Coders are enjoying the benefits of a boost in status that began to gain momentum with the introduction of the Prospective Payment System in the 1980s and that is now driven in part by the adoption of the Medicare Outpatient Prospective Payment System (OPPS). Concurrent with coders’ elevated stature, and perhaps linked to it, is the rising popularity of coding software.

The prime motivator in the rise of the coding profession and the growth of the coder’s role has been the Prospective Payment System, says Beth Friedman, RHIT, director of marketing for eWebCoding, a firm that provides the industry with a remote coding application that facilitates home-based coding. Coding software, Friedman explains, has evolved largely to meet the the coding challenges created by that new payment system and to help facilities ensure compliance with its guidelines and requirements.

Similarly, the OPPS (which has been in use at most hospitals for three years and is to be implemented by the remaining facilities no later than January 2004), along with the transition to ambulatory payment classifications (APCs), has made the job of coding still more complex and more urgent. “It’s a brave new world of coding,” says Diane Jepsky, RN, MHA, LNC, vice president of compliance at CodeCorrect, Inc., a producer of Web-based coding reimbursement intelligence. “Although we’re three years into the program, it’s still a challenge for the hospitals to code the way they need to code to get reimbursed under the OPPS program.”

Impeccable coding has increasingly become recognized as key to the financial viability of the healthcare facility. Yet the new payment systems place ever greater burdens on coders, requiring them to have vast amounts of information at their fingertips, distinguish between a greater number of modifiers and HCPCS (Healthcare Common Procedure Coding System) codes, and keep track of constantly shifting regulations and guidelines.

At the same time, however, the shortage of qualified coders has diminished healthcare organizations’ ability to collect accounts receivables in an efficient and speedy manner. As facilities acknowledge that both their financial stability and their ability to minimize compliance risks are dependent upon the accuracy and timeliness of the assignment of codes, they recognize that, more than ever, coders need access to the best tools available.

SIMPLIFYING CODE SELECTION
A variety of coding software—from encoders to ambulatory payment classification grouping software to integrated billing and compliance packages—is now available to meet a wide range of needs and expedite various types of coding tasks.

The primary type of software used by most coders, says Friedman, is encoder software, which helps coders identify the correct code.

Coding software is also bundled into electronic medical records (EMRs), says Friedman, which, as another step toward automation, is a huge help to coders. “Online access to medical records,” she suggests, “makes coders more efficient because they can find things that they previously would have had to get up and look for, call another department to find, or physically hunt down. It helps make them more productive and more technically astute as well.”

Coding software programs that are integrated within other programs, such as an EMR package, are more content-driven, explains George Alex, CPC, managing partner, Iatro, LC, a Baltimore, Md.-based consulting firm that specializes in coding and reimbursement. These programs, based upon what the physician has entered into the medical record, use a series of algorithms to determine the appropriate code or service level. The coder uses this software to arrive at a preliminary code selection.

Another type of software allows the coder’s role to shift somewhat from selector of codes to fine-tuner of coding. A physician may make the preliminary code selection, says Alex, “but the coder is responsible for ensuring it’s the correct code for quality assurance, it has the right modifier assignment, and that the right diagnosis code was linked.”

Integrated compliance software packages, such as Encoder Pro by Ingenix, usually have tools to help coders find codes, Alex explains, but they also have more robust tools that help coders understand Medicare guidelines, unbundling edits, Current Procedural Terminology and ICD-9 linking, and compatibility edits at the click of a mouse. “They’re all similar in what they offer, with search tools for coding. And, once they let you determine a code, there are typically other buttons that allow you to look, for example, at Medicare relative values, postoperative time periods, or other types of information.”

Automated coding, which, says Friedman, is the next great development in coding software, “will perform simple coding and will transition coders so that they won’t have to deal with mundane cases but can focus on the more complex cases.”

Coding software is rapidly evolving, says Alex, and exciting new products that will further empower coders to comply with ever-changing guidelines are on the horizon. He points to an experimental field of coding software that, whether one is using an EMR or scanning hard copy documentation, applies various algorithms and, based upon the words that it finds, uses an artificial intelligence to arrive at the most likely codes based upon the content of the note. This technology, says Alex, is being used experimentally at Johns Hopkins University with more than 90% accuracy.

Forward-thinking facilities are quick to supply coders with software solutions that automate and accelerate the coding process. It appears to be a win-win situation for the coders and facilities. Coding moves along at a faster clip and thus maximizes revenue-generating capabilities, while coders enjoy greater ease, prestige, and job satisfaction. The question remains, however: Does software use improve a coder’s abilities?

THE PROS AND THE CONS
“I began in coding years ago when all we had to use were coding books and notebooks full of updates,” says Friedman. “It was largely a manual process, and now much of it is automated and streamlined. Coders now continue to learn new computer systems and usually get the latest and greatest software in the department, so it has increased their role in facilities.” The software, she suggests, is, becoming more sophisticated and intelligent.

The automation of the coding process, says Robert Cohen, director of business development at IRP, Inc., which provides coding software solutions to hospitals, “has helped people code records more completely than they could have done before because it’s faster and has edits to help them if they make mistakes. Edits will tell them if they enter unreasonable information. With automation, coders can code more records in one day than they could without software.” Coding software, agrees Friedman, has provided more tools to coders than have ever been available before to assist in identifying the correct code.

Reliance on these tools, however, may prove to be a double-edged sword. Coders, suggests Alex, expect their coding software to provide answers, but the reality is that coders must continue to bring their training and skills to the table.

“Software tools in the right hands are wonderful, but in the wrong hands, unless they are basic and can help train you, they can be dangerous,” says Jepsky. In the long run, explains Alex, coding software may remove the coder somewhat from the science and the “hard and fast rules” of coding. “Depending on how sophisticated these systems become, people will rely more and more on the system as opposed to using their books,” he says.

In his own work, Alex uses both books and software because he’s found that many software systems are not coder-friendly. “They were developed by computer programmers as opposed to coders, so they don’t approach code selection in the same way that a coder does. They do it in the way a computer does. For example, if you have many different available codes, all with lengthy code descriptions, the quickest way for the computer to find the right code is to match certain words and terms associated with it using search capabilities. For example, if I were to look for appendectomy codes, I could type in appendectomy and it will pull up whatever codes are available that have appendectomy as part of the description. Often, they will have a hidden field that includes appendectomy as part of the description.”

That, he says, is not how coders naturally approach such a task. “Coders think almost by process of elimination. If I were to code something such as a skin lesion excision, the first item I might question is what kind of lesion was excised. Then, I might ask if it was full or partial thickness. Then, I might wonder if it was benign or malignant. Eventually, by process of elimination, I determine my code.” Systems, he says, are not designed that way, which can lead to problems. For example, he says, if the procedure to be coded were excision of appendix, rather than appendectomy, and appendectomy wasn’t included in the hidden field, “I might type in appendectomy and it might give me all the appendectomy codes but it leaves out the excision of appendix code, which might be the right code in that situation.”

According to some coding experts, as long as coders understand that software is only a tool and not a replacement for coding books, it empowers coders and enhances their ability to perform their responsibilities. “The problem,” says Alex, “is that some coders don’t understand the fact that the software tools don’t give all of the answers and that the products are only as good as the programming that went into them.” The ideal coding tool, he says, is one that provides the answer that you need but at the same time leaves you with the skills that are necessary so that you know what the answer is next time around. His company, Iatro, LC, maintains the Coding Online Web site. In conjunction with that site, it’s created an intuitive decision-based coding tool that it hopes will be further developed by an enterprising company or organization.

It’s for this reason that some believe coding software, although helpful, contributes to the erosion of coding skills. “Many of these systems,” says Alex, “weaken our coding skills by making us too reliant upon the systems. We lose a lot of our rudimentary skills in terms of being able to use coding books, and these skills are necessary to be good coders. I have students that have been coding for a while using software systems, but when I ask them a question, they say, ‘If I had my system here I’d be able to get it, but because I only have my book, I can’t come up with the right answer.’” This same overreliance on software can cause problems when there are system outages or if the computer is down for any reason. In such circumstances, observes Friedman, productivity can come to a halt when coders forget the manual system of coding. Fortunately, she observes, system problems are becoming less frequent as technology becomes more sophisticated.

Cohen maintains that coding software has diminished the role of the coder by allowing coders, in a sense, to get away without basic knowledge. “One of the items that coders should understand, for example, is anatomy. But, what’s happened with technology is that the systems are asking the coder questions. The coders answer questions and they get answers, but they don’t know if these answers are right or wrong because they might not totally understand the anatomy.” Cohen maintains that because of the shortage of coders, the industry is rushing coders through training, and software is allowing that to happen more easily. He concedes that this is largely a problem for newer or less well-trained coders, rather than highly credentialed coders who have had extensive training in anatomy among other subjects. Cohen acknowledges the enormous value of coding software but cautions facilities against taking shortcuts with training. He urges coders to guard against complacency and continue to develop and hone their skills.

No matter how sophisticated the software, says Jepsky, the coder must know when to question and must have the ability to stay on top of changes and do basic research. “You must have the perception to know that things are dynamic, not static. You can’t simply do what the software tells you to do. You still have to be able to access the Centers for Medicare & Medicaid site, the Federal Register, obtain American Health Information Management Association updates, and know what’s going on in the real world or you’re going to get denied claims, and it’s going to cost your facility money to resolve.”

ENHANCING SKILLS
Not all experts believe that software is degrading coders’ skills. “Software,” says Friedman, “is providing many more tools for coders than have ever been available before to assist them in identifying the correct code.” The software is becoming intelligent, and rather than eroding coders’ skills, she says, it’s sharpening them. “It’s making coders much more productive and much more efficient and probably overall smarter because it’s pushing them to ask themselves questions as they do their jobs that they wouldn’t be asking if the software wasn’t prompting them.” She observes that many encoder software tools will ask the coder “Did you really mean this?” or will encourage the coder to consider additional information. “The system intelligence is pushing coders to improve their performance.”

While some argue that these same qualities of software soften coders’ skills and allow them to become complacent, Friedman insists that a coder’s personality plays more of a role in that process. “If a coder is generally a lazy person, he or she will use whatever code the computer suggests no matter what, so that’s more user-specific. They could get lazier in some regard because the software provides the answers for them. But, an experienced professional coder wants to continually sharpen his or her skills. This coder will use the software as a catalyst to further investigate the record and identify the correct code using books or other tools.”

Coding software, says Alex, can help coders keep up with one of the more complex nuances and idiosyncrasies of coding. To use it to its full advantage, however, he cautions coders against myopia and the tendency to think of software as the end-all and be-all of coding practice.

— Kate Jackson is a staff writer at For the Record.

A Role for Coders in Developing Software
Although she suggests that vendors don’t aggressively seek the input of coders and that few coders step up to the plate to be involved, Beth Friedman, RHIT, director of marketing for eWebCoding, says “There’s a big role for coders to help in the development of software systems.” eWebCoding, for example, turned to coders for counsel when it developed its remote coding application. “HIM professionals in general have an opportunity to look to the vendor community for job opportunities. Although many of them haven’t looked there, it’s can be an exciting world for them.”

— KJ

Choosing and Using Software Wisely
When choosing coding software or providing input on selection, says Beth Friedman, RHIT, director of marketing for eWebCoding, one of the most important steps is to go beyond the demo. The demo may look great, but it’s crucial, she says, to talk to other people who are using the software, particularly peers, to see if it works in the real world. “Don’t only talk to directors of the department who are using the product. Talk to actual coders, and maybe even sit and watch over their shoulders.” Better still, she says, is to see if you can drive the mouse and get a feel for how it really works. If it’s not possible to test drive the software at a current customer site, she advises, at least spend some phone time with your peers. “If you’re a director, spend it with a director. If you’re a coder, spend it with a coder.”

More important still, maintains Friedman, is to know your needs before software shopping. “Hospitals that seem to have regrets with software products are the ones that didn’t take the time to look at their processes and reevaluate how they do business, whatever that business may be: pharmacy, medical records, or nursing.” Diane Jepsky, RN, MHA, LNC, vice president of compliance at CodeCorrect, Inc., agrees. “Think through the process, know your needs, and know how you source your needs before you make a decision on a software product. It should meet all your needs—you shouldn’t have to compromise.”

Often, says Friedman, hospitals become heavily invested in the status quo. “We have this mentality that that’s the way we’ve always done it and that’s the way we have to do it. Instead, imagine that the limits you’ve had in the past no longer exist. Then, ask yourself how you would do the task at hand differently if there were no boundaries, and use the software to your advantage to make that happen.
“Don’t only use the software to create what you already have. When we see frustration with a software product, we see that people have tried to do things the same way they’ve always done them, and that doesn’t always work very well. No. 1, you’re stuck with your old problem, only now it’s automated. And No. 2, you’re not really taking advantage of what the system can do.”

Once you’ve determined your needs and believe you’ve found a vendor that meets those needs, advises Jepsky, request three good references. “Don’t only ask for the references,” she stresses. “Call them and ask for the pros and cons of the product.”

It’s vital for all coders to stay apprised of developments in coding software, advises Friedman. Read publications, go to conventions, visit with vendors, and don’t be afraid to ask questions, she suggests. “Be aware of what’s coming down the road.”

— KJ

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