Two fundamental activities define the daily grind for most healthcare providers, especially in rural settings. First and foremost is patient care. Closely following, and often competing for time, is the meticulous documentation of that very care. Both are essential, yet the clock only has 24 hours. This time crunch can unfortunately lead to a critical gap: in the eyes of the external world, undocumented care is often perceived as care not given. Experts emphasize that this disconnect represents a missed opportunity for providers to showcase their efficiency and the true quality of care they deliver. For rural America, this can mean that stories of successful healthcare delivery remain stereotyped, overlooked, or simply untold, failing to demonstrate the real How Coding Can Impact The Quality Of Care provided.
Decoding Medical Coding: Translating Clinical Stories into Data
Nelly Leon-Chisen, expert in medical coding and classification, explaining the importance of standardized medical coding.
To effectively communicate the narrative of rural health and its unique challenges and successes, understanding the basics of medical coding is paramount. Nelly Leon-Chisen, a leading voice as the American Hospital Association’s executive director of Coding and Classification, has dedicated her career to clarifying the often-misunderstood process of medical coding. This process essentially translates the detailed clinical documentation provided by healthcare professionals into a standardized numerical language. These numbers, seemingly abstract, are what ultimately tell the comprehensive story of health and healthcare delivery, revealing how coding can impact the quality of care narrative.
“Medical coding provides a standardized numerical system for physicians, hospitals, and all healthcare providers to describe patient care,” Leon-Chisen explains. “By converting medical conditions and treatments into numerical codes, we create a powerful dataset that can be analyzed and aggregated to tell stories, much like reading a book. These numerical codes reveal trends in the health and well-being of populations within specific regions and across the nation over time. Furthermore, because these coding systems are internationally standardized, we can even compare healthcare delivery and health outcomes in our country to those around the globe, understanding how coding can impact the quality of care on a global scale.”
The Language of Healthcare: Medical Codes Explained
The concept of systematically classifying diseases dates back to the 1700s, reflecting a long-standing scientific need for organized systems. European professionals continuously refined and expanded these classifications over centuries. The United States formally joined these international efforts in the late 1890s through representatives from the American Public Health Association, as detailed in a federal agency historical report. This ongoing evolution resulted in the International Classification of Diseases (ICD), a globally utilized, standardized numerical classification system. The latest iteration, ICD-11, was finalized in January 2022, marking the eleventh revision of this crucial system.
Currently, the United States utilizes ICD-10, adopted on October 1, 2015, after more than 35 years of using ICD-9. A significant shift with ICD-10 was the transition from primarily numeric codes to alphanumeric codes for diagnoses. This expansion dramatically increased the number of available codes by over 100,000, offering far greater specificity in describing medical conditions and procedures. (While officially termed ICD-10-CM, with CM denoting clinical modification, it is commonly referred to as ICD-10).
The transition to ICD-10 was a monumental undertaking, requiring seamless integration across all facets of the healthcare system, including providers, payers, software vendors, clearinghouses, and billing services. However, experts and researchers agree that this change was essential, enabling the U.S. to more accurately assess and compare its population health on a global scale. According to the Centers for Medicare and Medicaid Services (CMS), ICD-10 supports several critical improvements, demonstrating how coding can impact the quality of care and healthcare systems:
- Advancement of public health research, surveillance, and emergency response: Enhanced detection of disease outbreaks and adverse drug events through more specific coding.
- Improvement of coordinated patient care: Facilitating better communication and understanding of patient histories across different providers and over time.
- Enhancement of fraud detection efforts: More precise coding aids in identifying and preventing fraudulent billing practices.
- Better understanding of innovative payment models that drive quality of care: Providing data to analyze and refine payment models that incentivize and reward high-quality care.
Example of hospital discharge documentation translated into ICD-10 alphanumeric codes, demonstrating the tangible output of medical coding.
The Direct Impact of Medical Coding on Quality of Care Measurement
Leon-Chisen emphasizes that while medical coding is intrinsically linked to healthcare billing and financial processes, its fundamental purpose extends far beyond revenue cycles. Ultimately, medical diagnoses and procedure codes become data and information that provide invaluable insights into community and population health, and critically, they serve as a representation of the quality of care delivered, illustrating how coding can impact the quality of care perception and measurement.
Robyn Carlson, quality reporting specialist, highlighting the importance of accurate coding for quality measurement in healthcare.
Robyn Carlson, a quality reporting specialist at Stratis Health, brings over two decades of experience “mining” medical records to extract data for various purposes, from workflow analysis to quality measure evaluation. Working with the Stratis technical assistance team for the Medicare Beneficiary Quality Improvement Program (MBQIP), Carlson assists Critical Access Hospitals (CAHs) in voluntary quality reporting. She shares a compelling, albeit somewhat simplified, example to illustrate how coding can impact the quality of care as perceived through quality measurements.
“Imagine a patient presenting with chest pain, abnormal lab results, and an EKG finding suggestive of a heart attack, specifically an ST-elevation myocardial infarction,” Carlson explains. “Based on the initial documentation, this case might be coded as a heart attack. However, let’s say further investigation reveals the chest pain was actually due to chest trauma. When this case is then assessed against acute myocardial infarction (AMI) quality measures, it would incorrectly appear that quality measures were not met. In reality, the care provided was entirely appropriate for chest trauma, but because the initial coding pointed to a heart attack, the case would be miscategorized, demonstrating how coding can impact the quality of care assessment even when the care itself was excellent.”
This example underscores not only the critical role of accurate medical coding but also highlights the essential communication loop between the healthcare provider and the coding professional. Carlson further explains how these types of coding discrepancies, which directly influence how coding can impact the quality of care metrics, often come to light.
Coding really matters, especially for telling the story of quality. People are really looking at the relationship of medical coding and quality so much more now.
“Often, coding issues are flagged by the quality department in a rural hospital, perhaps triggered by a CEO’s concern about a drop in heart attack quality rankings,” Carlson notes. “These quality rankings are significant, especially for rural hospitals that typically have a smaller number of cases to begin with. Coding really matters, especially for telling the story of quality. The healthcare industry is increasingly focused on understanding the intricate relationship between medical coding and quality, recognizing how coding can impact the quality of care perception and reality.”
From Documentation to Data: The Coding Workflow
The coding of a provider’s documentation adheres to strict medical coding rules. While a comprehensive medical chart review encompasses a broad range of information, the data that can be translated into numerical codes is primarily derived from documentation explicitly recorded by a clinical provider. For instance, if a provider documents a high pulse rate, fever, and elevated white blood cell count, and orders IV antibiotics, a medical coder cannot automatically code the case as sepsis, a severe bloodstream infection, unless the provider explicitly documents “sepsis” as the diagnosed condition. Crucially, even if another member of the clinical care team, such as a nurse, documents this diagnosis, it cannot be used for coding purposes unless a qualified provider also includes it in their official documentation. This highlights the rigorous standards that dictate how coding can impact the quality of care data.
So, how does a coding professional address potential discrepancies or missing information in a chart? While it might seem straightforward to simply call or email the provider for clarification, informal queries are not permitted. Instead, a formal clarification process known as a query must be initiated. Even the language used in these official queries is governed by strict guidelines to ensure it remains non-leading. For example, a permissible query might be: “What condition is being treated with the IV antibiotics?” This illustrates the structured and precise nature of the process that influences how coding can impact the quality of care data integrity.
Experts emphasize that this seemingly rigid approach is absolutely necessary. Coding professionals are not clinicians; they cannot interpret clinical findings or make diagnoses. However, this formal query process, while essential for accuracy, can add an extra layer of effort for both coders and clinicians, potentially posing a challenge to achieving the comprehensive coding needed to fully tell the story of rural healthcare and truly represent how coding can impact the quality of care in these communities.
Research Insights: Coding’s Influence on Public Health Studies
A 2020 research paper comparing coding practices and their impact on mortality rates in Critical Access Hospitals (CAHs) and non-CAHs revealed significant insights into how coding can impact the quality of care data used for research. The study suggested that coding accuracy and completeness might be a higher priority in non-CAHs, leading to the capture of more diagnoses and potentially more comprehensive coded data. Researchers attributed this difference to the larger, more specialized teams dedicated to documentation and coding processes typically found in non-CAHs. This is often because Medicare payments and public report card measures for non-CAHs are directly linked to the accuracy and completeness of the codes used, further demonstrating how coding can impact the quality of care metrics and financial implications.
Cyrus Kosar, PhD, lead author of research on coding practices in CAHs and non-CAHs, emphasizing the limitations of claims data for measuring health status.
Cyrus Kosar, PhD, lead author of the paper and a researcher at Brown University School of Public Health, reflected on the study’s findings. He concluded that while the research indicated potential under-coding in rural CAHs, a crucial takeaway was the inherent limitation of using claims data for research purposes. As stated in the paper, “The underlying issue is that claims diagnoses are primarily recorded for billing purposes, not for measuring health status or illness severity.” This perspective highlights a critical consideration in understanding how coding can impact the quality of care data interpretation in research.
“As researchers, we must always be mindful that the unobserved health status of patients is a significant data element that is not always captured by coding,” Kosar cautions. “This inherent limitation can permeate datasets and introduce bias into our research, impacting our understanding of how coding can impact the quality of care as reflected in research outcomes.”
Alana Knudson, PhD, rural public health researcher, expressing optimism about ICD-10’s potential to improve rural health research and address health equity.
Alana Knudson, PhD, a renowned rural public health researcher and director of the NORC Walsh Center for Rural Health Analysis, has long been a leading voice in guiding researchers and policymakers through the nuances of rural health data and coding. While acknowledging the financial drivers behind coded data, Knudson affirms its continued value for public health research. She expresses optimism that the increased specificity offered by ICD-10 codes compared to ICD-9 will facilitate more nuanced and robust comparisons within rural America, enhancing our understanding of how coding can impact the quality of care in diverse rural contexts.
“Rural America is far from a homogenous environment,” Knudson emphasizes. “Different rural communities face distinct challenges. I believe that the granularity of ICD-10 coding allows us to move beyond simplistic rural-urban comparisons and delve into understanding the differences between small and large rural communities, their unique healthcare experiences, and their specific needs. ICD-10 can also be invaluable for epidemiological research, helping us to better understand regional variations in illness severity and comorbidities, for example, comparing the rural Pacific Northwest to the rural Southeast or the Great Plains. I am confident that this richer data will inform more targeted interventions, process adjustments, and organizational and cultural changes aimed at improving health outcomes and advancing health equity in rural America, ultimately showcasing how coding can impact the quality of care and health equity.”
Unlocking Social Determinants of Health with ICD-10 Z Codes
Knudson further highlights the transformative potential of ICD-10 Z codes in capturing the impact of social determinants of health (SDOH) in rural communities. SDOH, the conditions in which people live, learn, work, and age, are increasingly recognized as crucial factors influencing health and well-being. Leon-Chisen provides further insight into these unique codes and how coding can impact the quality of care by addressing SDOH.
Leon-Chisen explains that Z codes are specifically designed to capture “factors influencing health status and contact with health services.” Within this broad category, a subset of codes specifically addresses SDOH, defined by the WHO as the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” These codes offer a powerful tool to understand how coding can impact the quality of care by incorporating social context.
Infographic illustrating the use of Z codes for social determinants of health: Collect, Document, Map, Use, and Report. Source: CMS, emphasizing the practical application of Z codes to understand how coding can impact the quality of care.
“Clinicians have long intuitively understood the significant impact of social issues on health outcomes, but quantifying and demonstrating this impact has been challenging,” Leon-Chisen states. “Z codes associated with social determinants of health offer a solution by allowing us to utilize administrative data, often routinely collected in medical records and healthcare organization admission screening tools, to understand how coding can impact the quality of care through the lens of social factors.”
She cites examples of Z code categories, outlined in the AHA’s SDOH Z code fact sheet, including issues related to education and literacy, economic stability, upbringing, and psychosocial circumstances. She finds the Z codes related to housing instability particularly illustrative of the value of Z codes in demonstrating how coding can impact the quality of care by capturing nuanced social realities.
“Homelessness provides a compelling example of the granularity Z codes offer,” Leon-Chisen elaborates. “Homelessness is not a monolithic condition. Does it mean living on the streets, ‘couch surfing,’ or residing in a shelter? While all are forms of homelessness, the Z codes differentiate these situations, distinguishing between someone living without shelter and someone in temporary or unstable housing. This level of detail provides invaluable information for understanding how coding can impact the quality of care for vulnerable populations.”
She emphasizes that Z codes are unique in that they are coding elements unrelated to direct reimbursement.
“Currently, there is no direct financial incentive to collect Z code-related information,” she notes. “This contributes to their underreporting. However, the growing interest in these codes is evident in the increasing number of proposals to expand the Z code set, adding even greater granularity. Z codes hold immense potential to improve our understanding of community health and well-being, demonstrating how coding can impact the quality of care by incorporating social context into healthcare data.”
Redux on Coding of Care: Z Codes Differ
Leon-Chisen highlights a crucial distinction in the coding rules for Z codes compared to other medical codes. For Z codes, SDOH information can be captured if documented by any healthcare professional authorized to contribute to the official medical record. This includes documentation from non-physician providers such as social workers, community health workers, case managers, nurses, and other members of the care team. This broadened scope recognizes the multidisciplinary nature of addressing SDOH and further enhances how coding can impact the quality of care narrative by incorporating a wider range of professional perspectives.
Unique Coding Challenges in Rural Healthcare Settings
Experts point out that many clinical providers, both in rural and urban settings, are either unaware or lose sight of the fact that their medical record notes undergo a coding process that disseminates data far beyond payers and employers. This coded data informs numerous healthcare-related datasets, impacting resource allocation, quality assessments, and public health initiatives. Furthermore, some providers have limited awareness that these datasets tabulate provider-specific data, reflecting individual resource utilization, quality of care patterns, and health outcomes. These same databases also play a critical role in detecting fraud, waste, and abuse, highlighting the far-reaching implications of how coding can impact the quality of care and the healthcare system as a whole.
Patty Harper, rural coding and health technology expert, discussing the need to increase awareness among rural providers about the impact of medical coding.
Patty Harper, a specialist in rural coding and health technology, emphasizes the critical need to raise awareness about documentation and coding among rural providers, many of whom handle coding responsibilities themselves.
“Clinicians often feel that their primary contribution—their ‘good work’—is the direct patient care during the visit, not the subsequent documentation,” Harper observes. “It’s estimated that approximately 80% of rural providers in ambulatory settings assign their own medical codes, often as the only way to finalize a patient encounter and submit a claim. Many of these providers have never been educated on the broader impact of medical coding beyond billing. They are often unaware that coded data from their work extends far beyond the payer, influencing quality measures, public health research, and more. This lack of awareness persists even among providers in Accountable Care Organizations (ACOs), who may believe that payment structures are solely based on delivering high-quality care, rather than the documentation of that care, missing the crucial link of how coding can impact the quality of care perception and reality.”
Presentation slides illustrating rural palliative care coding considerations, highlighting the practical coding challenges faced in rural healthcare.
Harper further notes that rural providers’ coding efforts are often constrained by limited resources. They may rely on pre-populated superbills or limited drop-down menus in electronic systems, restricting their ability to capture the full complexity of patient encounters. The prohibitive cost of sophisticated electronic health record (EHR) programs further exacerbates these limitations in many smaller rural healthcare organizations, impacting how coding can impact the quality of care data completeness.
Tammy Norville, a coding expert and technical assistance director for the National Organization of State Offices of Rural Health (NOSORH), corroborates Harper’s observations. Year after year, NOSORH member needs assessments consistently identify “documentation, coding, and billing” as top-three areas of concern for rural healthcare providers.
“Clinical documentation and coding issues, and their impact on financial and quality outcomes, are consistently among the most pressing and anxiety-inducing topics for those working in rural primary care clinics and hospitals,” Norville states. She reports conducting at least 26 presentations on this topic in 2021 alone, underscoring the widespread need for education and support in this area, and the pervasive question of how coding can impact the quality of care in rural settings. “Despite differences between outpatient and inpatient settings, the core concerns and needs remain strikingly similar.”
Tammy Norville, coding expert and technical assistance director for NOSORH, emphasizing the critical importance of coding in rural healthcare and its impact on quality storytelling.
Norville notes a common initial misconception among her audiences: a belief that coding is not particularly important.
“Coding really does matter,” Norville emphasizes. “It’s transformative to witness audiences grasp this concept as they learn how clinical documentation and coding empower them to truly tell the story of the patient care they provide, demonstrating how coding can impact the quality of care narrative.”
Through her extensive presentations over the past four years, Norville has observed a universal gap in understanding, regardless of rural organizational structure. Providers often fail to recognize that documentation and coding extend far beyond immediate reimbursement and financial considerations, impacting quality reporting, research, and resource allocation.
Both Harper and Norville highlight another commonality: because the vast majority of clinical providers are trained in urban settings, urban and rural clinicians often share similar levels of limited awareness regarding the broader implications of their clinical documentation and how coding can impact the quality of care data.
Clinical providers need to become aware of the relationship between what they’re writing and what can be coded.
“Clinical providers need to become aware of the direct relationship between their documentation and what can be coded,” Norville stresses. “In my experience, once providers grasp this connection… well, they get it! Once the clinical language required for effective coding ‘clicks,’ it’s a game-changer. By educating providers early in their training, at the PGY1 level, by the time they reach PGY3, they often master documentation needs and become educators themselves, mentoring junior residents. Imagine the long-term impact of successive generations of medical providers who truly understand how coding can impact the quality of care and patient outcomes.”
A Miniscule Amount of Time: Teaching Medical Learners Coding Concepts
Pre- and post-education results on clinical documentation, demonstrating the significant impact of even brief educational interventions on improving documentation quality and understanding of how coding can impact the quality of care data.
Numerous graduate medical education initiatives across the country are incorporating clinical documentation and medical coding education, often driven by financial considerations within healthcare settings. However, health information experts emphasize the broader potential benefits of standardizing this education. Remarkably, as little as 16 hours—approximately 0.2% of a 3-year primary care residency—can significantly transform both the financial and non-financial narratives of healthcare. The core of this essential education is not to train learners to become coders, but rather to instill a deep understanding of why codable clinical documentation matters for all healthcare professionals, including physician assistants and nurse practitioners, and to demonstrate how coding can impact the quality of care story.
Elevating Rural Healthcare Value Through Coding Awareness
Harper expresses concern about potential consequences stemming from these clinical provider awareness gaps, particularly for rural providers. She emphasizes the urgent need to highlight how coding can impact the quality of care narrative for rural safety net providers.
We need to be able to use that information to plant our flag and say, ‘We are rural safety net providers and we do great patient care.’
“Rural safety net providers must be able to effectively demonstrate the breadth and depth of services they provide to their communities,” Harper asserts. “Without accurate documentation and correct coding, the significant impact they have on their communities remains invisible. To ensure rural providers continue to benefit from cost-based reimbursement models and other incentives designed to support them, we must tell our story in a language that is universally understood—by translating excellent clinical care into accurate alphanumeric data. This is how we demonstrate the exceptional work being done in rural healthcare. We need to leverage this information to ‘plant our flag’ and proudly declare, ‘We are rural safety net providers, and we deliver outstanding patient care,’ showcasing definitively how coding can impact the quality of care in rural America.”
