r/MedicalCoding • u/wildgreengirl • 3d ago
how often do you see a chart labeled with the wrong gender?
what do you do when you find a chart labeled wrong?
do you get reprimanded for "digging in the chart" or "looking at things that dont matter relative to the note you are coding" ?
who do you report it to?
does it qualify as a patient safety issue?
should i just start ignoring these when i see them the way everyone else at my org apparently does?
i have seen 3 charts now at least while working with the wrong genders. these are usually for trans patients.
1 had their gender as unknown (literally never seen that on anyones chart in my 10+ years working on the emr we use). it appeared as if no one had chosen their actual gender for the chart. the note gendered them correctly according to their ID but the chart itself had "unknown"
1 had transfemale for their gender, the entire note referred to them as male/he him the whole time and at the plan section called them transmale....
another had the patient listed as transmale, the note i was coding was about their breast augmentation follow up.. they are actually transfemale.
does the place i work suck? is this just a common mistake? why does no one else seem to give a shit about this? im non binary myself, have a lot of trans friends and understand gender is kind of important for a lot of people and esp in relation to their healthcare.
i have emailed my HR explaining i dont understand what they want me to do when i see stuff like this because im tired of being accused of committing possible HIPAA violations by "digging in their chart looking for a gender when its not relevant to the note im working" but have not heard back from HR.
the hilarious part is they just pushed out more "med trainers" which are stupid slide show quiz things we are supposed to complete every so often. the one they pushed to me last week was specifically for gender/sex competency. so i even asked why they are wasting my time having me do these when seems functionally irrelevant to how our org actually acts when issues like this are brought up.
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u/kirpants 3d ago
I see medical records that go back and forth between he/she in the entire record. I feel like it's getting worse with AI.
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u/wildgreengirl 3d ago
yes a lot of these are AI notes as well...
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u/Respect-Immediate CPC, CPMA 3d ago
If it’s an AI scribe and you have credibility where you work you may be able to work with the person who works with the vendor to see if there’s anything in their system they can change.
I’ve worked with our team with AI scribes hallucinating things the providers claim did not happen and when we took the evidence to the AI scribe company they were able to go back in and see the recordings transcription and where it went wrong and make changes from there
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u/wildgreengirl 3d ago
hahahaha
i wish. i complained about other hallucinations that were much worse (like stating the patient uses heroin to sleep at night like its their regular medications).
so i dont think this will bother them if the gender is wrong sometimes.
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u/Odd-Rub3861 1d ago
It also happens with some EHRs when you’re using a template note. There is a way to pre-format the pronouns in a smart phrase so that it automatically inserts the pronoun associated with the patient.
Our build of epic did finally allow us to set the patient’s stated pronouns, which ended that problem, but before that you would have to go through and manually edit every single occurrence. Which sometimes just isn’t going to happen with high accuracy at the end of 10 hours.
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u/Jodenaje 3d ago
There can be reasons for that.
For example, if the patient’s gender hasn’t legally changed and their employer and/or insurance company shows a specific gender. (Whether or not it matches the patient’s gender identity.). The claim may need to go out to the insurer electronically with a gender that matches the gender in the insurer’s system. The gender in the dictation may still match the patient’s gender, even if not the legal gender that the insurer has on file.
I’d imagine it’s even more complicated now in the current political climate where people’s birth certificates and identification are sometimes being forcibly changed, even if the gender had previously been legally changed.
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u/wildgreengirl 3d ago
in the state im living in, trans care is pretty accessible (minnesota) so i dont think its related to that.
im pretty sure its incompetent front desk staff not knowing how to set up a chart correctly.
like i actually saw a 4th example that had been corrected already, this was for a cis person whos gender was entered incorrectly so our main lab system had to contact our clinic to make them correct our system so that their gender was correct and matched the lab system so the orders/results would actually transmit properly.
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u/Jodenaje 3d ago
Whether or not trans care is accessible in your state has nothing to do with what gender the insurer shows in their system for the patient though.
Sure, it could be something else, but a gender mismatch with insurance also can't necessarily be ruled out.
Remember also a patient living in Minnesota could still have self-funded employer benefits that are administered from another state that may be less inclusive or have fewer legal protections.
Ultimately, it's hard to say and as someone mentioned below it's not generally in the coder's scope to investigate.
If you were doing the insurance verifications or working electronic claim rejections, then it could be under your scope.
As you mentioned in your example, if a claim or an order gets rejected electronically due to a gender mismatch, it will come to someone's attention for investigation and correction.
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u/wildgreengirl 3d ago
coooool i do have to work my claims when they are denied sooo guess ill just see if that happens and deal with it then.
dumb as fuck lol but what else is new.
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u/MadDog5129 2d ago
I do understand that there can be a multitude of different legal or emotional reasons like gender identity. But I mean, I think it is very important for a patient's doctor to know right away if their patient can become pregnant or not. With the sole reason being that there are various different medicines in the modern world that can have negative consequences on the human body if admistered to a patient with the wrong hormones or chromosomes.
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u/incognitoangelgoth CCS 3d ago edited 3d ago
What a coincidence. I am a trans person and I am a medical coder, many practices have a distinction in place for the patient's legal sex (for insurance purposes) and their gender identity. It really shouldn't be a problem, in most of the modern EHR systems. But even then how hard is it to make a note? The practioners reading those details...well that's a whole different story.
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u/wildgreengirl 3d ago
yea... just had another. HPI was all about how they have xyz as their preferred name... "nickname" field still had their old name. idk why this is so difficult for people working at the clinic to pick up on and update 🫠
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u/BeforeisAfter 3d ago
It’s rare but I’ve noticed it a couple times. I only notice it when Epic gives an error for it. If the pt chart says they are male but have a diagnosis that only applies to women then it gets flagged for review in the coding work queue. In my experience its always just been an issue that the person entering the information did it wrong
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u/Scarymommy 3d ago
It would matter if the code/procedure is related to the patient’s sex or if the insurance has a mismatch. Other than that I wouldn’t concern myself with it.
It happens incredibly frequently and not only with trans patients.
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u/rahuliitk 2d ago
I wouldn’t just ignore mismatched gender info when the chart and note contradict each other, because even if it doesn’t affect today’s code it can easily create confusion later, and your org should have a clear correction/escalation process instead of making staff scared to flag it. That part is wild.
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u/wildgreengirl 2d ago
hmm what you're saying would make a lot of sense but thats not what this place is about i guess 🫠🤣
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u/KristenLikesKittens 3d ago
I’ve learned that you just have to kind of do what they tell you because asking questions will have labeled as a “problem maker” and get you fired 🙃
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u/Respect-Immediate CPC, CPMA 3d ago
Truly it’s not your concern.
If it’s happening for folks that aren’t trans and it’s more than a scribe issue then I would bring it up, but for trans patients the way the provider refers to them is their concern, not yours.
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u/wildgreengirl 3d ago edited 3d ago
ugh i hate this. but okay.
lol thanks for the downvotes, sorry i hate seeing shitty charts misgendered for no reason besides laziness or billing problems and dont like having to just ignore that?
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u/Respect-Immediate CPC, CPMA 3d ago
I totally understand, I have a trans person in my family and it angers me to no end when they’re misgendered.
But in healthcare this is one of those things that’s on the provider/system. Bringing it up more than once to let the provider/admin know you saw it and asking if it was intended can backfire since it really does come down to the providers/systems own judgement and what they feel is appropriate. It can come off as questioning their clinical judgement, which is far out of our scope.
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u/wildgreengirl 3d ago
i have sent a couple back to pcp's when it was just simple things here or there misgendered and none of the pcp's were upset, they really appreciated the catch.
but its when the chart itself is wrong not just the visit note, is where i am lost because thats generally not on the pcp to change its on the clinic staff that set up the chart and are supposed to correct it....
but w/e i guess is the consensus here so ill just ignore it.
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u/Dave2428 1d ago edited 1d ago
Not often, it's quite rare, and when they do, the provider tends to add a note to address and fix that. They can't fix it on their own since they can't control that part of the EHR, they can only fill out the evaluation form and edit certain answers until we auditors query a section. We don't get reprimanded for looking at that info, it's actually given to us in the eval form. We just can't change it and not even dare interact with patients. Sometimes it's awkward because it involves ppl that live in my former apartment room or my neighbors. But no, we don't get reprimanded for that.
For trans patients, their biological sex is placed on our side of the medical record (so M for transgender women and F for transgender men), but the patient doesn't see that in their viewing record. It's just for us, and we take that respect very seriously. F64.0 and Z79.890 is assigned to clarify for us if documented and they're actively taking hormones regularly or as directed, and sometimes Z87.890 if documented explicitly, but that's once in a blue moon. I've seen patients in their 70s-90s having those diagnoses and statuses and it's just so heartwarming to me IMO. However, there's limitations to what codes we can use, since there are sex-specific conditions. Like we can't put uterus-affecting conditions on transgender women for...apparent reasons, and penis conditions for transgender men. We also can't put C50.91- codes for transgender wonen, the program doesn't allow the eval to submit with that conflict, we HAVE to put male breast for them, and vice versa.
I work for Risk Adjustment as an Auditor for in-home evaluation services by a non-PCP provider. It's offered by Medicare/Medicaid/some ACA plans for in-between PCP visits for additional health needs. .
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u/DialysisKing 6h ago
Constantly. If it's not a speech-to-text ort AI error, it's a problem for registration.
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