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October 10, 2011

Coding’s New World
By Elizabeth S. Roop
For The Record
Vol. 23 No. 18 P. 10

Numerous changes, including the advent of ICD-10 and the expanded use of computer-assisted coding, promise to transform the profession in the next decade.

By the year 2020, the U.S. healthcare industry will presumably have survived its drawn-out transition to ICD-10, and advanced HIT systems will be the norm rather than the exception. While these changes will transform the industry as a whole, perhaps no individual healthcare profession will be impacted as significantly as coding.

 “A lot of coders have basic [medical] knowledge, but that isn’t going to be enough. When ICD-10 comes out, I would say that about half of the coders today do not have enough education to make it,” says Deborah Linehan, RHIT, PCS, CPC-I, CCP-P, manager of coding and compliance for Denver Health-Physician Administrative Services. “ICD-10 requires more in-depth anatomy and physiology than, for instance, many CPC coders have. If they haven’t prepared for that, they will be left behind. It will be a completely different world in coding in 10 years.”

Indeed, many HIM professionals agree that ICD-10 will inexorably alter the profession. The need for a higher level of clinical knowledge alone will change education requirements and, subsequently, the type of individual attracted to a career in coding.

Drivers of Change
Although its impact will be significant, ICD-10 is far from the only healthcare initiative that will ultimately change what it means to be a professional coder. The move to the expanded code set is just one of several forces driving that change, joining accelerated EHR adoption, healthcare reform, and expanded use of computer-assisted coding (CAC) as the principal movers and shakers.

Advances in technology and increased regulatory compliance are creating a new emphasis on both the speed and the accuracy of coding, in particular, as electronic records sharing expands to encompass healthcare facilities across the nation.

“While reimbursement is the driver for coding today, patient care, data management, and data integrity will be additional drivers 10 years from now,” says Peggy Pricher, group president at Kforce Healthcare Inc in Tampa, Fla. “Visibility and access to patient medical data will be crucial for comparisons of effective and cost-efficient approaches to patient care. The end goal is to provide better patient care at a much lower cost while utilizing a more preventive approach. In order to achieve that goal, national and international data must be accessible and analyzed effectively. The required data points on a record will continue to evolve, and the complexity will require a more analytical, technically oriented coder.”

Susan Proctor, RHIT, CCS, CPC, a trainer with the AHIMA Academy for ICD-10, concurs, noting that the advances made in information exchange and the increasingly critical role data plays in measuring quality outcomes to determine reimbursements are upping the ante in terms of the skills coders will need in the coming decade.

Proctor says enough progress has been made toward the “grand scheme” of a fully electronic record that the industry is already seeing the first blush of changes, including the publication of quality report cards and the Centers for Medicare & Medicaid Services’ (CMS) decision to no longer pay for hospital-acquired conditions.

These changes promise to reshape HIM and, in particular, coding.

“If those other things weren’t in play, it wouldn’t matter about ICD-10 or even the change to electronic records,” Proctor says. “The capacity for electronic transmission has finally progressed enough so that this grand vision to collect clinical data and use it in very sophisticated ways can be executed. As a result, you will have to have a really impressive clinical understanding to be able to work in this new data collection environment and to crunch that data.

“Coding is a specialized task that has never had a college degree track, and we are moving into the stage where the computer can scan the record and the software assigns codes fast and constantly based on coding algorithms,” she continues. ”Those people with CAC are doing that work better and faster, so a coder may really be out of a job. The work that remains is at a very high level of clinical understanding and ability to interact well with clinical staff.”

A Shift in Focus
Perhaps one of the biggest changes to the profession in the coming decade will be the transformation of coders into auditors, a development being driven in large part by the technical advances that are automating significant portions of the documentation and coding process.

“With advances in technology, I anticipate the coder role will be more of a coding reviewer or auditor, with most of the actual coding performed by either EMRs or CAC. Coding will be required more on an exception or completion basis rather than today’s comprehensive requirements,” says Pricher. “That doesn’t mean the job will be any easier, though. The skill sets required will be analyst-type, with an understanding of billing, clinical documentation, and utilization in addition to coding. They will code for hospital systems as a whole rather than individual hospitals, as hospital systems will operate on the same platform.”

While CAC and other technologies may take over many of the actual coding functions, they won’t replace coders no matter how intuitive or advanced their programming may become, according to Jacqueline Thelian, CPC, CPC-I, a healthcare consultant at Medco Consultants, who notes that although software has the capacity to identify Corrective Coding Initiative edits or bundled codes, it cannot identify the coverage determinations and regulations required to make the final code selection.

“You hear a lot of controversy where people are saying that we are moving to the software-driven world and EHRs and we won’t need coders. That’s actually one of the selling points of EHRs—that you won’t need coders or billers because the system will magically do everything for you,” she says. “To some extent, that’s true. To some extent, it’s not.”

Thelian points to her own auditing experiences when physician documentation did not adequately support the medical necessity of a service at the level indicated or when the software identified the word “physical” in one sentence and “therapy” in another and determined a physical therapy code was needed when that was not the case.

“That is something the computer is not going to pick up,” she says. “Software helps speed the process, but ultimately that coder will have to analyze the data, do the extrapolation for specific cases, help with documentation improvement, ensure the integrity of the data, and see how the data flows from multiple systems. They will also have to educate providers with coding clarifications. Coders in the role of data analysis, communications, analytics, and education—that’s the direction we’ll be going in the next 10 years.”

Linehan predicts that in addition to more auditing to ensure accuracy and data integrity, coders will be managing more complex cases, leaving run-of-the-mill coding to CAC systems.

“CAC has its limitations. Some of them are roadblocks for us. For instance, we have issues with [CAC] putting codes on anesthesia when the modifiers are overlapping,” she says. “There are certain things it cannot do because they are way too complicated. Over the years, it may develop a more complex algorithm to help, [but now] it just looks at a snapshot of the service and puts the code in.”

That is why CAC will likely be limited to simple surgeries and common diagnostics—the bread-and-butter types of coding that are well suited to its capabilities, says Linehan. Coding for trauma and more complex cases will be managed by experienced coders, who will also find themselves in the role of mentor and educator.

“We’ll be using the coders for the more advanced cases that involve little quirky things. Then the coders with more experience above that will mentor [new coders] to handle the more complicated surgeries. Then the ones above that will be the auditors and educators. They will educate the providers and coders and will be the ones who are working to make sure that we are in compliance, that everything the providers are doing is documented, and that we get reimbursed for everything to which we are legally entitled,” says Linehan.

Alleviating the Chronic Coder Shortage
Whether the changes taking place in the coding profession will finally alleviate its decades-long coder shortage remains the subject of much debate. For example, ICD-10 will likely increase the demand for coders, particularly those with experience in the new code set. However, it will also create more opportunities that may bring new coders into the profession.

“On the bright side, I believe ICD-10 will provide many new jobs and career opportunities in the HIM space,” Pricher says. ”Today, it is very difficult, if not impossible, to get a coding job directly out of school with no experience. There are many inexperienced credentialed coders looking for jobs, but employers require experience. It’s a catch-22. With ICD-10, I suspect ICD-10-educated coders will have an easier time getting jobs. Employers will more likely hire an ICD-10-trained employee and partner them with an experienced ICD-9 coder so they can benefit from each others’ experience.”

At the same time, growing acceptance of CAC will help facilities deal with the near-constant coding backlog that has been the by-product of the coder shortage. It can also help current coders increase their skill levels to ensure they remain competitive in the rapidly changing world of HIM.

“Coders should continually reinvent themselves. Advance. Become better. Continue learning all the time. Because CAC does those stagnant duties, it encourages coders to move up and develop themselves,” Linehan says. “If they work with CAC, it helps them learn. It codes things a certain way and gets the coders to ask how. They learn by figuring out why the codes it assigned were either right or wrong. They can’t help but learn through the process of using the CAC tools.”

The Coder of the Future
Those coders who succeed in reinventing themselves to fit with their future profession will be the ones who emerge unscathed from the rapid renovations that will take place throughout the next decade. This means increasing their clinical knowledge, recognizing their new roles as educators and auditors, and ensuring they have a voice in the design of the new systems and processes being implemented as part of the ongoing automation of documentation and coding.

For example, while many predict that it will be more common for clinicians to be coding on the front lines, it is the coder who has the experience and knowledge necessary to minimize workflow disruptions and maximum accuracy.

“Can [clinicians] really look through 35 diagnosis codes until they find the right one? If you have a coder who works with the physician to identify the four or five they most commonly use, you can set up a system that will expedite the coding process,” says Thelian. “At the end of the day, a lot of [the charts] will end up in the work queue, even the edits. You take an EHR and put in all the edits a coder would have to go through and the doctors will go crazy because they want to click the code, close the encounter, and move on to the next patient.”

What that means is that the coders of tomorrow will need to have extensive communication and analytical skills and the wherewithal to stay abreast of rules and regulations so changes can be communicated effectively back to the facility. They must also have the ability to implement those changes efficiently.

“It’s a good field to be in over the next 10 years. There is more than enough work for everyone, but it’s going to be different,” says Thelian.

To ensure they are regarded as credible additions to the clinical team, tomorrow’s coders will need a much higher level of clinical education, which may mean at least an MA or LPN degree.

“You don’t need a full-on RN [degree], but any clinical training and background will serve you down the road because you will have that clinical credential. That will be really important to anyone who is young enough and planning to stick in the field,” says Proctor, noting that the best coders will also be dual credentialed. “It’s better to be well rounded. We need to have desegregation of inpatient and outpatient coders, and dual backgrounds help that happen. And since the CAC system will code it all, you need to be as good as the machine you will oversee.”

Pricher likens the changes underway in the coding profession to those she experienced early in her career when she was a certified public accountant, before personal computers, spreadsheets, and accounting software were the norm.

In those days, an accountant had to be good at math and enjoy mundane tasks. Little time was spent on concepts and analysis because there wasn’t much data available. However, that changed with the influx of computers, which freed accountants to perform analyses, review best practices, and focus on risk areas and controls. Accountant jobs became more specialized, requiring a different kind of skill set entirely, one that was more analytical and could apply concepts, interpret cause and effect, and interact with people at all levels.

“Many new roles were created in the accounting profession as a result. I’m sure you can see the similarities to the coding arena,” says Pricher. “Many coders will remain coders or become obsolete and others will embrace the changes, sharpen their skills, and elevate the profession.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.