by Trey La Charité, MD
Physicians spend years learning how to take care of patients. As humans, however, accidents happen. Even the best of medical care has complications and consequences. Unfortunately, society has not always encouraged the medical community to be forthcoming when these things occur.
While significant improvements have occurred with the institution of “the just culture,” many physicians remain reluctant to admit when a complication occurs as the direct result of the medical care they provide.
Surgeons seem to be the most reticent of the medical staff to admit that something went wrong. While some of this is certainly driven by the legal community and the very real fear of being sued, I believe there may be other factors at work that explain their reluctance.
Understand surgeon personality traits
To say that surgeons are driven to succeed is a colossal understatement. To get to where they are now, surgeons had to be at the top of everything they did—for their entire careers. Surgeons feel more pressure than other physicians to get everything right. This pressure may be a source of fear, causing them to hesitate when something goes awry.
In other words, if a surgeon has to admit they made a mistake, or if an accident happened on their watch, they believe they failed. For a surgeon, failing anything has never been option. To underscore this notion, remember that surgeons are still evaluated to this day by their performance improvement departments with periodic “report cards” such as HealthGrades, Physician Compare, or other publically reported assessments.
Many surgeons view these report cards negatively, as reminders of their medical school education and residency training. Some surgeons believe that report cards only focus on what they got wrong, and not what they got right.
The unfortunate result is that surgeons end up feeling abused by the very data that is meant to help them improve their outcomes even if provided in a purely constructive manner.
This phenomenon drives the surgeon to avoid documenting anything in the medical record which could potentially be considered a complication. Surgeons expect straight A’s because that is what got them where they are. Anything that could be perceived as a B is avoided at all possible costs.
Now add the CDI specialist to the personality trait conundrum. The well-meaning CDI specialist comes to the surgeon seeking more complete and thorough documentation of a possible surgical complication and soon tension and conflicts develop. The CDI professional must anticipate and be able to manage these issues.
Complication situations
Let’s review hypothetical situations to help illustrate this problem.
In our first example, a surgeon takes a patient to the operating room to remove a colonic mass. During the procedure, the surgeon accidently “nicks” a portion of the small bowel while lysing some adhesions necessary to mobilize the portion of the colon that needs to be resected, resulting in a small enterotomy.
The surgeon discovers this problem, quickly sutures it, completes the procedure without further incident, and the patient makes a routine recovery.
While the surgeon dutifully notes that this accidental laceration occurred in the dictated operative report, he or she never states whether this was a complication or not. When the coder reviews the medical record and discovers this occurrence in the operative report, he or she is suddenly placed in a coding quandary:
- Should the coder assign a code for the accidental cut in the small bowel as a complication, since any cut into the small bowel is not a routine part of a colon resection?
- Should the coder simply ignore the accidental cut because he or she can assume from subsequent documentation that it really did not affect the outcome of the case?
- Should the coder simply ignore this accidental cut because the surgeon did not state this was a complication?
- Should the coder simply create a post-discharge query to the surgeon to ask him or her if this was a complication of the procedure or if it was expected and unavoidable due to the patient’s anatomy?
While we all know this nick probably did not significantly impact the patient’s care (and thus is not a complication), the last option is the official and correct answer. However, if the surgeon had stated in the operative note that the small bowel “nicking” was expected, integral to the procedure, and unavoidable due to the patient’s anatomy, the coder would be confident in not assigning the complication code (998.2, accidental puncture or laceration during a procedure) and would not need to send a post-discharge query for clarification.
Ideally, surgeons would learn from CDI professionals that documenting these types of injuries in their future operative notes with an appropriate description of their significance (e.g., the injury was expected and/or was integral to the procedure and/or was unavoidable and/or that the injury was in fact a complication) would allow their records to be coded without a time consuming query.
Let’s now consider a different example where this same surgeon takes the same exact patient to the operating room for the same exact colon resection.
This time, however, instead of just “nicking” the small bowel, the surgeon accidently puts a two-inch longitudinal laceration in the hepatic artery. The procedure is halted due to the subsequent hemorrhaging and the vascular surgeon on call is urgently paged for assistance. Fortunately, the vascular surgeon is able to repair the damage and the colon resection is then completed as originally planned.
Again, the surgeon dutifully notes what happened in the dictated operative report but again fails to label the injury to the hepatic artery as a complication. Once again, our coder now faces the exact same quandary with the same exact four possible options for resolution as before.
In contrast to the first example, however, this incident was obviously not a routine part of a colon resection. Additionally, it is difficult to argue that the need to urgently call a different surgical specialty to repair a life-threatening injury did not significantly impact the patient’s care.
To further complicate this hypothetical second example, let’s now say the coder does the right thing and sends the needed post-discharge query asking the surgeon if this hepatic artery laceration should be coded as a complication.
Again, remembering the previously mentioned pressures that all surgeons face, let’s also say this surgeon states in the answer to the query that the hepatic artery laceration was not a complication of the colectomy.
Unfortunately, the coder and the hospital are now stuck in a substantial ethical dilemma. If the hepatic artery laceration is coded as a complication (as that injury does seem to be a significant event), the facility opens itself to allegations of fraud as the surgeon explicitly stated that is was not a complication.
However, if 998.2 is not assigned, that incident is lost to your quality and performance improvement review processes as the complication code will not be present when evaluating that surgeon’s performance data.
In other words, a pattern of repeated yet preventable complications may not be brought to the surgeon’s attention until it is too late for future patients who might suffer a similar catastrophic, yet potentially avoidable outcome.
Documentation success
These two examples illustrate the fundamental question of: How does one get a surgeon to become more comfortable with documenting complications and answering queries about possible complications? While multiple strategies exist, one that may not have been previously considered might prove to be the most effective.
First, explain to your surgical staff that complication rates are averages. Therefore, they can relax a bit as one isolated complication will not ruin their reputation or destroy their perfect report cards. After all, some baseline surgical complication rate is expected, as a surgeon who has never had a complication has not performed enough surgery.
Next, explain that all complication rates are risk-adjusted. A sicker patient with additional documented comorbidities has an increased likelihood of a complication occurring. Therefore, if two surgeons have the same number of complications but one surgeon routinely operates on relatively healthy patients while the second has elderly patients with congestive heart failure, end-stage renal disease, malnutrition, sepsis, etc., the second surgeon’s complication rate will receive less scrutiny than the first.
While every insurance carrier and performance improvement software vendor uses different methodologies to calculate complication rates, most are risk adjusted in some manner. Therefore, one of the key strategies surgeons can easily employ to reduce their complication rate is to accurately document in the medical record how sick their patients actually are in reality. Once they realize this, I suspect you will see their compliance with your CDI initiatives dramatically increase.
Occasionally, I still encounter a surgeon who expresses fear that documenting all of the things requested by our CDI program is only going to inflate their complication rates. And, to be fair, some diagnoses like 998.2 will always be considered a complication regardless of the risk calculation methodology used. However, once you show that surgeon the graphs that reveal the consistent, year-after-year, downward trend in the overall complication rates for every surgical specialty in the institution despite the increased documentation we encourage, they suddenly become believers.
In summary, the CDI specialist needs to recognize that surgeons are different. Therefore, the tactics and strategies that seem to work with other physicians may not resonate with them. Surgeons are very complication conscientious but their concerns are by no means insurmountable. Once you overcome the surgeons’ stigma of being repeatedly abused by negative data, I think you will find them much more appreciative of your CDI efforts.
Remember that this acceptance won’t happen overnight. It certainly did not happen that way at my facility. However, results are achievable with gentle and persistent reminders that the CDI specialist is only there to help them and their performance data look better.
Editor’s Note: Dr. La Charité serves as the physician advisor for the University of Tennessee Medical Center at Knoxville's (UTMCK) Clinical Documentation Integrity Program, Coding, and RAC response. A hospitalist at UTMCK, he is board certified in internal medicine and a clinical assistant professor with the Department of Internal Medicine. His opinions do not reflect necessarily those of UTMCK. He is also a former ACDIS advisory board member. Contact him at Clachari@UTMCK.edu.