Transcript: Using the Documentation and Coding Tool

AHRQ Quality Indicators™ Toolkit for Hospitals: Interview Series
This is the transcript of an MP3 audio file, Using the Documentation and Coding Tool, one of a series of interviews will orient users to the AHRQ Quality Improvement Toolkit for Hospitals. The topics provide an overview of the toolkit and information on how to use the tools and engage stakeholders and staff in quality improvement efforts.

Speaker: Kathy Vermoch, Project Manager, and Suzanne Rogers, University Healthsystem Consortium (UHC)
Interviewer: Lise Rybowski
Date: April 2012
Audio format: Using the Documentation and Coding Tool (MP3 audio file; 9 min., 24 sec.)

Interviewer: On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to a series of interviews designed to orient and educate users of the AHRQ Quality Indicators Toolkit for Hospitals. This toolkit was designed to support hospitals seeking to improve their performance on the AHRQ Inpatient Quality Indicators and the Patient Safety Indicators (PSIs).

Today's topic is the strategies you can put in place to improve your hospital's documentation and coding, which are both critical to the accuracy of your AHRQ Quality Indicator rates. You can find a tool that addresses documentation and coding on the AHRQ Web site at To get to this tool, open the roadmap and select the tool labeled B4, Documentation and Coding for Patient Safety Indicators.

I'll be speaking with two people from UHC, which is an alliance of 116 academic medical centers, along with 261 of their affiliated hospitals and 80 associated physician practice groups. UHC provides a wide array of products and services to support members' performance improvements, including powerful clinical, operational, financial, and safety databases.

We'll hear from Kathy Vermoch, who is the project manager for performance improvement, and Suzanne Rogers, who is a senior specialist for health information management. Kathy facilitates UHC's documentation and coding networking group and served as a project leader for several UHC collaborative and benchmarking studies for clinical documentation and coding improvement. Suzanne has over 25 years of experience in coding and documentation improvement in a variety of health care settings and has taught coding and classification systems in accredited health information technology programs.

Kathy and Suzanne, thanks so much for talking with me today.

Kathy and Suzanne: Thank you.

Interviewer: Kathy, I understand that UHC was involved in the development of this tool. Can you tell me something about that?

Kathy: Yes. UHC partnered with the RAND Corporation on an AHRQ grant to develop the QI toolkit. Under the guidance of an expert advisory panel, the tools were developed, tested, and refined. I was actively involved in creating the documentation and coding tool and working with clinicians, clinical documentation specialists, and coders to ensure its value.

Interviewer: Great, thank you, Kathy. Let me start by asking, why is accurate documentation and coding important when working with the AHRQ PSIs?

Kathy: PSIs can be publicly reported or used internally to indicate hospital and provider performance. You need to make sure that the data being reported is an accurate and true picture of the care provided and the outcomes of that care. PSIs also impact Medicare reimbursement revenue.

Interviewer: Okay, thanks, Kathy. Suzanne, would you like to add anything?

Suzanne: Sure. PSIs are risk adjusted. Therefore, the documentation and coding need to reflect the true severity of a case by accurately, specifically, and completely including all the complications, comorbidities, and other chronic conditions. There's much variation in documentation and coding that must be addressed for accurate PSI reporting.

Interviewer: What do you feel are the most important PSI documentation and coding issues?

Kathy: In our experience, false positives and also false negatives by omission are usually the biggest issues. These often occur because the providers may not always understand the coding process, the rules, and the guidelines, so providers really need to receive ongoing education to raise their awareness of the ways that their documentation is interpreted by coders. On the other hand, some coders may not fully understand how the administrative data that they generate is translated into quality metrics.

Suzanne: That's right, Kathy. We've also found that providers' clinical language does not always translate well to the coding language. For example, the physician may document that an incidental durotomy was made to access a cerebral hematoma for drainage. To the provider, this is not an accidental laceration. But the coder may interpret it as such because of the use of the term "incidental."

Kathy: Also, coding regulations allow for the coding of rule out and possible diagnoses as if they actually do exist, so providers need to remember to clarify when a differential diagnosis is no longer a consideration. They should use terms such as "ruled out" so that it won't get coded. Suzanne, would you like to talk about the POA issues?

Suzanne: Yes. Another issue is the present on admission indicator, or what is known as the POA. It may be misassigned when there are signs or symptoms that are present on admission but the provider does not document a definitive diagnosis until a few days later. Here's an example. The physician may document in his H & P that the patient has fever, low blood pressure, and pallor on admission. But he does not give the diagnosis of sepsis until the blood culture that was taken at admission is reported back as positive. The coder may interpret this documentation to indicate that the condition was hospital acquired rather than present on admission. Kathy, do you want to explain for us false negatives?

Kathy: Sure. False negatives occur when PSIs are not appropriately documented—for instance, when the diagnosis was only documented in the nursing notes, which can't be coded, or if the provider does not clearly document that the condition was due to a procedure, such as postoperative respiratory failure. False negatives also occur when the documented signs, symptoms, test results, and/or treatments that the patient received suggest the presence of a condition, but no specific clinical diagnosis was given.

Interviewer: Thanks, Kathy and Suzanne. That was really helpful. So tell me, how can the Documentation and Coding for Patient Safety Indicators Tool help hospitals to improve the accuracy of their PSI rates?

Suzanne: Let me just say that the PSI toolkit is based on extensive research and testing, so the tools can be applied to your organization with confidence. However, you're still going to want to do some internal documentation and coding audits to personalize your education and training based on those specific findings.

By using this tool, hospitals can examine the documentation and coding practices in their organization and determine the impact that it has on the reporting of the PSIs. Then they can isolate the root causes for both the false positives and negatives and implement targeted actions for improvement. The tool offers a variety of specific documentation and coding advice for each individual PSI. It details many of the relevant documentation and coding issues. This would be an important part of any education and training that you would provide.

Interviewer: Thanks, Suzanne. Kathy, can you tell us what actions hospitals should take to be sure that they can effectively manage the issues involved in documentation and coding of PSIs?

Kathy: Absolutely. They should use the toolkit to guide a collaborative process and be sure to include all of the key stakeholders—providers, other clinicians, documentation specialists, quality and data improvement experts, and of course, coders—and come to a consensus about documentation and coding practices. It's a good idea to develop a written organizational guideline or policy when you do reach that consensus.

Remember to include the impact of coded information on public performance data in order to gain buy-in from your physicians. Also, consider instituting a documentation and coding committee to oversee your efforts and address ongoing changes. Anything to add, Suzanne?

Suzanne: I'd only add that once your organization has confidence in the accuracy of the data that is being reported, then you can truly move forward to improve the actual quality of clinical care. Also, be sure that you track, document, report, and of course, celebrate all the improvements made.

Interviewer: Thank you so much, Suzanne and Kathy, for sharing all your expertise and your experience with us. I think your advice will be invaluable to the many people dealing with documentation and coding issues in their organizations.

As I mentioned earlier, you can download the documentation and coding tool from the AHRQ Quality Indicators Toolkit by going to Click on the link for the roadmap, and select the tool labeled B4, Documentation and Coding for Patient Safety Indicators. The roadmap is a great way to orient yourself to all of the tools in the toolkit.

I also suggest checking out a video recording that you can use to introduce the toolkit to quality improvement teams and other staff. You can find the video and other materials from a Webinar about the toolkit by clicking a link on the bottom of the toolkit page or by going directly to

Again, this is one in a series of audio interviews about the use of specific tools in the quality improvement process, so please check the toolkit page for additional interviews and watch for announcements from AHRQ. Thank you for listening.

Page last reviewed October 2014
Internet Citation: Transcript: Using the Documentation and Coding Tool. Content last updated October 2014. Agency for Healthcare Research and Quality, Rockville, MD.