by Kevin Heubusch
Coding departments are hectic places in 2008, busy adapting to new requirements. To meet the challenges, they are seeking the right staffing, education, and coordination.
How many challenges does coding face today? Open positions, revenue cycle, MS-DRGs, POA, RACs, hybrid records—a coding professional could jot down dozens.
However, many of today’s toughest challenges roll up into a formula of more work for fewer people. As reporting requirements and coding changes increase, facilities across the country struggle to hire skilled professionals, adapt to the changes, and keep the revenue cycle moving.
The Journal polled coding experts on the top five challenges they are experiencing today (see the sidebar [below] for detail). Topping the list was the general crunch of responding to increasing coding requirements. Adapting specifically to MS-DRGs and POA requirements was high on the list. Revenue cycle management remains a top challenge. Each of these is compounded by an ongoing shortage of skilled coding professionals.
Respondents to the poll shared examples and the ways their facilities are finding solutions.
The Commonalities: Staffing and Slowdowns
In many instances, staffing isn’t keeping up with increasing workloads, and productivity is getting squeezed.
The overload problems spill over to other HIM functions. “The increased workload on the coding area of the department puts a burden on the other parts of the department, since the director devotes most of her time to coding, coding-related, and revenue cycle issues,” wrote one respondent.
“Revenue and the CMI may be decreasing,” wrote another respondent, “but we don’t have the bandwidth to do a thorough assessment.”
Coding managers who have coding responsibilities are put in a special bind. The more time they spend anticipating and preparing for change, the less time they spend coding. The more time they spend coding, the less time they spend preparing for change.
Outsourcing isn’t always an option. One respondent noted that at her organization “budgetary constraints do not allow for outsourcing of coding functions if there is staff in the budgeted positions, even with the additional burden of POA [and] MS-DRGs.”
Respondents report difficulty finding experienced, certified coders, a problem compounded when departments lose talent to retirement. “Coders that are going into retirement aren’t being replaced fast enough with qualified candidates,” reported one respondent.
Coding shortages remain widespread, but hiring skilled staff is most difficult in rural areas. “I work in a critical access hospital in rural Illinois,” commented one respondent. “There are no RHITs in the area.”
Facilities with unique processes or needs face greater challenges. “We code a little differently than the industry standard,” reported one respondent, “packaging inpatient, outpatient, and professional services encounters together.” Finding applicants who can code all of these settings makes hiring more challenging. The same facility requires a minimum of an AS degree in a healthcare-related field with an RHIA, RHIT, or CCS credential—standards that reduce the pool of qualified candidates further.
A respondent noted that the movement of established coders into concurrent settings is creating strain elsewhere: “As experienced coders move to the concurrent setting, the ability to hire certified coders to fill the gap and keep the revenue cycle in balance is hampered.”
How are coding professionals rolling with the changes? By staying aware of the requirements and addressing the issues upfront instead of having to correct problems later.
“We read the notices published by the insurance companies with which we participate and stay aware of the flags they provide regarding code changes or documentation requirements. Trade journals are very valuable as well. We visit our Medicare Web site regularly and participate in the trainings. Claims are submitted electronically, so any errors are picked up immediately. Finally, any discrepancy between the anticipated reimbursement and the amount paid or the code paid on is appealed immediately.”
—Fredrica S. Lisgar, MA, CCS-P, CCP, EFPM, president and CEO of the Compliance Officer
New reporting measures are slowing down coders as they learn the requirements, gather the additional information, and work with clinicians to establish new levels of documentation.
Respondents report they are querying more extensively due to the new MS-DRGs. In some instances, slowdowns are hampering the ability to spend time querying.
Some respondents cite the education around MS-DRGs and POA as the largest contributing factor in the slowdowns. “This has been extremely time consuming [and] challenging,” one respondent reported, “and the turnaround on the queries due to lack of understanding is still not good.”
“The more challenging part has been getting physicians to document more specifically for coding purposes,” writes another.
Nonacute settings face similar but unique challenges. For one respondent in long-term care, the challenges “relate more to obtaining more specific diagnosis information and being able to update the coding on a quarterly basis as required by the MDS. The MDS is currently in the process of being completely revised, which will change our entire workflow.”
Significant time commitments come even before new requirements hit. In the case of RACs, analyzing the pilot program and advocating for improvements have been time-consuming in states next to be affected. “South Carolina is in the second tier of states that have been hit by RAC audits,” wrote one respondent. “We are actively working with our hospital association and our representatives in Congress to ensure that the RAC process is reviewed and improvements made before implementation in all states.”
Increased reporting requirements are not the only cause of slowdowns. As facilities migrate to electronic records, productivity takes a hit as coding professionals work between paper and electronic records in hybrid systems. One respondent reported that coders at her facility currently must double enter all coding into the billing and clinical systems.
Some electronic record systems lack a “quick view” summary screen that presents coders with the complete information they need. In those instances, they must cull information from multiple sites. Some departments resort to multiple monitors and multiple active windows to speed up work.
As can be expected of any new system, working through the kinks takes time. One respondent noted the time it took to “work through the layers of committees” to establish system access for nonhospital employees who had been overlooked during planning.
All of this must be achieved while producing quality work, of course. One respondent described this juggling act as “matching volume to productivity and maintaining staffing levels to meet the demands of organizational goals on AR and coding turnaround time while balancing quality.”
The Solutions: Staffing, Education, and Coordination
The solutions vary by situation, but coding departments are approaching these challenges through a blend of creative staffing solutions, inter- and intradepartmental education, and plenty of cross-departmental teamwork.
Those departments that can have added staff, contract coders, or outsourced work. Those who can’t, in the words of one respondent, “just have to work harder with less people.” One respondent noted that she reviews staffing on a weekly basis, hiring temps to cover if necessary.
One respondent has proposed a pilot program to add a full-time staffer to the DRG program to “increase MD queries and hopefully stabilize revenue.” Another added a revenue cycle specialist to the staff to problem solve. The move is also expected to help with case-mix issues and RAC audits.
Having assistance in other areas can help indirectly, easing the overall strain. One respondent reported that consultants onboard to help with an EHR implementation at her facility “ease some of my time to dedicate to the other pressing issues.”
One respondent adjusts to the shortage of experienced coders and increased work load through a mix of hiring. She has hired newly credentialed coders without experience to start with the most basic cases and then gradually take on more difficult ones. She hires part-time experienced home coders for the more advanced work.
“These part-time positions have been easier to fill than full-time positions, as many full-time coders from other hospitals in the community like the opportunity to work a few extra hours per week,” she wrote.
Other respondents have explored remote coding, computer-assisted coding, and other IT that can increase productivity and decrease turnaround time. Some have responded to the shortage of experienced professionals by “growing” their own coders through facility-led training. One respondent reported that her facility offers CCS prep classes in an “effort to recruit qualified, certified coders.” Some facilities work with local colleges to develop training programs.
Nearly all solutions to today’s challenges involve education. “Education for staff is probably the ongoing approach to most of these challenges,” wrote one respondent. “Naturally our first goal is education,” wrote another.
Education might include in-house mentoring, anatomy and physiology training, training and education on identified risks, and analysis of coded data.
Respondents reported a range of outreach efforts aimed at educating physicians on the documentation requirements for MS-DRGs and POA. One respondent reported using one-on-one conversations with providers, increased queries and follow-up, and sharing specific data one-on-one with physicians.
Another reported attending medical staff meetings, conducting one-on-one educational sessions with providers, sending fliers to physician offices, putting up posters in provider areas, and involving coders and case analysts in the physician education efforts.
“There is gradual improvement, but we have a long way to go to reach the same level of performance in coding and billing days that we had pre-POA [and] MS-DRG,” the respondent wrote.
Clinical documentation improvement programs continue to grow in response to the new reporting requirements. One respondent reported that her plan includes a physician advisor, clinical documentation specialist, and audits.
Another described addressing incomplete or inadequate documentation “through new initiatives, placing documentation improvement specialists on the inpatient units, working with physicians to improve documentation during the hospital stay, and utilizing concurrent coding.”
To prepare for POA, one respondent reported that she had analyzed data from the California and New York pilots and worked with clients in those states to understand the issues surrounding the use of these indicators.
The Journal polled AHIMA ACE members with coding expertise on the top challenges they face today. ACE is the Action Community for e-HIM Excellence, a network of experts and change agents that help transform HIM practice. Sixty-two members took part in the poll, selecting their top five challenges from a list of a dozen common coding issues.
The difference between the fifth and sixth items was slight enough that the top six choices are included here.
For more on the ACE program, visit www.ahima.org/ACE [web site no longer available].
Please choose the current top five challenges in your facility:
|Increased workloads from increasing coding requirements
|Adapting to MS-DRG changes
|Managing revenue cycle management (RCM)
|Adapting to present on admission (POA)
|Coding from a hybrid record
Today’s challenges are knitting HIM departments ever closer to other departments and professionals within their facilities. As one respondent put it, “I am working with IS and patient financial services daily.”
When it comes to revenue cycle management, POA, DRGs, and any issue that requires new and better documentation, working cross-departmentally is increasingly common. Many respondents reported that they belong to cross-functional teams formed specifically to address these issues.
In particular, close work with others keeps the revue cycle spinning. “We have created a revenue cycle team at our facility, which includes members from registration, patient financial services, reimbursement, case management, and HIM/coding. We meet monthly to discuss improvement opportunities,” wrote one respondent. Another reported spearheading a performance improvement subgroup for RCM.
“Our HIM management staff has worked with the revenue cycle team (top management) to identify barriers which delay billing and partnered with staff from ancillary departments to reduce days in A/R by helping us to receive the documentation we need for coding more timely,” wrote another. “The medical staff has also rewritten their policies to tighten controls on delinquent dictation so that we have H&P, OP notes, and discharge summaries timely. We decreased A/R days by three last year and the goal is three more in 2008.”
“To manage revenue cycle we are concurrently coding Medicare cases and meet often with case managers to discuss documentation,” a respondent shared. “The case managers prompt physicians for improved documentation.”
Another respondent reported working closely with “partners in revenue cycle such as case management, patient access, and business office to get good documentation, get patient status correct upon admission, and quickly correct errors once identified.”
Building and maintaining interdepartmental relationships is becoming a key skill for coding managers. One respondent reports attending regular management meetings with “other areas and services to understand each other’s requirements and processes.” Another wrote, “We have an excellent relationship with the utilization review nurses [who] work with the coding staff for POA and MS-DRGs.”
One respondent reported, “We have a revenue cycle steering committee which meets at least monthly to resolve barriers, system issues, etc. We have a good working relationship with other departments as a result of our efforts.”
Facilities are responding with RAC audits in a similar way. Respondents report forming RAC teams to “identify issues and hopefully correct them before the RAC review and subsequent financial impact” and “develop a plan to preview some of their target areas so that we are ready.”
The increasing workload is causing some facilities to revisit and adjust productivity benchmarks. “We are adjusting productivity requirements,” one respondent wrote. “We are struggling to get cooperation with our business office with regards to revenue cycle.”
And some methods don’t change. Turning to colleagues for ideas in these hectic times is always a good idea. “If I am stumped with an issue,” wrote one respondent, “I use the [AHIMA Communities of Practice] or e-mail a peer.”
Kevin Heubusch (firstname.lastname@example.org) is editor-in-chief of the Journal of AHIMA.
"Coding’s Biggest Challenges Today"
Journal of AHIMA