims data. This can be frustrating when coder knows the Official Guidelines for Coding and Reporting were followed and, indeed, the record was coded right.

Personally, I come from a clinical background, working as a nurse, and transitioned into CDI more than 10 years ago. My inpatient coding team taught me basics and patiently explained and re-explained to me why the record needed to be coded in a particular way. As I grew in my experience, I began to understand that clinical language does not translate into codes as easily as one might think.

I’m not alone. Any number of related healthcare workers—whose daily efforts either have an effect on or are affected by code assignment—also have limited understanding about the rules governing code assignment. You know who you are: providers, quality management staff, risk management, population health, and finance. These professionals working in silos adds a dimension of conflict between the teams and their goals, often leaving coders as scapegoats, needing to explain, “why was the record coded or sequenced this way?”

As ACDIS’ lead CDI Boot Camp instructor, I visit organizations in which the conflict can actually lead to dysfunction. For example, at one organization the quality department instructed physicians NOT to answer CDI or coder queries because they would lead to the assignment of codes classifying complications, patient safety indicators, etc. Soon providers read CDI queries suspecting an incorrect response could get them ‘dinged’ for negative outcomes. And soon, query response rates fell related to the misunderstanding. Another CDI team complained that quality staff instructed providers to never document heart failure in the record because if they did it would fall to the any number of heart failure quality measures- no matter how it was sequenced. Again, misinformation was provided to the physicians which interfered with the capture of the patient’s true story.

I call these occurrences “silo storms.”  Healthcare organizations are full of silos, everyone working to support their specific mission without an understanding of the big picture, without understanding how their works affects that of the next silo. If you do not understand what another is doing it is very easy to think they are not doing anything or that they are performing their work wrong, especially if their work potentially negatively affects your team’s efforts. I have been on the receiving end of a “silo storm” many times and, unfortunately, also confess to having stirred up such a storm myself. These storms can lead to incorrect assumptions, decreased productivity, and negative feelings. More importantly, providers find confusion frustrating which, in turn, leads to unwillingness to support (or trust) the information or efforts of either group.

How do we prevent such occurrences? Step out of our silos. Learn from each other. The more we can understand how one department functions, the more we can teach them about our work processes, guidelines, and constraints the more we can support each other. Although each department has their own mission--each is subservient to the mission of the organization as a whole—one which we must work together to support.

When you disagree with a coder, the conversation should not start with the words, “You coded it wrong” but with the question, “Is there a guideline which instructs you to code or sequence the record this way? Can you tell me more about how that rule works?” Such questions recognize that professional coders must follow industry guidance and cannot arbitrarily change the rules to suit the “clinical situation” or “organizational need.” If guidance is cited, we must defer to this guidance and acknowledge the record was coded correctly, even if we do not like the consequences.

If guidance cannot be cited, then a respectful conversation should ensue, allowing the team (all concerned) to voice their thoughts so mutual decisions can be reached. Silencing potential “silo storms” allows for consistent education of providers, and learning by all involved. For CDI professionals in particular, remember that the overall objective is to ensure that the record is documented so the claims data explains exactly what happened during the patient’s encounter and supports the patient’s true medical story.

And, this process takes a village working together from all disciplines.

Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.