How Medical Coders Feel About Jargon Is Worth Knowing

January 25th, 2023 - Find-A-Code

Categories: Coding

A fascinating study recently published in the JAMA Network Open journal reveals what many of us have known for a long time: doctors and nurses speak in terms we patients often don't understand. Thus, we are confused by the medical jargon. It would be worth knowing how medical coders feel about it. Do they have trouble understanding clinicians?

If you are a medical coder or biller by trade, you know your main task is to convert electronic health records (EHRs) into ICD-10, ICD-11, and CPT codes. Everything you do has to be done through the lens of HIPAA compliance. But how often do you have trouble translating those EHRs? How often do you spend way too much time trying to decipher a clinician's meaning just so that you can choose the right code?

Jargon isn't exclusive to the healthcare industry. Every industry has it. But in healthcare, using jargon could actually be dangerous. The University of Minnesota researchers who conducted the previously mentioned study say that misunderstanding a doctor or nurse can actually lead to patient harm. In the billing department, misunderstandings merely lead to denied claims.

My Condition Is Occult?

NBC News' Erika Edwards produced a piece in late November 2022 discussing the University of Minnesota study. In that piece, she cited several examples of jargon that, at the very least, confused patients. One of the more interesting examples was the word 'occult'.

When a physician refers to a patient's condition as 'occult', they are referencing the fact that the condition was previously unknown or hidden. But to the rest of us, the word 'occult' conjures up images of witches, demons, and Ouija boards. Hearing a doctor refer to a condition as occult would lead many of us wonder if they were playing with a full deck.

Here are two additional examples cited by Edwards:

Impressive – We tend to associate positive things with being impressive. When we say something is impressive, we are saying that it had a positive impact on us. But when a doctor says something is impressive – like chest x-rays or biopsies – it means they are concerned about what they see.
Putting One to Sleep – A doctor might tell a patient that they intend to "put the patient to sleep" prior to a particular procedure. Imagine if that patient's only experience with the phrase relates to euthanizing a pet.

One of the physicians interviewed by Edwards for her piece mentioned the fact that clinicians suffer from "jargon oblivion." This is to say that they forget that they had to learn the terms they use in their daily practices. They forget that there was a time they did not know the terms either.

What Did the Doctor Really Do?

Take the same jargon mindset and apply it to medical coding and billing. Imagine being a medical coder trying to decipher a doctor's EHR relating to an obscure diagnosis or treatment. The coder is already at a disadvantage because they are faced with the diagnostic lookup of something they are not familiar with. If the doctor were not clear, a mistake could be looming on the horizon.

The coder might find themself asking, "what did the doctor really do during the office visit?" They might be left scratching their head trying to figure out terms they have never seen before.

According to the doctors interviewed by Edwards, the solution is as simple as clinicians choosing to speak in language that people understand. Simply put, it is to use simple English rather than industry jargon. It would be fascinating to know if medical coders and billers feel the same way.

###

Questions, comments?

If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.

Latest articles: (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.

The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox

Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.

Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period?

Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox

Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.