November 7, 2016

Clinical Coding Reflects Patient Care

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Often we talk about the patient care team and who makes up that special group of professional caregivers. We similarly look at the role that the coding professional plays in healthcare and with that team in particular. Certainly there can be clarifications made regarding the “direct” patient care team, and that of a more global healthcare team.

The "patient care team" implies the inclusion of individuals who provide direct care to patients. Professionals such as the following are most often recognized as members:

 

Physicians                                           Nurses

Dentists                                               Physician Assistants (PAs)

Nurse Practitioners (NAs)                   Pharmacists

Nutritionists                                        Therapists and Rehab Specialists         

Social Workers                                    Case Mangers and Discharge Planners

Clinical Technologists and Technicians

Mental Health Workers

Chaplains or pastoral counselors

 

The patient care team works as a multidisciplinary interactive group, providing direct care and treatment to the patient. The team also will communicate and advise the patient family.

When we then look at the full “healthcare team membership,” we often find that it also includes the above, with the following additional staff and groups as well:

  • Admitting/Patient Access
  • Scheduling and Call Center
  • Patient Financial Services and Billing
  • Health Information Management and Coding
  • Information Technology and Systems
  • Administrative
  • Collections and Finance
  • Research
There is a direct correlation however between the patient care team and that of the health information management clinical coding professional and the work they (coding staff) are responsible for and manage. The clinical coding process brings forth the data that is a direct reflection of patients’ medical condition(s) and the work of the patient care team. Clinical coding provides information that is the source for comprehending the story of the patient encounter and any outcomes.

As we all know, we can’t discuss clinical coding without mentioning documentation. With clinical documentation, coding can reflect the severity of illness and risk of mortality of each patient. Documentation must be complete, timely, and accurate for each and every encounter. In today’s healthcare environment, clinical coding is gaining greater importance as we gauge the quality of healthcare using data, both for individual healthcare and the quality of a healthcare group as a whole. 

One area that healthcare can do a better job with is the sharing of information and data, particularly as it pertains to clinical coding and the patient care team. We can and should be discussing what the coded data is telling us and what it is reflecting. Without greater collaboration and understanding of the clinical coding, our healthcare can’t and won’t be able to help us know how to improve patient care.

The time is now to work more closely with the patient care team and the overall healthcare team. We cannot and should not be working in silos.

With clinical coding being the reflective source of data to judge our patient care quality, we all should take the time and effort to develop lines of communication, align together, and build strategies that drive us to the highest quality in healthcare.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Gloryanne is a coding and HIM professional with 40 years of experience. She is the past president of the California Health Information Association. Gloryanne is a member of the ICD10monitor editor board and is a popular guest on Talk Ten Tuesdays.

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