By Janie Batres, RHIT, CDIP, CCS
With emerging technologies like electronic health record systems (EHRs) and computer-assisted coding (CAC) gaining traction in the healthcare industry, coding professionals are being presented with more challenges and opportunities than ever before. The shift from paper-based records to electronic records has had an impact on the coding process, and requires changing workflow and processes.
Coding professionals are particularly adept at keeping up with change. The code sets and guidelines they work with require annual updates to maintain relevancy with current medical technology and clinical practice. But even the most successful coder knows that change can be exhilarating and frightening. There are several challenges and opportunities that arise for coding professionals when an EHR is introduced into their day-to-day life that affects the coding process.
EHRs Create Coding Challenges
Challenges arise when changes are introduced into well-established processes-typically the case when implementing a new EHR. However, challenges are necessary to grow as individuals, to improve skills, and to polish talents. Above all, challenges assist in discovering what individuals and healthcare system processes are capable of accomplishing in difficult situations.
EHR systems bring information right to the fingertips of coding professionals. But coders need to learn how to navigate and maneuver the EHR to find the information needed to appropriately code a patient’s visit. Paper record documentation outlined a patient’s visit in a systematic order familiar to most coders. Documentation in the EHR, however, could be located in various places within the system. Coders new to the EHR often spend more time looking for the necessary documentation since they are not familiar with the format.
With any new system or process, training on the EHR is required to ensure that each person understands how to find, enter, and use information within the system. Often coders do not receive adequate training in the navigation or use of an EHR, which in turn may slow down coding workflow.
There is also the potential for an increase in missing provider documentation if the coding professional is not aware of all areas of the system that contain provider documentation. Coders must have access to all documentation pieces to correctly apply diagnosis and procedure codes. This ensures appropriate reimbursement and data integrity. Lack of access to pertinent information has far-reaching consequences, such as lost revenue and inaccurate claims.
EHR system designers should consider the backend coding process so that coders have access to all applicable patient information.
In some EHR systems, the ability to automate the coding function or implement CAC software may be available. A coder’s role may change to that of a coding auditor if the CAC function applies the majority of codes to patient records. In this role the coding professional would review the documentation and the codes applied by the CAC to ensure the appropriate code has been applied and all coding guidelines have been followed. The coding professional would also verify that the present on admission (POA) indicators that have been applied are accurate based on the documentation in the patient’s record.
Healthcare facilities are recognizing the advantages of EHRs and CAC. Coding professionals must advance with these emerging technologies and ensure they have the skills necessary to utilize EHRs and CAC systems. This may provide a challenge for those coders who have only utilized a paper-based record. Coders must learn new computer skills and how to navigate multiple screens, and apply new critical thinking skills in order to operate health IT systems.
Coding Opportunities Created
Many of the great opportunities available to coders today are disguised as insoluble problems. The opportunities found within the implementation of an EHR are plentiful. Even though there are challenges that may negatively impact the coding process, there are positive impacts as well. Coders have the opprotunity to advance computer and technology applications skills, and to learn how to apply new ways of thinking. Perhaps most importantly, these challenges can become opportunities that allow the coding profession the chance to advance successfully into the future.
The EHR also brings flexibility to a coder’s work. In a true EHR environment, the information is available to the coder instantaneously-provided that the appropriate security access has been obtained. Unlike prior years when coding professionals may have had trouble reading murky scanned images, the EHR gives coders direct access to digital documents that help solve legibility issues.
The coding professional may now have the opportunity to work remotely, if they meet the productivity and quality standards developed by their facility. Remote coding can also open the door to increased productivity and recruitment advantages. The ease of access and the availability of the electronic record can lead to improved coding turnaround times. In the paper-based record, coders would often have to wait for the record to be picked up and assembled in order to begin reviewing. With information now readily available, coders are able to review and start coding as soon as the patient has been discharged.
Face and Embrace Change
The wide implementation of the EHR has brought considerable changes to the HIM department. The EHR presents both opportunities and challenges for coding professionals, impacting the coding process while allowing for further professional growth in the HIM industry. Coders must be prepared to face the obstacles ahead, and embrace these new coding role changes.
Janie Batres (email@example.com) is a director of HIM solutions at AHIMA.
"EHRs Offer Coders Opportunities, Challenges"
Journal of AHIMA