They just don’t get it: Who is to blame for increased complication rates?

Nov. 30, 2015 / By Cheryl Manchenton, RN

Let me start by saying Happy Holidays to everyone. However, I am feeling a bit like Mr. Scrooge. I have heard from many clients lately regarding their struggles with obtaining accurate complications rates. In almost every instance, there is finger-pointing (with coding and CDI taking the hit) and even software gets blamed for the increased capture of complications rates.

So let me explain a few things:

1. Coding staff can only code what is actually documented. They can’t invent documentation. So where are they getting the complications code from? Yup…provider documentation. And most of the time it is due to the lack of detailed documentation. Had there been more complete (and more honest) descriptions of procedures and conditions, it would be much easier to make determinations of whether or not significant complications occurred that need to be captured.

2. Patients are more complex and living longer in much sicker health states. This puts more patients at risk for adverse events occurring during their stay. But providers do not seem to be accepting the fact that with sicker patients comes increased risk of adverse effect and are angry when HIM staff capture complications that occurred.

3. There are more complications being measured. Back in 2005 when the Deficit Reduction Act (DEFRA) began and HAC penalties were assigned, there was a relatively short list of conditions. But with the advent of the HAC reduction program, Value-based purchasing, Physician Quality Reporting System (PRQS), Hospital readmissions reduction program, potentially preventable complications, etc., there are an increased number of conditions being measured as complications.

4. There are more organizations looking at complications. As stated before, prior to the DEFRA and HAC reduction program, there were some quality measurements out there. But the trend for everyone (government, commercial and private) to measure quality increases the number of potential fines and deceased reimbursement. And in many cases they are all looking at similar metrics so an organization is penalized sometimes up to seven times for a single complication. So is it that complications are increasing or the number of times we report them?

5. Software and software solutions are made to enhance our workflow not replace it. Although computer-assisted coding and auto-suggested queries have been a boon in terms of productivity, no machine forces a coding professional or CDI specialist to accept a code suggested through natural language processing (NLP). And to even entertain the thought that it does or should is insulting to the HIM and CDI professionals who have spent years working hard at their craft. Not too long ago, a coding professional was a contestant on a game show and was asked if machines were going to replace her. Her intelligent answer was no; that it takes someone with knowledge of the rules and regulations and interpretation of those to assign codes. Right on! Let NLP enhance your workflow, but do not be complacent. Remember, you are the final auditor when it comes to accepting auto-suggested codes.

Studies have shown an overall decrease in the incidence of complications throughout the country. So health care must be doing something right. And if an organization is seeing an increase in complications, perchance they should look at the actual care delivered instead of the coding of the complications.

Please be clear, I am also aware of hospitals doing some potentially unethical things by not screening for complications and making coding decisions on what to code/not code. And this hurts those who report honestly. By doing this, it does not provide the true number of complications and does nothing to improve patient care.

Finally, I do see some error rates in capture rates of complications, but in my audits the number of “errors” is far outweighed by the number of cases in which there were clarification opportunities based on conflicting or incomplete documentation. Let’s stop finger-pointing and improve quality of care!

Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems.

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