by Gail I. Smith, MA, RHIA, CCS-P
As our country faces the COVID-19 pandemic, coding professionals have an important role to play capturing critical health data.
Guidelines from the National Center for Health Statistics and CMS provide strict instruction to ensure consistent data collection. Coders take this responsibility seriously and both internal and external auditors review the coding to ensure it accurately reflects the patient’s record and that the coding is compliant with guidelines. This accuracy and completeness of data collection is essential to public health efforts to combat illness.
From the perspective of data collection for an illness we are just starting to understand, we have been here before.
In July 1985 I was working at a Cincinnati Hospital when a 25-year-old male was admitted with a ten-day history of fever and a temperature that peaked at 105°. In addition, the patient suffered from cough, sore throat, headache and blurred vision. Treatment included rehydration and antibiotics. Four days later the patient was discharged with the final diagnosis of fever of undetermined origin. The principal diagnosis was a symptom code for fever. It was later discovered that the 25-year old male had AIDS. Subsequent readmissions allowed us to properly capture the AIDS diagnosis with an ICD-9-CM code.
In a sense AIDS and COVID-19 are similar: they both emerged suddenly into our national consciousness and both demonstrate the vital importance of consistent, reliable health data to make public health decisions.
While the AIDS epidemic had its share of political implications, I recall no controversy about data collection methods or application of principal diagnosis. Back in the 1980s and today, coding professionals’ contribution to healthcare included following guidelines for proper reporting.
As HIM professionals, this is our life work. It is important work, vital to our nation’s efforts to combat illness and promote public health. I want coding professionals to know we applaud their efforts.
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