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March 25, 2002

WHERE HAVE ALL THE CODERS GONE?
By Hannah Fiske

In this whodunit, the mystery revolves around why more physicians aren’t utilizing the skills of these valuable employees.

In an age when technology and federal requirements are increasingly complex, finding and keeping qualified coders is becoming more difficult. Some say coders are frightened away from the field by low salaries, and others explain the cost and scope of training required for certification are prohibitive. However, as deadlines for compliance with federal regulations near, many physicians and hospitals may find themselves scrambling to acquire these elusive professionals for their staff.

In days gone by, during office visits, physicians hand-wrote notes that were given to billing clerks or medical receptionists who submitted reimbursement forms, on paper, to insurance companies. “It used to be coding was a function of billing,” explains Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, owner of A+ Medical Management & Education, a coding consulting and certified professional coder training firm in Absecon, N.J. “Because of governmental fraud and abuse investigations, as well as insurance companies’ increased auditing, professional coders have become increasingly necessary and valued.”

As coding evolved, the former medical receptionists and billing specialists who peopled the profession were often asked to perform some coding functions. With no formal training, many of these early coders learned the ropes as they worked. Others, including many registered nurses, were trained in clinical aspects of the medical profession and brought a variety of skills to benefit employers. But changing requirements and regulations within the medical community resulted in a demand for certification programs, and coders began to seek training and education to achieve and maintain this status. At the same time, the advent of widespread computerization, which many hoped would simplify the billing process and save money, actually resulted in the demise of traditional “generic” coding, Jandroep says. “That is when coding really became a profession.”

This necessity for advanced education is a primary reason for the recent shortage of medical coders, according to Jandroep. As an example, she continues, a woman who worked as a coder for 25 years in the billing office of a medical practice may wonder why she is not encouraged to take a certification exam based on her experience alone. “She could do that, actually, but the exams are based on a broad base of knowledge,” Jandroep explains. “When I teach a class, I typically start with ICD-9-CM, and I often hear students say they wish they had known all along that the book works the way it does, but they never had any foundational training.” That is one reason, she adds, why she never worries that students will find her classes boring or redundant.

In addition to the “in-person” classes Jandroep teaches, she also offers Web- and telephone-based distance training programs for coders who are unable to attend conferences or full-time classes. “People can attend remotely by listening to my lectures on the telephone or on CD-ROM,” she explains. This enables employers to gather their staff for a one-hour program in a conference room, saving time away from the office, as well as travel expenses. “For those studying from home, the teleforums are a convenient way to fit the courses coders need into their busy schedules,” she adds.

Even though the benefits of comprehensive training are clear, they may also be a contributing factor in the shortage of coders who often feel they are overeducated and undercompensated, according to Katherine Abel, CPC, vice president of operations at PriCare Inc. in Franklin, Tenn.

Although it is important for coders to possess a broad base of knowledge, many do not understand the necessity of learning about more specialized fields of practice. “If you work for a family physician, why would you want to learn the coding for something more specific? If you work for an ophthalmologist, why do you need to learn about the urinary tract?” she asks. “People don’t want to undergo the training that is required outside of their specialty areas.” And, she explains, these specialities—including radiology, anesthesiology, cardiology, and otolaryngology—abound in the coding profession. As more coders choose to specialize, the shortage of coders available or willing to work in a small family practice—where they are really needed—may worsen.

Opportunities for education exist, but many employers do not encourage their coders to pursue certification. Aside from reimbursement costs, many employers are afraid that well-trained coders will choose to move on in their careers. “In general, most doctors don’t want to pay higher salaries for certified coders,” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president, Cash Flow Solutions Inc., Lakewood, N.J. “To be fair,” she adds, “they can hardly afford to pay. It is even hard for me, as a billing company, to pay them what they deserve.” Governmental and societal pressure to cut rising healthcare costs is forcing physicians to squeeze the most they can from existing office staff members, she says, resulting in lower profit margins and less money available for training and certification reimbursement.

Perhaps the best solution for many small offices and hospitals is outsourcing to a professional billing and coding firm. Outsourcing offers physicians the opportunity to work with well-trained professionals without bearing the financial burden of their training and education. “It can really work if you take the time to find the right person who specializes in your area of practice,” Cobuzzi says. “By outsourcing, physicians don’t have to invest in a coder’s education because the outsourcing company typically does it for them.” By choosing an appropriate outsourcing company, she adds, small practices and hospitals will often see an increase in revenue. “But if they don’t do their homework and pick the wrong person, they could lose money,” she warns. “There is no free lunch.”

The proliferation of professional billing and coding firms has had a negative impact on the number of coders willing to work in a private practice or hospital, according to Abel. The fact that it is often cheaper for a doctor to work with an outsourcing or consulting firm than hire a certified coder as a regular employee has resulted in an abundance of consultants—and a shortage of available full-time, on-staff coders—within the industry. “If a coder has the certification and knowledge and is good at what he or she does, he or she can make more money by consulting than being hired onto one job,” Abel comments.

As long as outsourcing remains a cheaper alternative, most physicians will continue to hire consultants rather than spend the time and money necessary to train full-time coders as regular employees. “It’s a catch-22 situation,” she says. “Physicians don’t realize how much money a coder can save them,” Abel says. “Having a good coder on staff who understands different health insurances can actually help prevent them from being audited.” And if they are audited, having a well-trained coder on staff can ensure the office will be better prepared and more likely to emerge unscathed.

Cobuzzi agrees but explains that many physicians in private practice tend to let their coding and billing operations run virtually unsupervised. “That is fine if they have a good coder and a good office manager who understands what the requirements are,” she says. “They need to have a compliance plan in place and have someone who is running the office according to that plan; but, in so many of the smaller practices, that is just not happening.” She believes physicians need to be more involved in all aspects of their practices, including the business side. “They need to know what is going on, and if they don’t know that, they need to provide enough education for their staff to make sure those people understand what the requirements are.”

By choosing to work with an outsourcing firm, she adds, doctors who prefer to take a less proactive approach can ensure their coding is up to standard. By training staff members, physicians will not only be solving their office-related problems but will also help alleviate the overall shortage of qualified coders, according to Jandroep. She tells the story of a family physician who called her recently to inquire about a course for which one of his staff members requested enrollment and reimbursement. “He was asking how this would benefit him,” she recalls, “and I told him that, first of all, he would be well prepared to meet HIPAA requirements.” She also told the doctor how intricate and tricky coding had become and that employing an experienced, well-educated coder could prevent potential penalties resulting from overcoding, she explains. “He didn’t seem concerned,” she says. “He was sticking his head in the sand, only worrying about the fact that if she were better trained, this coder might move on to another practice.”

Not all physicians are so shortsighted about training coders, Jandroep adds. Many have a thorough appreciation for the fact that a good coder is usually the product of many years of training. “Half of the battle, though, is getting the rest of them to comprehend that,” she says. “The shortage of coders is based on the relatively small number of doctors who realize how much they need them.” If more physicians understood the value and usefulness of employing and educating certified coders, she believes there would be a more intense shortage combined with a scramble within the medical community to recruit and train more coders.

Coders themselves should take a more proactive role in rectifying the problems, which include low salaries, reimbursement for continuing education, and respect for the profession, according to Cobuzzi. To start, they need to be more aggressive in negotiating with prospective employers. “Coders have to ask for what they need, such as attending national conferences or being reimbursed for continuing education, so they can maintain their certification,” she says. She suggests they join and support the American Academy of Professional Coders (AAPC) as a networking tool and a means of promoting the coding community. “The AAPC brought a level of professionalism and credibility to a profession that was not even recognized before the academy existed,” she says. “They focus on attracting more people to the profession and are advocates for certification and recognition.”

Recognition is vital in a profession where job image is all too often tarnished by a perception of negativity. “Historically, coding is not a very revered profession, but it has gained recognition in recent years with the advent of compliance regulations, the AAPC, and certification,” Cobuzzi explains. “Most coders are people who started out in billing or even as medical receptionists and who have risen through the ranks.”

Because many coders learned their trade as they worked, there is a resulting lack of formal training that can perpetuate the image of coders as unprofessional or, even worse, uneducated. By investing in training for their coders, doctors can retain them as valuable—and valued—employees. “Doctors need to provide advancement opportunities,” Cobuzzi says. “They should understand that training is a retention tool. On the other hand, they also have to take advantage of that training and reward their coders with higher salaries and more responsibility or they’ll lose them.”

The negative light associated with being a coder is based on their traditional role as “naysayers” as opposed to an understanding of the benefits a certified coder can bring to a medical office. “Coders are often perceived as the ‘bad guys’ who have to say what can and cannot be done,” Abel says. “It’s hard for most of us to have to tell doctors, who have eight-plus years of college training, that they will not be allowed to do something.” Opportunities for advanced education and certification, along with an increasing demand for certified coders due to implementation of federal requirements, will likely result in higher salaries and more respect for this evolving profession. “If we are able to shed a more positive light on coding, it will have a tremendous impact,” Abel says. “We may be in a dry spell, but there are doctors who realize the potential of what coders can do. They are the ones who will benefit.”

— Hannah Fiske is a staff writer at For the Record.

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