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How a Wrong Diagnostic Code May Affect a Patient

Submitted by Karyn Nilson, who is studying diagnostic coding.  This is an excerpt from a class assignment. While it does not fit the parameters I usually ask for in a guest post, I felt it was important information to share, and thank Karyn for allowing me to share it with all of you.

August 2009

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Assigning a wrong diagnostic code may be enormously costly, time-consuming, and ineffective for patients; more critically, it is a threat to patient safety and quality.  It comes down to time, money, expense, costs, research, training, physician and hospital visits, treatment’s, surgeries, drugs, disabilities, death, quality healthcare, higher medical and life insurance premiums, lack of or no health insurance, heartache, malpractice, and just feeling down right ill!  Not only to mention, ‘do I trust you?’

The New York Times recently interviewed President Obama about health care:

“I’m a pretty well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor.  But ultimately he is the guy with the medical degree.  So, if he tells me, you know what, you’ve got such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.”

This is shockingly bad advice.

Numerous studies have shown that patients get the wrong diagnosis as much as 20% of the time and also receive the wrong treatment half of the time.  35% of doctors and 42% of patients report errors in their own care or that of a family member (s).  Studies have shown that most errors happen because of a failure to analyze the patient’s problem correctly.  The National Patient Safety Foundation stated that 42% of medical patients feel they have experienced a medical error or misdiagnosis, resulting in the cost of medical tests, drugs, and operations.  Results from a separate survey of 2,201 in the United States, 35% of those experienced a medical mistake within the past 5 years.  Of these, 35% resulted in permanent harm or death.  It has also been shown that that at least 44,000 Americans die each year as a result of medical errors and misdiagnosis (that is more than motor vehicle accidents, breast cancer , or AIDS), resulting from patient safety problems.  More Americans die each month of preventable medical injuries than died in the terrorist attacks of Sept. 11, 2001.

Physicians are strapped for time, deal with complicated problems, and patients easily fall prey to poor quality healthcare due to physicians not acquiring and applying the correct knowledge.  This is an unfortunate substitute for evidence-based medicine.  Be accurate when giving your family and medical history information and have access to your information.

It is you that is in control, not the guy with the white coat and the medical degree.  Watch what goes on your medical record and put the pieces together.  Ask questions, be skeptical, and disrupt the physician’s thought process.  A direct approach to overconfidence is to simply ask the physician how confident they are in their diagnoses.  Make sure the decisions about your care are correct.  Make sure what is written is a true diagnosis.  If it warrants research on your part for better clarification, then do it!

So now – what happens to someone lets say is told she has cancer instead of a more benign, less problematic diagnosis (or the other way around) or when assigning the wrong diagnosis code on a mother’s record that might influence how her baby is born and tested.  The upset and heartache could be enormous.  The patient suffers during the process by experiencing physical and psychological discomfort.  These mistakes from assigning the wrong diagnosis code could result in serious harm, such as disability, adverse events that lead to death, additional or prolonged treatment, lost income, and/or lost household production.

There’s the possibility of applying for and being denied medical and/or life insurance due to the incorrect information indicated on your medical record.  You now would have to spend the time and research (money?) to have your medical record corrected.  You may have to ‘prove’ that you indeed do or do not have the assigned diagnosis.  The other drawback?  If you can’t get approved for insurance through your own carrier you could get insurance through the state (if provided) but it would not be cheap.  You will also have to update your information with the Medical Information Bureau (the purpose behind the MIB is to provide background information to its insurance company members so they can determine who they will accept for insurance or who they will reject).

Medical misdiagnosis is a serious risk every time you go the doctor or the hospital.  It does not come with the guarantee that everything will be handled at its full capacity.  Out of the 2,201 adults surveyed in the United States, 55% listed their greatest concern while seeing a physician in an outpatient setting, while 23% listed concerns in a hospital setting.  A physician could cause major financial hardship and exposure to tremendous health risks by not assigning the proper diagnosis code.

There are several signs to watch out for which may indicate misdiagnosis has occurred. If any of the following apply after undergoing any form of medical treatment, it should be investigated further:

  • Treatment does not seem to be working
  • Symptoms that don’t usually occur with the given diagnosis
  • The condition was diagnosed based solely on a lab test
  • The physician attributes symptoms that are common among other conditions
  • The physician references a test that was not performed as a factor in the diagnosis

Misdiagnosis is also a form of medical malpractice.  Diagnostic errors are typically the leading or the second-leading cause of malpractice claims in the United States and abroad.  This type of error also has the potential to cost the patient thousands of dollars in needless expenses and treatments (and the doctor thousands of dollars in expenses in the process).  This form of medical malpractice includes diagnosis errors of both physical and mental conditions.

There is also the possibility of healthcare fraud and abuse.  Regence of Washington reports that health care fraud will result in the patient paying a higher premium and more taxes.  Patients pay for errors when insurance costs and copayments are increased due to services that would not have been necessary if the proper care was provided in the first place.

The Centers of Medicare and Medicaid Services estimates that it loses $60 billion in tax dollars alone to fraud each year and The National Health Care Anti-Fraud Association estimates as much as three to ten cents of every health care dollar is lost to fraud and abuse, up to $170 billion.

Six years after the “To Err is Human” report, the Washington state Legislature responded with a law mandating medical error reports.  The vision was to someday have a Web site where patients could compare hospitals’ safety records. The new law didn’t establish that groundbreaking service but did call for steps in the right direction.

The law said all hospitals, birthing centers, prison medical facilities, and inpatient psychiatric centers are required to report any one of 28 “adverse health events” to the state Health Department after they are confirmed.  Ambulatory surgical centers were added as required reporters last month.  None of the 11 birthing centers, 17 prison facilities or three psychiatric hospitals has been credited by the state with filing a single report since 2006, according to the Health Department.  A third of Washington’s roughly 100 hospitals haven’t shown up on the list as reporters, either, records show.

If national studies are any indication, there should be thousands, not hundreds, of reports from such facilities.  The law is pretty clear that they are supposed to report.

Washington requires hospitals and some other medical facilities to report medical errors, including suspicious drug-related deaths, but a one-person office in the Health Department has no authority to enforce it, and more numerous hospital-licensing officials who could, admittedly don’t.  The information is not readily accessible to the public, and the system has loopholes.  For instance, doctor’s clinics are exempted. Patient-safety advocates believe errors are grossly underreported.

The fact remains, that if one of the states top 20 hospitals reporters a medical error, where few seem to fully report, that report can make the hospital look bad.  If the hospital admits to each error properly, the hospital can be flogged for its accumulated record.   Don’t report, and there’s no risk of any action.

It be could said the Legislature and the Health Department have protected hospitals more than patients.

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Need information about obtaining your medical records and making corrections?  These may help: