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For other articles and previous issues click here. September 9, 2002 Breaking
the Code of Silence Everything isn’t hunky dory down
in the coding trenches. In this article, several coders air their
gripes as they address why there’s a shortage in the field. Following publication of that feature, a number of full-time coders responded with letters to For the Record, clarifying their concerns and expressing the “real reasons” for, and factors contributing to, the current shortage of medical coders. Through honest and straightforward appraisals of their work environment, job responsibilities and expectations, and compensation, these coders painted a far different, and often harsher, picture than that described in the March article. The costs and commitments associated with initial and continuing education, varying degrees of salary concerns, and poor working environments—combined with a sense that they are not appreciated or respected as highly specialized professionals—are the primary concerns of full-time coders and the reasons behind the decrease of available coders in the medical industry. When asked what they are seeking in their full-time positions, the underlying message conveyed by each coder was the same—respect. “Coders just don’t get the respect they feel they deserve,” says Julie, who works in the coding department of a well-known hospital in the northeastern United States. “Often, when we have a problem that affects our productivity, it isn’t important enough for administration to come into the equation. The ‘higher ups’ who come up with the number of charts we are supposed to complete each day have no clue about what we do and treat us like peons whose only purpose is to bring money into the hospital.” Most coders, she adds, eventually tire of being expected to produce like automatons and are concerned that upper management personnel often have little or no understanding of what is expected of a coder on a daily basis. “I have been working at this hospital for five years and have yet to meet anyone above my director,” Julie says. “Management makes all the decisions
and takes all the credit, and at the end of the year when the hospital’s
profits are reported, they talk about the wonderful job they did,
but they never mention the wonderful job the coders did.” Michelle, who is also employed as a full-time coder at a large metropolitan hospital in the Northeast, says that she does not expect the situation to improve until hospital administrators are able to understand exactly what is included in a coder’s job responsibilities. “Maybe if they knew what we did, they would understand why we ask for more money,” she adds. “We aren’t trying to be greedy; we are just asking for competitive salaries.” In addition to better compensation, Michelle and her colleagues would appreciate increased respect for their profession and its extensive training and credentialing requirements. “It would be nice if management knew what we had to go through to get our credentials,” Michelle says. “I wish they understood that we go through all that training for a reason, and that our credentials really mean something to us.” Many hospital administrators, coders say, hold misconceptions about the level of complexity of a coder’s daily work. To help administrators understand the challenges coders face each day, Marie, a coder employed by a hospital system in the Great Lakes region, likes to draw a comparison of the amount of time and effort she expends reading a complex medical chart with that involved when a manager reads an intricate business report. “Reading a business document or a medical chart takes a huge amount of concentration,” she explains. “It’s not all cut and dry. We don’t just read it, pick things out, and code them.” When she first started working in the medical records department, Marie recalls, physicians wrote procedures and diagnoses on charts that were passed along to clerks who performed the coding according to those notes. No interpretation was required. Since then, however, there have been many changes, such as added responsibilities and increased complexities resulting from the rapid development of new medical procedures. “We do much more interpreting,” Marie explains. “It takes a high level of education to read operative reports, which are sometimes quite complicated.” She offers the example of the surgeon who performs hand and wrist surgeries at her facility and who often submits eight- to 10-page, highly detailed reports. “He is a very good surgeon and is very detail-oriented, so I understand why he submits such complicated reports,” Marie says. “At the same time, though, it makes it very difficult to code the procedures. The reports can be confusing, and we often have to go back and review them several times.” With new medical advancements increasing exponentially, physicians are performing procedures that most only dreamed of 20 years ago, she adds. “These procedures are very involved, sometimes difficult to understand, and even more challenging to code.” Despite the complexity of the coding process, many coders are finding themselves confronting rapidly increasing productivity requirements and expectations that most feel are unrealistic. “It seems administration feels we should be doing more and more every year,” explains Sharon, a coder employed by a hospital in a large East Coast city. In school, Sharon recalls, she was taught that coders were typically expected to complete 30 charts each day, but in her first hospital position, she was required to complete only 17 charts during an eight-hour shift—a number she thought seemed low at the time. “When I started working here, though, and learned that we have to do all the abstracting, I realized that it was often difficult to complete even those 17 charts a day.” Her supervisor, she says, told the staff that she preferred coders to do their best to meet the quota, but wanted their primary emphasis to be on ensuring the accuracy of coding for completed charts. In the ensuing years, the number of charts coders are responsible for completing each day has risen. “It is clear that administration is not looking at the issues that often interfere with our completing a higher number of charts every day,” Sharon says. “Sometimes we are given extremely large and complicated charts, or we might have problems with admission and discharge dates, wrong medical record numbers, or someone who was admitted to the wrong doctor.” When a chart is inaccurate, she adds, coders often find it difficult to locate hospital personnel willing to take responsibility making the corrections. Because their intricate work requires discipline and concentration, the coders explained that their productivity is negatively affected by distractions in their office environments. “We all work in a large, open area where there is constant foot traffic and interruptions by clerks who come in to look for records,” Marie explains. “We don’t have a place where we can just close a door when we are doing a really difficult chart and need to concentrate.” Many coders in her department have resorted to using earplugs to block out background noise or using portable compact disc players with headphones to try to obtain some semblance of privacy. Michelle adds that in her hospital, coders were moved two floors up from the rest of the medical records department, ostensibly to provide them with some peace and quiet. “At first it seemed like a good idea, but it soon became a problem,” she says. “We spend a lot of time going up and down between floors to pick up charts. If a chart is incomplete because an analyst missed some components, we have to go back downstairs to find the missing items ourselves.” Noise, often from nearby coders, is a continuing problem in many offices, according to Sharon. Although office policy at her facility prohibits coders from using telephones for personal reasons, contract or part-time coders apparently follow a different guideline, she observes, adding, “Some of them seem to be on the phone all day, and itís very distracting. Management needs to understand the interference the phone causes when we are trying to complete our work.” The distractions are exacerbated by the fact that coders in her department no longer have individual telephones on their desks—they are required to take turns answering a telephone installed on the wall. “When I have to get up and leave my work to answer someoneís personal call, that is extremely frustrating,” Sharon remarks. The coders explained that, in addition to creating distractions and unnecessary noise, contract coders often evoke negative reactions from hospital-employed coders because of pay discrepancies and quality control issues. “At one time, we had overtime available,” Julie explains. “Now, we are paid less per chart than contract coders receive, and we know what they provide is not quality work because we see it. They get huge paychecks, and we are left to wonder why they didnít offer the work to us. So, yes, there is a degree of ill will there.” Inexplicably, contract coders seem to receive more respect from hospital administrators who view them as “specialists” or “consultants,” rather than part-time or temporary help, Julie continues. In fact, many of her colleagues, lured by increased respect and higher salaries, have left their full-time positions to become contract coders. Most coders agree that they are not
adequately compensated, considering the training required to perform
their jobs. “We have to go to school to learn to do this. It’s
not a skill any monkey can learn,” says Julie. “Anyone
can be taught how to put a chart together because itís all color-coded
to begin with. When clerks tell me they wish they were in our shoes
because we earn more money, I tell them to go back to school and
experience what we are expected to do in our jobs.” “We haven’t lost anyone from our department lately, but I think it will come to that pretty soon,” Sharon explains. She and her colleagues recently requested a raise, she says, and were turned down. “Administration said they compared our salaries to other hospitals of the same size and the same case mix and felt our salaries were competitive,” she continues. “But we have done our homework and found that coders at many other hospitals earn far more than we do. We received nothing more than our usual yearly increase.” Sharon adds that one coder in her department has already received an offer that she plans to accept, and several others are preparing their resumes. “I suspect many of us would like to leave at this point,” she says. “I know I would like to.” Unrealistic expectations, poor work environments, inadequate pay—what can administrators do to retain and recruit experienced coders? When asked for suggestions about what would help solve these and other concerns, all of the coders said they believed that regular meetings with hospital administration could play an important role in alleviating their concerns. “I came from a hospital where I worked in various jobs for 20 years, ending up in the medical records department,” Marie recalls. “It was a very old hospital, and I got so disgusted with the environment that I ended up looking for another position.” Her current position as a coder in a Midwestern facility is more enjoyable, she says, but could be improved greatly if management had a better idea of what coding involves. “The coding section developed a productivity standards committee, including the coding manager, an inpatient coder, and an outpatient coder,” she explains, “but since they first began, they have only managed to get two meetings together.” In future meetings, she hopes the team can explore the problems with coders’ job expectations and reach an agreement regarding the number of charts coders are required to complete each day. At her facility, Sharon explains, coders have discussed the benefits of asking administrators to spend several hours in the department to gain a better understanding of coders’ responsibilities. “I’m not talking about just a five- or 10-minute visit,” she clarifies. “They need to sit with one of us and review a large chart for a patient who has been in the hospital for two or three months to appreciate its size and see why we are unable go through a chart that size—plus the 23 or 24 more they expect us to do in a day.” Another solution, Marie suggests, may be allowing more coders to work from home. Most transcriptionists at her facility work from home, she says, and their productivity rate has increased dramatically. Most of the coders say they continue to find their jobs rewarding and challenging, but are so frustrated by the conditions and expectations they face that they are considering a career change. “Some of the coders I work with talk about wanting to do something else, but the catch-22 is that, with all of our added responsibilities, we make a decent salary at this particular hospital,” Marie says. “I have spoken with many coders, though, who say that if they hadn’t gone into this field 15 years ago, they wouldn’t go into it now.” Marie, herself, adds that if she could go back in time, she also might choose a different profession. “But, then again, I’m a single woman, and I earn pretty good money.” Julie, on the other hand, has returned
to school to become a computer information specialist. “I just
became so disillusioned,” she explains. “I am at the highest
level I can achieve in this institution, and there is no place for
me to go. I don’t want to be in management, so I’m looking
for another career.” Sharon would also like to find another
career in which she feels she is compensated fairly without the
responsibility of an ever-increasing, unmanageable workload. “I
have been working at this hospital for a long time, I have seniority,
and I like the work. It is so interesting, and I love the feeling
of always learning something new in my work,” she explains.
“But, overall, if I could find something that doesn’t
feel quite so stressful, I would not mind giving it up.” |
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