I remember about 20 years ago a coder came to talk to me about my wound care documentation. I can’t remember if she was sent from the University or the hospital. I was a relatively young faculty member and the wound center I started at UT Houston had not been open for many years. She was sent to counsel me about some charting “issues” in reference to the documentation of a diabetic foot ulcer. She showed me a particular chart, re-read the note I wrote and then said, “You can’t use that word.” “What word are you talking about?” I asked. “The word ‘wound’”. “See, right here, after you say that it is a diabetic foot ulcer, in your note you say that ‘the wound has been present for six months,’ and you can’t say that.” I replied, “I am not following you about what it is that I did wrong,” I said. She then explained to me that I was not able to use the word “wound” in the note of a patient with an “ulcer” because wounds and ulcers were different things according to CMS. I was confusing to the coders by using these words interchangeably. I needed to stick with the word “ulcer” at all times in reference to a DFU.
I could digress here and wax philosophical about “a rose by any other name.” But there she was, sitting on the ratty little sofa in my office, explaining the way that CMS had redefined a word in the English language and made it off limits in certain situations. This was a problem, given that I was running a “wound center” (and had the words “Wound Center” on the letter head of my consultations) and had just been told not to use the word “wound” except on odd Sundays and only with permission.
I really did not understand the huge favor she was trying to do for me. I was upset. I was frustrated. I was – yes, I was probably condescending. And now I absolutely get it. I wish I could remember her name. I am sure she has retired and is not having to talk to arrogant young doctors about ICD-10. I hope she is not having to explain this next, much more complicated diagnosis system that incorporates E codes (external causes of injury) and V Codes (factors influencing health status), that groups injuries by anatomical site rather than by type of injury, and reclassifies diseases. I’d like to apologize to her, and I wish I was retired, too.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/channel/UCbxBv_PCAYkbUCvnCjTzW0A/videos