What a Difference a Word Makes
By Salath Hard
After sorting through our busy schedules, my friend and I finally sat down for a chat over coffee. We did the usual small talk that progressed to shop talk. We laughed about all the drama in the Emergency Department and reminisced about the past, the present, and how the issues are all the same; just different patients, staff and physicians. Throughout all this, I had a suspicion that our casual meeting was a case of curiosity that needed satisfying. “What exactly is it you do?” Without realizing it, she asked the question that has been the catalyst to all my inner turmoil. After blundering through an explanation about coders and physicians, I resigned myself to deflatingly reply, “I review patient charts.” The blank expression on her face was something I would see over and over, whether it be a medical or lay person I was talking to. So started my transition from a definable role of ER RN to the muddy waters of Clinical Documentation Specialist; from direct patient care to a peripheral observer of a multi-disciplinary team, whose care and chart notes I scrutinized daily like a detective searching for clues.
In those first few months of ICD-9 codes, DRGs, and coding guidelines, I thought I comprehended enough to finally answer that question. However, I arrived at more questions than answers, and inside I felt very much conflicted.
Was I less of an RN for leaving bedside nursing? Was my job created for the better good of the patient, or to fill the pocket book of the hospital? And who was I to tell a nephrologist or a pulmonologist that insufficiency is nothing and that failure is everything. Like the saying goes, “Don’t shoot the messenger.”
Truthfully, after 10 years in the Emergency Department, I was ready for a change. After years of working swing and night shifts, my body was rebelling. Aching joints, acid reflux, and sleep deprivation plagued me on a daily basis. Instead of a day or two to recoup from those hectic 12-hour shifts, it now took me a week or two, only to have it repeated again. I never felt caught up physically. Emotionally, my compassion turned to cynicism and my caring to impatience. It was definitely time to move on. Moving on meant leaving bedside nursing.There is a part of me that misses the interactions with the patients and their families. Patient care is my passion, and that hasn’t lessened since I left the bedside.
My desire to take care of my mental and physical well being and to achieve a balance between work and home life made me think, deep down, that I wasn’t less of an RN for leaving bedside nursing. Instead, I altered my perspective and thought positively. Nursing offers such a variety of opportunities, and this was one of them. I now advocate for patients by ensuring that their hospital documentation is accurate and compliant.
Initially, I felt that making a positive impact meant that I was feeding into the hospital’s bottom line. However, once I researched it, I understood the hospital’s intent.
When the Centers for Medicare and Medicaid Services (CMS) implemented MS (Medicare Severity) DRGs in 2007, physician documentation had to be more specific to ensure accurate reimbursement and reflect severity of care. For example, CHF. Was it acute or chronic; diastolic, systolic or combined? Coders had less success retro- querying physicians on the back end. Hospitals had to think forward or else fall backwards. It was a sink or swim situation, a play or go home mentality. So hospitals brought forth CDSs to play with the physicians and coders. It was then that I realized hospitals had to implement CDI programs to survive the constant cuts to Medicare reimbursement. I didn’t believe it was solely for profit. Our government changed the rules, and physicians were caught in the middle. By accurately documenting, the physicians were showing that they took care of really sick patients and those patients had positive outcomes vs. negative, i.e. death. The program was a win for patients, physicians, and the hospital. Being the messenger wasn’t so bad after all.
Now, when someone asks me, “What is it you do?” I don’t go into any lengthy explanations about physicians, DRGs, severity, CMI, or taking a negative impact for chart integrity. I tell them with a smile that I review patient charts. In my heart and mind, I know exactly what I do, and that truly, what a difference a word makes.
