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August 2014

Recruit, Retain, Rejoice
By Lisa A. Eramo
For The Record
Vol. 26 No. 8 P. 10

With ICD-10 (still) looming, finding and keeping qualified coders takes on added significance for HIM departments.

Let’s face it, coder turnover is frustrating. It’s expensive and time consuming to fill vacant coding positions, particularly when organizations continue to pour resources into ICD-10 training.

As the October 1, 2015, ICD-10 implementation deadline approaches, no HIM director will want to hear that a coder who has amassed significant ICD-10 knowledge at the organization’s expense has chosen to leave and work at another facility. Experiencing a vacant position during such a stressful transition can be devastating. At the same time, HIM directors must be prepared to hire additional coders to offset anticipated productivity declines.

Experts say establishing a coder recruitment and retention strategy is an important—and sometimes overlooked—part of ICD-10 implementation. Directors must find a way to keep knowledgeable staff members while also recruiting new coders who will fortify future plans.

Recruiting the Next Generation of Coders
Many areas of the country continue to experience a coder shortage, and with so many HIM professionals retiring in light of ICD-10, it remains somewhat challenging to find qualified candidates who can meet the ongoing demands of today’s coding positions.

Although some seasoned professionals may indeed choose to retire in the next year, the industry also is constantly churning out talented new graduates, says Brooke Palkie, MA, RHIA, an assistant HIM professor at The College of Saint Scholastica in Duluth, Minnesota. “You have this great opportunity to train this person who has this fresh knowledge of ICD-10,” she says. “You can mold this person to your specialties.”

Pam Brooks, CPC, CPC-H, a coding manager at Wentworth-Douglass Hospital in Dover, New Hampshire, agrees. “They don’t have any bad habits,” she said during the presentation “Hiring and Retaining Excellent Coding Staff” at the 2014 AAPC annual HEALTHCON conference. “If you’re looking to groom somebody into a particular position … then there’s nothing wrong with bringing on someone new and mentoring them. They’ll be incredibly grateful for the opportunity.”

Still, some directors are hesitant to hire new graduates who have no real professional experience. In response to this sentiment, Palkie says to “remember that we were all new graduates at one time.”

As the profession grows and changes, the most successful HIM departments will include a mix of both seasoned and novice professionals, each of whom has something special to contribute, Palkie says. This mixture of unique perspectives creates a learning environment in which information and innovative ideas are exchanged regularly, she says.

It’s important to build relationships with local schools and universities, says Palkie, who recommends contacting these institutions to inquire whether students can assist with facility projects. Get to know the students and observe their work ethic to determine whether they might be a good fit, she adds.

Over the last several years, Palkie has noticed more collaboration between organizations and schools in general. “Organizations have so many competing [regulatory] requirements. They just don’t have the time or money for some of the things that need to be done,” she says.

For example, The College of Saint Scholastica recently sent some senior HIM students to work at a local health care organization to develop specialty-specific clinical documentation improvement guides for the facility. The students met weekly with an ICD-10 provider champion and a transition team. “That becomes a win-win situation,” Palkie says. Students gain experience, and organizations can complete projects while also getting to know potential future employees.

Searching for the Right Skill Mix
When it comes to qualifications, top-notch coding skills, while essential, are just the tip of the iceberg these days. Today’s coders must follow rules and guidelines but also consider how they fit into an organization’s overall scheme, Palkie says. “You have to be able to communicate and work with different disciplines,” she says.

Coders must articulate to others why codes matter and how coded data are used. “Everyone needs to understand the big picture,” says Susan Parker, MEd, RHIA, CEO of Seagate Consultants.

Data analysis skills are a must. “When you have an EHR, you’re going to have to access a whole lot more data than you ever had before,” Palkie says. “That also means a whole lot more responsibility. Data governance and data analysis are important, as they contribute to data and information integrity.”

Parker says credentials always will be important because they signify a coder’s formal education and dedication to the profession. Those with a coding credential also must maintain continuing education credits, which means they’ll stay up-to-date on any changes, she notes.

As HIM departments become more centralized to include various components within a system, those coders who possess the unique combination of inpatient and outpatient coding credentials will be particularly valuable, Palkie says.

Parker agrees, noting how versatility can be a game changer: “I see a lot of people who are strictly inpatient or strictly outpatient, but when I see the person who can do both, the opportunities multiply. If I were a coder, I’d want to have as much training and exposure as I could,” she says, adding that the certified documentation improvement professional and certified health data analyst credentials also are highly desirable. “These add a layer of depth.”

“Education makes a difference,” Brooks said at the AAPC conference. “If you want a coder to have education, ask for it, and don’t settle for anything less. I think as this industry evolves and becomes more complicated, coders are going to need a bachelor’s degree.”

In addition to requiring a bachelor’s degree, Brooks said some employers may require formal training in anatomy, physiology, and pathophysiology. If candidates don’t have this educational background, employers must be prepared to provide it, she added.

Communication skills are crucial, Brooks told AAPC conference attendees. Coders with adult education teaching experience or another form of education can be helpful in terms of working with other staff members, including physicians. In that regard, HIM directors may want to ask candidates to provide a 10-minute presentation on a coding topic, particularly if the position requires frequent presentations to medical staff members, she added.

Ask Detailed Questions
The interview is the HIM director’s opportunity to get to know candidates. Set aside plenty of time for the process, including an allotment dedicated to questions from the candidates themselves.

When interviewing candidates, experts recommend directors first tackle the basics, such as coding experience and the types of charts coded. Directors must consider whether the candidate has the specific experience necessary for the position. For example, does the candidate have specialty coding experience? If not, is the individual willing to learn? It may be difficult to find a specific combination of credentials, Parker says. If that’s the case, directors need to determine whether they’re willing to broaden their search or be flexible for the right candidate.

The demand for specialty-specific coder training has grown in the past year as candidates attempt to set themselves apart from other candidates, says Tiffany Rankin, director of marketing at Coding Strategies, noting that physicians working in a practice setting prefer candidates with granular training. As a result, physician practices are willing to pay for these individuals or increase education budgets to obtain the training, she adds.

Ascertain the productivity standards of previous employers. Ask whether the candidate met these standards on a regular basis and what type of accuracy rate he or she maintained, says Pat Lozito, MBA, chief operating officer at HIM Connections. Speak with the candidate’s former supervisors to verify the information, he adds.

Brooks said to dig deep into a candidate’s career plans. “What I don’t like to hear is ‘I want to do coding,’” she said. “We all want to be coding and working, but I like to know if they’re interested in specialty coding. Do they want to audit? Do they want to perform education?” As coding roles expand to include other functions, it’s important to find candidates who are flexible, have long-term goals, and are interested in professional growth, she added.

Other interview questions to consider include the following:

• Tell me about a recent obstacle and how you overcame it. This allows directors to gauge critical thinking and communication skills, Parker says.

• How do you navigate documentation and coding questions? This is particularly important if the coder is going to work remotely, Parker says. However, all coders should be able to pose compliant queries, communicate professionally, and articulate the value of data integrity.

• Are you willing to travel? If the position requires travel—even if it’s only a few times per year—the director should ask whether the candidate is comfortable being away from home, Parker says. This avoids any surprises down the road.

• Are you willing to work remotely? Some organizations specifically hire for remote positions. However, even if an organization currently has no intention of sending coders home to work, the situation could change. Directors must know whether candidates are open to this possibility should the organization deem it necessary in the future, Parker says.

Some employers issue coding tests during the interview process. Although a test can provide a glimpse into a candidate’s abilities, it shouldn’t be the only form of assessment, Lozito says. “If a candidate doesn’t have experience with a particular specialty in coding, and some of the questions relate to that specialty, they’re not going to do well on that section of the test,” he says.

“Some people are good test takers, and some people are not,” says Kayce Dover, MSHI, RHIA, president and CEO of HIM Connections. “I do think it’s good to have a basic coding test to give to candidates, but I don’t think it should be used as the sole decision point.”

Ask candidates to explain their rationale behind their test answers, particularly the incorrect ones, Parker says. This gives directors yet another glimpse into the candidate’s critical thinking skills and logic, each of which are important as the industry heads into ICD-10.

If testing candidates, be sure to replicate the actual coding environment as closely as possible, Brooks said. For example, provide candidates with access to the encoder, coding manuals, the Internet, or other resources. “If you can’t replicate this, then candidates are at a disadvantage, and you need to think about whether it makes sense to do the testing,” she added.

Ultimately, HIM directors not only must ensure that the candidate has the requisite coding ability but also is a good fit for the organization. “You’ve got to look for the right cultural fit—someone who will be a good fit for your team, not just based on experience, but also personality and work ethic,” Dover says.

Brooks said to involve other HIM department members in the interview process. Let current staff ask questions and observe how they interact with the candidate. “It gives the team some ownership into the process,” she added.

Coder Retention
Once directors hire competent coders, they should do everything possible to keep them in the fold. The cost of employee turnover can be as much as 1.5 times the individual’s salary, Brooks told AAPC conference attendees. This includes expenses related to system-specific training, relocation, and productivity losses. “Turnover is painful, and it causes a lot of issues in the department and office. It’s disruptive, and it’s expensive,” she noted.

Consider the following ways in which HIM directors can increase the likelihood employees stay on board:

Offer a competitive salary. “We’ve definitely seen a rise in coder salaries, and I think we’re going to continue to see that,” Dover says. “You don’t need to be the highest-paying facility, but you need to be competitive, and you need to be able to offer a competitive employment package.” Benefits, paid time off, continuing education opportunities, tuition reimbursement, childcare assistance, and flexible schedules add to an organization’s attractiveness, she adds.

Focus on coder training. Coders appreciate any chance to learn; in fact, their certifications require ongoing continuing education, according to Brooks, who said organizations don’t necessarily need to increase training budgets to provide more education opportunities. Directors must think of smart, creative, and cost-effective ways to train while tapping into the knowledge that already exists throughout the organization, she said. For example, allow catheter lab coders to shadow providers to learn more about those procedures. Also, ask physicians to provide brief presentations on certain diagnoses or procedures.

Provide challenging projects. Some employees enjoy challenging themselves by developing noncoding skills. For example, Brooks permitted a coder who had a knack for research work on a project related to a local coverage determination (LCD) for the administration of iron in a cancer center. “She did some research not only into what the LCD said but also what we were documenting and failing to document on the physician side to get these paid,” Brooks said. “She took it a step further, identified a diagnosis that wasn’t part of the LCD, went back to our local contractor, and got them to reconsider the LCD.”

Offer flexibility. Because many coders welcome the opportunity to work from home or establish alternative work hours, employers should consider accommodating their needs, even if it’s only on a limited basis, Dover says.

Develop career paths. Like most other professionals, coders appreciate career mobility, Rankin says. Consider establishing a coder leveling system so employees can strive for promotions.

Check in frequently with staff members. Coders may not feel comfortable voicing their concerns. Lozito says don’t assume that employees are content, particularly those working remotely. Directors must ensure coders’ needs are being met and they feel part of the hospital team.

Survey staff members to determine what pleases them about their jobs and what can be improved, Brooks said. Ask open-ended questions and encourage honest responses to discover new incentives that managers can implement.

Create a culture of respect. “When you can create an environment where coders feel appreciated, they’re more likely to be loyal to you when someone calls and offers them more money,” Dover says. “As a recruitment firm, we always ask candidates what is going to get them excited about getting up and going to work each day. We want to know what is motivating them to look for a new position. Sure, everyone wants to make more money, but in most cases, money is not the driving factor.”

Provide a comfortable workspace in which coders can complete projects and code efficiently, said Brooks, who also suggested allowing work areas to be personalized as much as possible.

Although it may seem simple, providing positive feedback when appropriate also can lead to a happy work environment and demonstrate respect for staff members, Brooks said. “If they’re successful and happy where they are, they’re not going to leave,” she said.

Consider retention bonuses. Over the last 12 months, Dover has seen an increase in the number of facilities offering retention bonuses. “We’re seeing various ways to structure these bonus programs, but the goal is to do something to help you stay competitive with the other facilities in your area and retain the coders you are investing in each day,” she says.

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.