ICD-10 diagnosis coding: The impact of equivocal language

April 17, 2019 / By Karla VonEschen, MS, CPC, CPMA

Spring means different things depending on what part of the country you live in. For me, spring means melting snow, flowers and spring cleaning. This also seems like a good time to talk about use of equivocal language in medical documentation, kind of like spring cleaning for clinical documentation.

For medical coders, not a day goes by when we aren’t reminded about the impact of deficient documentation in a medical record. Physicians in a professional/outpatient setting may document “evaluate for…”, “follow up…”, “rule out…”, and “consistent with…” in a clinical indication or impression, but when no signs and symptoms are included this causes issues with appropriate coding, claims processing, compliance and payment. As a coder, think about the time it takes to try and determine what diagnosis code to assign and how this impacts workflow when physicians do not document signs and symptoms in a clinical indication and an impression is normal or negated. 

For most coders and those who do CDI, the challenge is always how to engage the physicians to improve documentation. We all know physicians can feel overwhelmed with all that needs to be done when treating a patient and incorporating change can be frustrating. There are all sorts of strategies for engaging physicians, but here are some simple but effective ideas to think about:

• Quality: Remind your physicians that better documentation is a quality initiative. Good clinical documentation, even if it’s signs in symptoms in the event they are trying to rule out an illness or injury, means improved communication, validation of the care that was provided, and showing compliance with quality and safety guidelines.
• Know your audience: Get to know your physicians and tailor your communication based on specialty and what motivates them.
• Find a physician champion: Having a physician who understands the goal of a CDI program, can back you up and help motivate or encourage other physicians to improve documentation.
• Include data: Including data as part of your education process is key. Physicians need to see and understand the financial and coder workflow impact when equivocal language is used without including signs and symptoms. This data could include payer denials, payment differences and cost to have coders work or rework claims due to lack of documentation.
• Use your EHR: Consider having your EHR prompt physicians for further documentation when equivocal language is used. A prompt with a drop-down box would allow physicians to easily document additional signs and symptoms that could be coded in the absence of a definitive final Impression.

Always remember that the patient medical record should tell a story about what happened and how the patient was treated. Generally, patients come to a physician with some sort of sign and symptom that must be documented and coded when appropriate. Physicians do not have to document a lot if they document accurately. This will help facilitate appropriate claims payment, reduced denials, and lead to better patient treatment, more accurate communication for other providers, and better coder workflow.

As you enjoy the start of spring and all the activities that go along with a new season, add in some spring cleaning for your physician documentation as well.

Karla Voneschen is a coding analyst at 3M Health Information Systems.