Guest post: A method to the madness

By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog

In college, you were supposed to seek out professors who would challenge you to think broadly, to contest accepted ideas and norms, to develop a social conscience, to learn and grow and become a better version of yourself. You quickly recognized, however, that these same instructors were likely to give you more work and tougher grades during the years when you had other things on your hormone-addled mind than evolving into an exemplary citizen of our fair land. So instead, you quickly gravitated to those who “taught to the test;” that is, they taught you exactly what you needed to know to get a fair grade, and not one iota more. This was perfect for me, especially for any course whose title included the words “Introduction to…” or “…Chemistry.”

When I started doing CDI physician education, I thought I wanted to teach to the test. I would talk to our clinicians about the key specialty-specific terms they would need to know to get at least a B in clinical documentation. Four years in, I find myself changing tack. Not because I believe I can make our clinicians into better citizens, but because in this case, broad principles are an easier sell.

I’m fortunate that at Baptist Health, my utilization management (UM) colleagues and I share an hour of orientation with each newly employed physician. For me, this is one of those times when I feel like I’m making a positive impact and not just spinning wheels for their own sake. I would imagine, however, that my presentations might annoy my erstwhile UM colleagues. While they always remind the rookie clinicians that they’re available 24/7 for questions about inpatient status, I make a point of explaining that there are no documentation emergencies on nights or weekends, and I make sure to do so while the UM gang is listening. Every. Single. Time.

In times past, I would transition from an initial discussion about how good documentation makes everyone go away (a concept I’ve written about in a previous ACDIS Blog) and move into a short laundry list of specialty-specific diagnoses to use. The list was compiled using peer comparison tools, external references, and our own experience. The curriculum was narrowed using a CDI version of the 80/20 rule: 80% of your CDI problems can be resolved by using better terms 20% of the time.  Pre-COVID, we did these meetings in person, so I could answer questions in real-time, dispense reinforcing pocket cards and other propaganda, and establish an initial rapport which would build with further appearances at meetings of the various specialty practices.

COVID has changed all that. It’s difficult to have a good, free-flowing conversation online. When you don’t need to pay attention to someone in the flesh, it’s quite easy to hide behind a screen and play World of Warcraft while the CDI physician advisor is droning on. (I know nothing about that myself, of course.) I can’t simply hand out my materials but leave them somewhere at the hospital and hope I can convince the newbie to pick some up. I don’t think this is changing anytime soon, and I suspect this is the new normal.

As a result, I started thinking about how I use webinars, and how I might enhance their limited impact. I clearly was not going to get across anywhere near the volume of information I could if I met the neophyte in person. If I wanted to get across a single thought rather than a list of terminology, what would that be? And I think it boils down to a simple concept: There’s a method to the madness.

Madness, you say? You have a better way to describe Coding World? ICD-10-CM uses language which has little bearing on how clinicians talk. Coding rules often run contrary to the common-sense experience of patient care. The entire system could likely benefit from continuous dosing of what we ER folks call a B-52. (IM Benadryl plus Haldol 5 mg and Ativan 2 mg, if you’re keeping score.)

Taking this approach changes the entire tenor of the conversation. Now my focus is that the system is crazy, and our role is to make sense of it, so the physician doesn’t need to do so. It removes any kind of implication that the provider is doing anything wrong or needs to memorize another set of rules and terms. I do explain certain terms and coding rules, but with the stated expectation that I don’t want or expect anyone to remember them. Instead, I want our clinicians simply to understand that when we ask a query there’s a reason for it, and responding to the queries helps to meet the first goal of clinical documentation, which is to make everyone administrative go away. It sets me up not as another taskmaster, but as an ally; trust me, I say, and I can make your life easier. All you have to do is click on an answer.

This approach has worked well for me. Personally, it’s just a lot more fun to present. You can poke fun at ICD-10-CM (“It’s really an epidemiologic tool; it can tell you how many people in Mongolia have left second toe gangrene, but it has no idea what to do with healthcare-associate pneumonia”), Coding rules (“It’s a Star Trek query: Dammit, Jim, I’m not a pathologist!”), and really the entire administrative side of medicine. There’s a reason why physicians tell a lot of doctor jokes, but few hospital administrator jokes. It’s because the latter are all true.

I use this same premise—that the system is nuts, so don’t bother learning it—as a means to negotiate other scenarios in physician documentation and coding. I tell clinicians that I have no interest in having them memorize ICD-10-CM codes, because that’s waste of time. Nor do I want them to worry about levels of service for E/M coding. In each case I remind them that we have people who do these things for a living, and as long as they just document what they’re thinking in the inpatient record or the office note most things will take care of themselves, and then we’ll take care of the rest.

And above all, I am sure to remind providers that there are no documentation emergencies on nights and weekends. Every. Single. Time.