Tuesday, September 18, 2007

How Do You Code Oral Diarrhea?

Have you ever watched a film of people working an assembly line who must pluck out the bad strawberries or undersized eggs as they whiz by on a conveyor belt? Their job is to weed out imperfections in order to assure a higher level of quality in the product delivered to the customer.

Medical transcriptionists do the same thing with words and punctuation marks. They listen to the raw data coming from a doctor’s mouth and weed out the wrong words, contradictions, inconsistencies, and bona fide mistakes so that the finished product has a reasonable level of coherency.

Trust me, folks. It ain’t easy. Nor should anyone ever assume that physicians are infallible. Last year, when a friend of mine was taken to an Emergency Room, her husband told the treating physician that she was allergic to a specific medication. What did the physician prescribe? That exact same medication!

With managed care forcing physicians to see more patients per hour (the medical equivalent of being ordered to turn more tricks for your pimp), doctors are going to get frustrated, angry, tired and sloppy. As a result, mistakes are bound to happen. Under so much pressure to produce, some of these mistakes are going to fall through the cracks in the system.

We all grew up with the adage that “You can’t make a silk purse from a sow’s ear.” Often, the function of a medical transcriptionist is to intervene in the physician’s thought process and catch a mistake before it is even given a chance to metastasize throughout the patient’s record. This presents a delicious intellectual challenge to MTs who take pride in their medical knowledge. Unfortunately, it’s also like trying to pull off a psychic intervention while someone is shooting at moving targets in a carnival arcade.

Let me give you an example.

A client of mine dictates the same type of report over and over. The quality of his dictation is directly proportional to how tired he is. Having transcribed hundreds of his reports, I know how to recognize a mistake that he is too tired to know he made.

It took us a while to convince this client that he should not dictate“Family history: The usual.” So now, when he dictates data for the patient’s family history, he does it in a specific order. The other night, although he was intending to give some information about the patient’s father, he dictated “The patient’s whereabouts is unknown.”

Examining a patient whose whereabouts is unknown is a pretty good trick. But what this doctor dictated was exactly the kind of mistake that

  • Would not have been caught by voice recognition software

  • Would not have been caught by a spell checker

  • Would not have been caught by a grammar checker

It would only have been caught by an experienced medical transcriptionist whose editing skills were accompanied by the mental acuity to notice such a contextual error, nab the little sucker and fix it!

Try straightening out this gem:

"By the way, this man's chart was labeled William, his original report was labeled William, his name is Norman, not William. Forget the name change on William/Norman, because Norman's name is really William but he goes by Norman but legally it is William."

You think that’s a real hoot? What about the doctors who rotate “left” and “right” all through a patient’s report? Or “male” and “female” (this gets to be a real challenge if the patient’s name is Kwok Bong Tsao).

Let me tell you my favorite story (and believe me, folks, I could not make this one up if I tried). Several years ago I was working on a hospital account when I started transcribing a report dictated by an Asian plastic surgeon. Although he was usually fairly easy to understand, he had a habit of clipping his words so that they sounded extremely precise. And with that precise form of clipped speech, this is exactly what he said:

"Patient comes to Emergency Room following motor vehicle accident with segmental pussy all over his face.”

I had four other medical transcriptionists listen to his dictation. Between us, we had nearly 100 years of professional experience as medical language specialists. We all heard the exact same statement. And no matter how desperately we struggled to figure out what the good doctor meant, we could only come up with two logical interpretations:

  • This was a case of roadkill involving a house pet

  • The driver got rear-ended while performing cunnilingus on his front-seat passenger as they were stopped at an intersection.

My question to the coders reading this article is: Had someone not tried to edit this sentence, how would you code this patient’s chief complaint? And if you coded it incorrectly, what would be the ramifications in terms of billing and future medical treatment?

For the past three decades, medical transcriptionists have dutifully protected physicians by surreptitiously cleaning up their dictation. However, many of the older MTs who routinely took it upon themselves to fix a doctor’smistakes have retired or been laid off. In some situations, their jobs have been eliminated as transcription has been farmed out to independent contractors who often have less experience. As part of this process, an editorial“safety net” has slowly and steadily been evaporating into thin air. Although few people think of this as a health information management issue, the brutal reality is that it represents a risk management disaster just waiting to happen.

No matter how hard one tries to refute the old GIGO equation (garbage in = garbage out), medical transcriptionists remain totally dependent on the quality of dictation they receive from dictating physicians. “Doctors really don't give a hoot until they get slapped with a lawsuit,” complains the Medical Record Director of a 375-bed hospital. “It's about time someone gave these docs -- and hospitals -- a good, stiff kick in the pants.”

Think about that the next time you attend some management seminar or HIM conference where someone keeps babbling on and on about the need for Total Quality Management (TQM).

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