Coding-Clinical Disconnect Reducing Apparent Child Abuse Incidence? Not on My Watch

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Original story posted on: June 4, 2018

Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT).

Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse, index to no codes at all, is that we lose the ability to track conditions.

Epidemiology is defined as the science that deals with the incidence, distribution, and control of disease in a population. There is so much information that the medical community gathers from epidemiological patterns. It is how we were clued in to AIDS (i.e., Kaposi’s sarcoma in a heretofore unusual patient population) and how we discover toxic waste cancer hot spots. It can give credibility to the need for new laws, like noting how texting while driving can contribute to motor vehicle collisions (Y93.C2 Activity, hand held interactive electronic device).

In the medical world, the way information is obtained about epidemiological factors is often in the use of external causes codes. This is how we can identify clusters of child attempted suicide in communities and how we can predict specific injuries from a vertical fall onto the feet (i.e., vertebral fractures, especially thoracolumbar; renal pedicle injuries; heel fractures).

But garbage in, garbage out. One of the dangers of transitioning to ICD-10 was that clinicians had to avail themselves of the rich specificity of the code set or it was going to be futile. If they don’t document such that the coder can get the most granular code available, the data is fundamentally flawed.

Another way this happens is when medical terminology evolves faster than the code set. We saw this with the explosion of queries for specificity of heart failure when HFpEF and HFrEF came into vogue.

One of my colleagues from my physician advisor days wrote me about a problem she is dealing with and asked my opinion. She deals with the pediatric population, and her providers have transitioned to using the expression “nonaccidental trauma” or “NAT” to indicate abuse (this could just as easily be found in the adult population). She related that the medical team seems hesitant to use the word “abuse.”

Physicians are given very little training in how to document. The vast emphasis is on medicolegal documentation. I remember vividly being instructed to always include the word “alleged,” because we were not drawing a legal conclusion, we were making a medical diagnosis. It was up to the justice system to remove the “alleged.”

So, I understand the reluctance of the pediatric trauma team.

We run into this problem often—documentation concerns are siloed. The sepsis consensus panel tells us to just use R65.20 when the provider uses “sepsis,” because clinically, they shifted severe sepsis into “sepsis.” We know this is not compliant. Providers do not understand that in order to get the right code, T76.12- Child physical abuse, suspected, they need to have both elements. “Suspected,” or they will get “confirmed,” and some variant involving “abuse.” NAT just doesn’t go there.

The provider also should give the specific injuries incurred. Is it T74.4- Shaken infant syndrome, or are there specific fractures or contusions which should be spelled out? Is there a head injury (provide type specificity, including duration of loss of consciousness, when applicable)?

Another complication is that abuse is sequenced first and establishes the DRG. If you can’t index to confirmed or suspected child abuse, you may land in the wrong DRG.

I have three suggestions for this dilemma. First, now that you understand their concerns, meet with your providers, and explain the implications of using an uncodable phrase. Feel free to share this article with them.

Next, create an acronym expansion (macro, dot phrase) for them in your electronic medical record. Have “NAT” expand to “Non-accidental trauma (i.e., abuse).” They will need to remember to include “suspected,” when applicable.

Finally, if you run into this in your organization, send the case to Coding Clinic and/or the Centers for Disease Control and Prevention (CDC). I have submitted to the CDC myself for consideration to adapt the indexing and inclusion terms.

We need to work together to eliminate coding-clinical disconnects when possible. Thanks for being my partner!

Program Note:

Listen to Dr. Remer report on this important issue today on Talk-Ten-Tuesday at 10 a.m. ET.


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Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk Ten Tuesdays. She is also on the board of directors of the American College of Physician Advisors.

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