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Achieving Accuracy in Healthcare Research among the Aged: The Negative Impact of Clinical Coding Practices on Research Outcomes and Proposed Solutions

Denise Fyffe, PhD, and Anna Barrett, MD, from Kessler Foundation, and Mary Ann Brigante, RN, MSN, from Kessler Institute for Rehabilitation, presented their perspective on the obstacles to conducting

February 8, 2010 Anna Barrett, MD, director of Stroke Rehabilitation Research at Kessler Foundation, delivered a presentation at the United Nations on February 9, 2010. Her presentation explained the importance of properly coding hidden disabilities that commonly occur after stroke but are often overlooked as obstacles to recovery. Coding is important not only for insurance reimbursement, but for identifying and tracking people who need evaluation and treatment.

The program, entitled, "Achieving Accuracy in Healthcare Research among the Aged: The Negative Impact of Clinical Coding Practices on Research Outcomes and Proposed Solutions," was part of the nine-day 48th annual session of the Commission for Social Development. The conference was sponsored by the United Nations Non-governmental organization (NGO) for Health and Soroptimist, a women's group participating in connection with the World Health Organization.

"It was very exciting discuss and bring the UN community's attention to problems that are not frequently discussed with relation to health," said Barrett. "They were very pleased because they said presentations on disabilities are just not something that they saw frequently over the last five to ten years." The presentation was attended by national and international community groups, members of the NGOs on Health and Aging, and those who have international goals of health development.

Barrett was asked to present because of the progress her lab has made in researching the best ways to treat hidden disabilities after stroke, and the work they publish for clinicians on how to best identify and treat these problems. She discussed the personal, social, and medical costs of hidden disabilities—for example, depression, difficulty communicating, or hidden disabilities of functional vision resulting from processing visual information improperly. Hidden disabilities are under recognized as causes of injuries due to falls and accidents, poor self care and social isolation -- factors that hinder recovery and reintegration.

In order to track the frequency, hospitalizations, treatment, and cost of medical conditions, the WHO assigns a universal diagnosis code to each condition. Insurance companies, Medicare, and Medicaid also use these codes to determine proper reimbursement to healthcare professionals.

Patient care is a priority for busy clinicians, which is why they often hurry to get through the coding process and back to patient needs. This makes it challenging for them to document every clinically applicable code. Hospitals sometimes hire coding professionals to submit codes based on review of patients' medical charts. In most instances, these professionals can only consider the medical event that is documented and this method favors visible disabilities.

Hidden disabilities are often overlooked in the coding process. "It may take longer review of the record to figure out that a hidden disability such as a memory problem influenced care, or the disability may not have a designated treatment code, so this information is much less likely to find its way into this diagnostic information base," said Barrett.

A person who had a stroke, for example, may receive appropriate treatment, but the after-effects may go undiagnosed. The stroke is under the coding category of neurological conditions, while hidden disabilities may fall under symptoms, which are overlooked in a billing process monitored by administrators.

Denise Fyffe, PhD, a research scientist at Kessler Foundation's Spinal Cord Injury and Outcomes Research Lab, also delivered a presentation on the health disparity that comes with not diagnosing hidden disabilities. If hidden disabilities are not recognized and treated, new health problems can emerge that will cost the system more money.

"There is a cost benefit of correcting health care disparities in racial and cultural groups, which could be as much as $230 billion savings in the US," said Barrett. "This suggests that social justice really is cost effective in terms of the treatment and identification of hidden disabilities."

Barrett also discussed the challenges of a universal coding system, especially in developing regions where access to healthcare is very limited. A panel discussion after the presentations searched for solutions.

They agreed that a multi-disciplinary team might work best for uncovering hidden disabilities after stroke. Mary Ann Brigante, RN, of Kessler Institute of Rehabilitation described how nurses build more intimate relationships with their patients and learn of, and observe, subtle signs of hidden disabilities. They, along with therapists and other personnel who work closely with patients on activities of daily life, have an advantage in detecting hidden disabilities.

When a team is not available, solutions still have to be found so that patients receive the proper treatment. The training of physiotherapists and practitioners of alternative medicine in developing nations, for example, could help them detect and code for the conditions and develop a plan of treatment. While the discussion is still in its early stages, progress and advancements have been noted.

The Centers for Medicare and Medicaid Services began giving incentives to hospitals for submitting codes and documentation for hidden disabilities. The problem with this system, according to Barrett, is that it does not reward the treatment that would be optimal for success in rehabilitation. If treatment were incentivized, coding would be indirectly rewarded, which would improve patient care.

"If you don't correct or treat the hidden disability, patients and caregivers bear the physical and emotional burdens that extend recovery and add to direct and indirect costs of care. And that perpetuates the social injustice and fundamental health care disparities that add to overall cost