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Optics over integrity?
Let coders be coders
Robert Oubre, MD
January 17, 2026 • Estimated Reading Time: 8 minutes
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All That Glitters Is Not Gold
“All that glitters is not gold.”
A relative reminds me of that often.
He’s a marriage counselor.
So he has insight into families who appear to have it all together…
but don’t.
He uses that aphorism when I compare myself to others.
But now my inbox has me applying that same idea to health system quality rankings.
It all started with a post on Linkedin.
And then someone in my online community posed a similar question:
“How are your facilities handling a condition that is documented and meets the definition of a secondary diagnosis (or principial diagnosis), but does not meet clinical criteria (either widely accepted consensus or internal facility definitions), and the provider is queried and doubles down on confirming the condition? (Think high risk diagnoses like AKI, acute respiratory failure, malnutrition, etc.)”
On both Linkedin and my online community, it led to a great debate. Most responses fell into two camps:
You code the condition.
You have an escalation process that allows the code to be removed if it is truly considered clinically invalid by a committee and would result in payment for a condition that was not actually present and did not consume resources.
You can see the debate in the comments on the Linkedin post but to me, point #2 seemed like the obvious more ethical stance - it’s an attempt to prevent fraud.
But then I started receiving private messages.
Coders had seen what happens next.
That same process, created with good intentions, became a slippery slope. It was later used to remove codes that were correct, but negatively impacted a quality metric. The rationale became that certain codes did not capture the “spirit” of the metric or reflected “coding weirdness.”
Personally, I accept those oddities as part of the system. Over time, these quirks tend to wash out in the averages. After all, most quality metrics are relative to peers, not absolute values. Every hospital plays by the same rules.
Or they should be…
I heard rumors that some hospitals were removing codes that “don’t really matter” because they don’t change the DRG. And that it became accepted that a physician advisor’s opinion should override coding conventions.
And over time, those small exceptions created cultures where:
Codes that “look bad” on metrics became negotiable
Clinical expertise became a shield against any challenge
Accuracy gave way to optics
And most concerning: Coding was left out of the room when coding-policies were created
And then you see reporting that hits you in the face, like Penny Jefferson’s work on admit type inconsistencies and their impact on Patient Safety Indicators:
According to one benchmarking organization’s data, the admission rates for the top-performing hospital in quality rankings were 4% elective, 48% urgent and 45% emergency, while the admission rates for the 10th best performing hospital were 42% elective, 22% urgent and 35% emergent.
(For context, many PSIs are only triggered for elective procedures, not urgent or emergent. So, changing the admit type to non-elective leads to less PSIs)
Does that prove fraud?
No.
But it certainly raises questions. Those inconsistencies not-so-subtly suggest that some organizations may be gaming the system.
Then you read about UnitedHealth’s in-home screenings for peripheral vascular disease using devices not used in clinical medicine, which resulted in dramatically higher rates of PVD (which triggers increased payment from CMS) in Medicare Advantage patients compared to Traditional Medicare.
Or health systems that appeared exemplary, later found to be adding unsupported diagnoses like morbid obesity in patients without a qualifying BMI, or “qualitative platelet disorder” simply because a patient was on aspirin.
Those stories force you out of naivety.
They also reframe your own metrics. When you perform well and know you’re playing by the rules… man that feels good.
Years ago, on Brian Murphy’s Off the Record podcast, he asked me what makes a good CDI Physician Advisor. My response focused on documentation.
Today, my answer is different: The top quality is internal integrity, that is, doing the right thing even when no one is looking.
So, do I still believe that having a formal escalation process for truly unsupported diagnoses is ethical?
Yes.
But only in the right organization.
With the right people.
Who hold integrity and compliance in high regard.
And that brings me back to coders.
With very rare exception, non coders should not be telling coders what to code or not code.
Coders are not obstacles to your goals.
They are guardrails.
Working around them is not being strategic.
It suggests that optics matter more than truth.
If your metrics look bad, the answer is almost never “change the codes.”
The answer is one of two things:
Either it just is what it is, or
Your clinical care and/or documentation need to improve
You do not fix quality metrics by distorting data.
You fix data by improving care and documentation.
Clinical truth, reflected through accurate coding, is our common ground.
Protect it.
Respect the people who defend it.
And let coders be coders.
Share your thoughts in the comments, or on Linkedin!
That’s all for now.
-Robert
Thank you to Laura Samson, RN BSN CCDS for editing this newsletter!
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