Clinical vs. Coding Terminology: Crucial Differences that Impact Patient Safety and Quality Ratings


The physician experts at Paramount Health Solutions have spent decades learning both the clinical and coding sides of patient care. This perspective enables us to understand both worlds and to become fluent translators, in a sense. Clinical documentation improvement is critical to capturing the true clinical picture of a patient’s stay. Proper documentation is essential for patient safety, quality ratings, accurate representation of population health, and claims submission. We know, for instance, that some coding diagnoses don’t actually exist in clinical terms. Since most physicians don’t receive coding training in medical school, they don’t know how to compare and contrast clinical language and coding language. Read on to see two examples of clinical terminology vs. coding language.

Example 1:

The difference between “Acute Post-op Respiratory Failure” vs. “Acute Pulmonary Insufficiency Following Surgery” could result in a major difference in the hospital’s quality outcomes. “Acute Post-op Respiratory Failure” in the patient record negatively impacts the hospital quality indicators and is a Patient Safety Indicator (PSI-11). Whenever a patient post-procedure requires extensive High Flow oxygen, BiPAP or CPAP, etc., “Acute Pulmonary Insufficiency Following Surgery” is a better description of the condition. The code for “Acute Pulmonary Insufficiency” was created to capture the cost of treating patients post-operatively that require greater-than-expected LOS or the use of oxygen for hypoxia. Codes J95.1 (Acute Pulmonary Insufficiency in Thoracic Surgery) and J95.2 (Acute Pulmonary Insufficiency Non-Thoracic Surgery) are not considered Patient Safety Indicators (PSI) and will not impact the hospital’s quality scores. They will also capture the severity of the illness. Thus, if a patient is not progressing as expected post-operatively due to the inability of the lungs to function normally, consider the diagnosis of “Acute Pulmonary Insufficiency” in your documentation, which captures the true clinical picture.

Example 2:

Another example we often see is a lack of documentation, even when a patient meets criteria for a diagnosis. Lack of evidence in the physician documentation means it is not coded and billed correctly, resulting in denials by payers and an incomplete record of services provided. Trained and experienced CDI specialists see opportunities and generate physician queries to uncover potential missed diagnoses and severities. We don’t “lead” the physician to a diagnosis, but rather, we help clarify the case and investigate if there is a diagnosis that is more relevant to the weighted clinical indicators. The basic ideology and principle of CDI is that whatever is in the medical record can be used to develop more concrete and specific documentation.

The PHS Approach:

We educate physicians at our client hospitals on what should be improved and the reason why they need to alter their documentation practices. We back up our suggestions with the coding standards that apply. The physician acceptance rate of our recommendations is eighty percent and higher, demonstrating the effectiveness of our services. To find out more about our services, click here. To connect with our team, contact us here, or give us a call at (615) 347-4867 or (210) 725-3444.