October 26, 2009

Balancing Act
By Annie Macios
For The Record
Vol. 21 No. 20 P. 10

Coders must perform quite the balancing act: maintain a high-quality standard of work and complete charts at breakneck speed.

Just as tightrope walkers must balance their weight and be precise in every step, medical coders must distribute the weight of their daily tasks with patience, poise, and precision to ensure success on both a professional and a personal level.

Judy Sturgeon, CCS, the clinical coding/reimbursement compliance manager at Houston’s Harris County Hospital District, has been in the coding arena for more than 20 years. “People who are coders like the job because you never stop learning new techniques, new surgeries. When you read medical records for a living, you appreciate what you have because you realize it can be gone on any given day,” she says. “But when it comes down to it, the expectation is ‘do it all, do it fast, and make no mistakes.’”

That mantra, however, acts as a double-edged sword because if coders are perfect, a cynic may argue that they then aren’t coding fast enough. It’s quite the conundrum, says Sturgeon. “If we lean too far to the left and upcode, the facility receives too much money and [that] puts us in federal compliance jeopardy. But if we lean too far to the right and code too slowly or miss critical codes, that doesn’t work either and we lose money to which we’re legitimately entitled. It’s a high-stress, demanding job because coders must balance so many things,” she says.

Sturgeon notes that, in general, a common minimum standard to evaluate a coder’s efficacy is to achieve 90% to 95% accuracy for diagnosis-related groups (DRGs), with 95% being a reasonable “high” expectation for Medicare and Medicaid claims.

Sue Plumb, RHIT, coding coordinator at Community Regional Medical Center (CRMC), a 328-bed nonprofit in Lorain, Ohio, says because CRMC is smaller than most facilities, the coding department feels an extra sense of urgency to stay caught up. “Productivity is the biggest pressure. You want to get it all correct and follow the rules but also get it all done,” she says. “Our coders must meet a 98% standard for accuracy and 100% for productivity. Depending on the patient type and requirements, the time to complete the jobs can be altered based on responsibilities.”

Some CRMC coders handle outpatient, inpatient, emergency department, and ambulatory surgery cases, while others focus on specialty areas such as rehab. To be able to keep up with the workload, Plumb says many staff are cross-trained to manage the volume from the various settings.

Meanwhile, Carolyn Larson, CPC, CPC-P, numbers among the HIM professionals who use their diverse coding skills in areas beyond hospital walls, serving as a revenue recovery specialist for an entity that has both a health plan and a large multispecialty medical group under its umbrella.

Coder productivity at Larson’s organization is measured by several metrics, including achieving more accurate diagnosis codes on claims that will result in decreased retrospective review for potential appeals to the Centers for Medicare & Medicaid Services (CMS). Coders are also expected to help identify members with chronic conditions for follow-up and appropriate disease management referral and involvement, reduce healthcare costs for treating chronic conditions, produce more accurate data, eliminate diagnosis errors, decrease the number of claim edits being applied to charges prior to billing, improve EMR functionalities, decrease the number of claim denial inquiries, and consistently meet the monthly gross dollar threshold.

Reaching the Boiling Point
The industrywide initiative to implement new HIT has added to the pressure facing coders who are learning new systems or working at facilities where records are partially electronic and partially on paper. During these transitions, they are still expected to uphold the primary directive of “do it all, do it fast, and do it right.” “I describe it as standing between a rock and a hard place with both sides beating on me,” Sturgeon says.

When coders are feeling stressed, says Sturgeon, who spent nine years as coding manager at the University of Texas Medical Branch in Galveston, managers need to understand the situation and avoid making it worse. Her response was to be as flexible as possible with schedules. “A happy coder is one that stays working for you. In a bigger city, there is a lot of competition for good coders, so you must be flexible with their time,” she says. “If my coders passed the quality assurance and productivity requirements, we let them work flex hours, and it has worked out really well. You’re not doing anyone any favors by micromanaging.”

Sturgeon also emphasizes the importance of communication on all levels: laterally, to keep the lines open with coding staff on a daily basis, and upward to hospital executives to enable them to have a realistic picture of the tasks coders perform.

If a coder’s quality of work begins to slip, Sturgeon does not recommend immediate disciplinary action but instead suggests increasing the number of quality assurance reviews, adding more training and mentoring, and providing more encouragement. Sturgeon says that “if you have standards, you must tend the standards” to keep the department running smoothly.

More Pressure Points
At CRMC, stressors beyond the general nature of the position have also affected staff. New computer system installations and new operating systems have meant relearning tasks that had become second nature. However, keeping the lines of communication open helped the process go much smoother.

“You can tell when a coder feels stressed or overworked,” Plumb says. “Our biggest thing is to reassure them that if they don’t meet productivity, we’re not going to immediately fire them. We’ve all had times when we’ve felt overwhelmed with the workload. It’s our job to help them get through it, talk to them. Just a simple conversation will often calm them down.”

When Plumb occasionally has a coder who can’t keep up with the workload or whose quality has slipped, she performs a more focused quality review, paying extra attention to the areas where the coder is lacking. “But we try to maintain a good balance at our facility,” she adds. “Occasionally, someone will ask why their workload is hard while others seem easier, but we really try to divide the work evenly. I tell them that in the end, it evens out—this week might be difficult, and next week might be easier.”

If there is the rare large chart—for example, a patient who was in the hospital for a month—Plumb will step in herself and help out. “I have done coding, and this kind of chart really could take up a lot of time, so occasionally I will take the heavy duty to help relieve the staff,” she says.

Larson also emphasizes the importance of communication to help keep stress levels in check. “I think there needs to be a meeting of the minds, so to speak,” she says. “Everyone needs to be able to converse about concerns, including the leadership, as there are stressors applied to managers and directors from executive level that coders may not be aware of. Each site has to be able to work out issues within their boundaries, and sometimes that’s not so favorable for the coder. But there are times when changes can be made because the leadership wasn’t aware of issues or the concerns of coders.”

Too frequently, Larson says, coders feel they’re not empowered to speak up, and, as unfortunate as it is, there are sites that manage coders in that manner. She notes that leadership needs to be able to coach someone without creating discord.

Larson also points out that coding leaders must make sure coding staff are focusing on what belongs in their area and not what other departments “dump” in their laps because there’s a code on a claim or charge ticket. “Member/patient benefits as determined by employer groups is restrictive on what is a covered service vs. not covered. Not all noncovered services are a coding issue,” she notes.

Transparent Responsibilities
One part of the coding profession that many outside the field often neglect to recognize is the need for continuing education (CE). There is a high demand for coders to keep pace with the requirements needed to stay credentialed. But, as Sturgeon notes, if they take time out to learn, they may fall behind on their actual coding. “Coders—and managers as well—must strike a balance between the two,” she says.

To maintain credentials, coders must participate in CE, a challenge that takes both time and money. As a benefit to the coding staff, Sturgeon’s previous facility provided CE hours and paid not only for the fees but also for recertification. It’s a major perk because it removes some of the hassle of working CE into a busy schedule.

Larson points out that employers often don’t address the amount of reading a coder must do to stay abreast of regulatory changes, quarterly coding revisions, new research for some specialties, etc.

“Not only are coders putting in longer hours to try and keep current with their responsibilities, but having to research and read on their own time puts additional burden on them. Too frequently, ‘non-coder leaders’ in coding departments do not have insight to this and, when informed, it’s usually not taken into consideration for determination of appropriate level of position profile or salary considerations,” says Larson, adding that these types of pseudo-managers sometimes are under the impression that staff merely open a book and choose a code.

To Outsource or Not
With so much work and only 24 hours in a day, some facilities choose to outsource some or even all of their coding duties. In addition, some areas of the country are experiencing a shortage of certified coders, which only adds to the workload.

Sturgeon believes facilities walk a fine line when considering outsourcing. Uncertainty over the quality and/or experience of the outsourced coders is often enough to make any coding manager think twice before sending work out the door. “Sometimes you have the directive to get the charts out quickly. If you only have DRG payers, you have to be careful which jobs you give to the contract coders. It all depends on who wants what done,” she says.

While outsourcing coding projects short term during times when the facility has a large number of backlogs can be useful, some facilities don’t want to deal with coding at all and believe it’s better to outsource the entire operation. That, too, has its drawbacks, says Sturgeon. “The difficulty there is that the outsourced company has no vested interest in the long-term success of your facility. What do you do if the quality isn’t there? It is very expensive and can become more so if you find you have to continually change vendors if you’re not satisfied with the quality,” she says.

Proponents of outsourcing argue that vendors stake their reputations on providing quality work at a price that works for facilities that do not wish to incur the cost of maintaining permanent staff or who can’t find qualified coders in their area. Plus, many vendors offer the ability to perform coding on site or remotely.

At CRMC, where all coding is done in-house, the shortage of coders has not been a factor, according to Plumb, because of the facility’s rural location. “We have community colleges and coding programs nearby that produce a lot of great candidates to choose from. However, closer to the city, there may be a shortage,” she says.

Plumb also notes that the current economic climate has kept patient volumes at the facility below average because the uninsured aren’t seeking care and others are leaving the area to seek employment elsewhere. “If anything, it’s more of an issue of not having enough work for everyone,” she says.

No charts are outsourced at Larson’s organization. “The metro area I’m in doesn’t really have a coder shortage. The issue is more that employers are looking for experienced coders, so those right out of an accredited program are having difficulty obtaining employment. Employers want to have someone step right into the position and know what to do with very little training,” she adds.

The Final Word
To keep stress at reasonable levels and minimize problems, Sturgeon recommends the following: pay coders well, train them well, keep good people, and maintain respect for their skill level.

“If you don’t respect the skills, quality, and competence of the coders, that’s an issue,” she says.

— Annie Macios is a freelance writer based in Doylestown, Pa.