A tale of two viewpoints: Nurses and coders

Nov. 29, 2023 / By Katie Patterson, CPC

I spent 18 years in the medical coding field before joining a new team combining nurses, other care providers and coders, to leverage both clinical and coding experience in building knowledge for our natural language understanding (NLU) products. I was so excited! One of my first projects was to help develop clinical concepts for evaluation and management (E/M) coding. I’d spent a year educating providers on documentation requirements for E/M and thought I had the language down, but I came to learn it wasn’t that simple!

Although coders are fluent in anatomy and medical terminology, we tend to think in terms of documentation requirement for reimbursement and claims. In contrast, nurses are thinking in terms of patient care. Both viewpoints are necessary for the job at hand – content development for our NLU products – but can also create misunderstanding in communication. E/M documentation is based on complexity of problem, data reviewed and the risk to the patient. These data points are extracted from the patients record and used to determine the appropriate level of E/M code for billing. Based on the number and complexity of presenting problems, there is an option to select one undiagnosed problem with uncertain prognosis.

For example, from a coding perspective, when I see a patient presenting with chest pain (the symptom) which requires further testing, I view the chest pain as the undiagnosed issue, and the pending testing is the “uncertain prognosis. That did not make sense to my nurse colleagues – that’s simply not the language they’d use with chest pain and the needed testing. This made me think. A nurse is used to being present with the patient, viewing vital signs, speaking with the patient and/or the family and generally able to assess the patient. This interaction changed my view on what documentation I need to search for when abstracting for presenting problem points.

Another example is determining if a surgery is considered minor or major. In coding, this is the difference between moderate or high risk, which can be a determining factor in the level of service billed. As a coder, my brain automatically asks: Does the procedure have a 10-day global period or a 90-day global period? This is the timeline that Medicare uses to determine how much of the postoperative care will be included in the fee for the surgery. On the other hand, my nursing colleagues would look at how invasive the procedure is to the patient. For instance, we discussed a colonoscopy with biopsy. Although the procedure is invasive and there are certain risks, the recovery time is limited, and those risks are limited as well. In the end, the procedure was mapped as minor due to the limited risk to the patient.

Having these discussions has opened my eyes to the importance of considering the background and education of each person within the team. Taking a moment to ensure you are clearly explaining your point of view can prevent misunderstanding and provide a teaching moment.

Katie Patterson is a clinical analyst at 3M Health Information Systems.