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August 2, 2010

Tips for Setting Productivity Standards
By Judy Sturgeon, CCS
For The Record
Vol. 22 No. 14 P. 6

When an HIM department establishes productivity standards, many questions need to be answered before a reasonable expectation can be ascertained. Being reasonable is a critical factor. The standards can’t be so demanding as to be impossible to achieve nor can they be so lax that it costs the department unnecessary labor in overtime or outsourced wages.

While modifications will be necessary for accounts such as emergency, clinic, day surgery, and observation charts, most concepts for establishing a standard are the same. In this article, the focus will be on measuring productivity in an inpatient-coding department.

• How does quantity affect quality? Before anyone becomes tempted to focus solely on speed, expect to achieve a balance between coding accurately and coding swiftly. The latter cannot become the department’s driving force, but it must be established as a standard in addition to those for competent and accurate coding.
Diagnosis-related group (DRG) billing accuracy must be monitored and corrected when found to be in error. Speed can be expected to be second in order of importance.

• What is the service mix? Now that the need for billing compliance has been established and prioritized, let’s look at another significant piece of information that can affect productivity standards.

If the majority of a facility’s cases are complex medical or surgical, major trauma, or intensive care patients, the time needed to code accurately and completely can exceed national productivity averages. If there is a high percentage of less-complicated cases, such as basic obstetrics, newborn, pediatrics, and simple surgeries, the final chart-per-hour expectation can trend significantly upward from the norm. If a general national average is in the neighborhood of four inpatient charts per hour, then any particular facility could vary significantly based on its service mix.

• What is the payer mix? If a low percentage of a facility’s cases are paid by DRG, the coding manager may want to establish different productivity standards for different payers. Some patients’ bills are covered by charity funds, some by commercial payers that reimburse based on charges or costs, and others are paid on a capped per diem (a flat fee per day). Because increasing speed takes a toll on accuracy, coding departments should be cautious before taking this route. Although typically unaffected financially by the codes and subsequent DRG assignment, these cases still need to maintain a minimum standard for coding accuracy.

Both internal and external decisions will be made based on the data created by correct—or incorrect—coding, so it is still necessary to include a minimum level of accuracy for reporting issues such as facility case mix, patient severity of illness and risk of mortality, disease tracking, core measures, and risk management.

Another major factor to consider is whether hospital charts are electronic, paper, or hybrid. A change from paper to electronic progress notes and becoming accustomed to a new review process can drastically reduce productivity. Because reducing billing accuracy is not an option, it may be necessary to rely on overtime hours or contract coders until both physicians and coders become accustomed to the digital format. Once familiarity is achieved, the legibility and ease of review can restore or even improve coding speed. While in the process of change, it may be necessary to modify any existing standards and then establish new ones once the crossover is complete.

A word of advice: Educate physicians prior to an EHR’s go-live to avoid excessive duplication of documentation (the copy/paste and “pull previous note forward” functions). If this is not curtailed, coders’ speed will drop as they sift through seemingly identical daily notes trying to determine which sentence, or even which word, is the only change in a new entry.

• Do your coders specialize by service? If there are no other considerations, a seasoned DRG coder may be able to competently process 15 or 20 normal newborn discharges per hour. Obstetrics with a majority of normal deliveries may be cranked out at six to 10 per hour without the coder breaking into a mental sweat. Simple surgeries may not be a challenge if the majority is comprised of hysterectomies or cholecystectomies. Once a coder learns the basics of a particular service, it should be possible to establish weekly or even daily productivity standards.

Complex medical cases, multiple surgical interventions, and even illegible faculty handwriting on a specific service can significantly reduce productivity. Transplants and cardiac catheters may be fairly speedy to complete at initial coding, but any subsequent complications can create a nosedive on the speed graph.

If all coders process all charts, a monthly or even quarterly productivity calculation is more fair than demanding a daily or weekly tally. While the staff may be able to make up time on stacks of straightforward surgeries or buckets of baby charts, the longer standard for calculating average productivity should compensate for the time required by the more difficult cases.

• Do the coders have noncoding tasks? Noncoding time must be subtracted from the total hours worked to calculate actual productivity. Establishing a reasonable standard is only one part of the project. Managers must also be able to determine how many charts were coded and completed (not just handled) in the time frame to be evaluated. Then they must identify how many actual hours were spent coding charts. For the time that was spent on other tasks, a good way to evaluate their validity and even necessity is to have each coder keep a detailed time log. Not only will the manager know where the hours are going, so will the coder.

If it is possible to identify the noncoding time, it should also be possible to better manage it. Should it become apparent that random interruptions are eating away at productivity, the staff can be encouraged to learn better time management. Managers can determine whether the unrelated tasks are necessary and whether they should be routed more appropriately to noncoding staff.

Where’s the calculator? Once the standard is set, the math isn’t difficult. Total hours worked minus noncoding hours equals hours spent coding. Total number of charts completed divided by the hours spent coding equals charts per hour productivity.

Unfortunately, only the math is easy. The staff must have the skill to maintain quality while meeting standards, which must be reasonable for the expected quality to be maintained. Productivity must be measured regularly and communicated to the respective coders. After all, they can’t improve if they don’t know how they are performing.

• Finally, the big challenge: holding the staff, including managers, accountable for attaining and maintaining department standards. If there are slower coders, managers must coach and encourage them to improve. Should quality begin to falter with the need for speed, both management and coding staff must refocus priorities to adhere to this critical goal. Education must be made available to nurture the skills necessary for overall success. Nevertheless, coders must be held accountable for their own success or failure, and consequences must be clearly established and enforced.

Job expectations are demanding for all coders, whether inpatient or outpatient, physician or facility. Establishing and maintaining the standards that create those demands will help healthcare facilities remain financially sound while maintaining compliance with state and federal billing regulations. To achieve this ultimate goal, coding staffs and their managers must continue working together for their own welfare and for the continued success of the department and the facility.

— Judy Sturgeon, CCS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.