Be Leery of Coding Errors in Evidence-based Medicine

Cookbook medicine may be a recipe for coding disaster.

Recently, I was asked to review the medical records of two patients involved in a motor vehicle accident. The patients were taken to a hospital practicing evidence-based medicine (EBM).

Dr. David Sackett, an early proponent of EBM, has defined it as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” The practice is also commonly referred to as “cookbook medicine” because it follows a “recipe” for treating patients. Those in favor of EBM claim it promotes greater uniformity and consistency of treatment. For example, the facility in our example states in its Trauma Handbook:

“The term ‘cookbook medicine’ is much maligned. However, few chefs would attempt a complex dish without a recipe to guide them, and few musicians would attempt a complex piece without written music to direct them. These guidelines are not meant to mandate rigid adherence, but are meant to provide a framework, based on extensive experience and knowledge.”

Opponents counter that EBM results in a lower standard of safety by deskilling practitioners: Instead of using clinical judgment, practitioners are encouraged to follow protocols that treat all patients as essentially interchangeable.

Dangers of Cookbook Medicine

Whatever the clinical merits of EBM, its practice can create a recipe for coding disaster if the concepts of “reasonable and necessary” and “medical necessity” are overlooked in favor of “standard protocol.” The medical records I was asked to review provide a good example.

Here are the facts of the case: Following an auto accident, the driver was complaining of chest pain as a result of the seat belt tightening, and the passenger had a laceration above his left eye, from the eyebrow to the hairline.

Emergency medical technicians (EMTs) use a severity scale that ranges from ALPHA (least severe) to ECHO (most severe). An example of Code ECHO would be a patient whose condition is life threatening, and requires immediate resuscitation and life sustaining measures. The EMTs arrived on scene and relayed a Code “ECHO” to the hospital to describe both patients.

Per the EMT’s own incident report, the use of a Code ECHO was not warranted in this case. The patient with the head laceration was alert, had 100 percent oxygen saturation, a Glasgow Coma Scale score of 15 (least critical), controlled bleeding, and good vision. The records for the driver were nearly identical.

Just Following Protocol …

But because the EMTs notified the hospital that they were transporting two Code ECHO patients, the hospital followed its protocol of “cookbook medicine” (their own term), which provided numerous predetermined treatments based on the initial EMT evaluation. The notes from each of the procedures performed at the hospital listed the “Reason for exam/procedure” as “trauma.” The ICD-9-CM codes were different for every procedure performed. In fact, there were no fewer than 13 different ICD-9-CM codes for each patient.

Here are some of the ICD-9 codes used for the various tests performed for these patients:

  • Abdominal Computed Tomography (CT) Scan: 959.19 Other injury of other sites of trunk
  • Pelvic CT Scan: 867.8 Injury to unspecified pelvic organ without open wound into cavity
  • Chest X-ray: 786.09 Other dyspnea and respiratory abnormality
  • Head CT Scan: 854.00 Intracranial injury of other and unspecified nature without mention of open intracranial wound with unspecified state of consciousness

The last ICD-9-CM code is particularly noteworthy for several reasons. First, the patient was never unconscious, so “unspecified consciousness” is incorrect. Second, “intracranial injury” is used to describe traumatic brain injury, for which there was no evidence. Lastly, this was a patient with a cut that required fewer than 10 stitches, and did not even meet the criteria of a “complicated” wound by ICD-9-CM standards (e.g., delayed healing, delayed treatment, foreign body, or infection). A more appropriate code would have been 873.42 Other open wound of forehead (eyebrow). But, that code would not have justified a head CT scan, would it?

From a coding perspective, it is improper for a facility to perform a pre-planned list of procedures on “trauma” patients, regardless of actual need or medical necessity. It is also improper to use vague or exaggerated diagnosis codes to justify CT scans and other diagnostic procedures when the objective findings, as well as the patient’s subjective complaints, do not support the use of those codes.

Medical procedures are supposed to be performed based on the diagnoses rendered. The scenario described above reverses this notion, putting “the cart before the horse,” so to speak.

What Can a Coder Do in This Situation?

Coders should work with compliance officers to make sure they agree on the specific documentation needed to support the diagnosis codes used for each procedure. Coders should also consult with physicians for clarification when they encounter conflicting or ambiguous information in the chart. As coders, we have an ethical obligation to assess the documentation, and to ensure it is adequate and appropriate to support the selected diagnosis and procedure codes.

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Jeremy Reimer, CPC, is president of Medical Coding Litigation Services, which provides medical coding and billing review to insurance carriers, legal counsel, and companies involved in personal injury litigation. He is vice-president of AAPC’s Brandon, Fla. chapter, a member of the American College of Forensic Examiners, and a frequent lecturer on medical coding and billing fraud. Mr. Reimer can be reached at: jreimer@mcls.co.

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