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October 29, 2007

Coding Crunch: Who Will Feed the Cash Cow?
By Annie Macios
For The Record
Vol. 19 No. 22 P. 28

As healthcare facilities look to fill coding positions, recruiters and HIM directors are doing their best to lure prospects into the fold.

Medical coders are entrusted with healthcare facilities’ reimbursement responsibilities; without them, providers wouldn’t get paid. The volume of medical procedures, an increased demand for data collection and analysis, compliance issues, and variations in coding courses have spurred an increased demand for medical coding professionals.

With the wellspring of opportunities now available throughout the healthcare system, finding qualified individuals to fill basic coding positions has become increasingly difficult. Healthcare facilities from across the nation have felt the pinch and are finding creative ways to ensure that their “cash cow” remains fed.

Deborah Grider, CPC, CPC-H, CPC-P, CCS-P, CCP, president of the American Academy of Professional Coders’ (AAPC) National Advisory Board, says the degree to which the coder shortage is evident depends on where you live. High turnover seems to be prevalent in the West and Midwest, whereas facilities on the East Coast appear better able to fill positions, she says. Nonetheless, healthcare facilities realize the importance of recruiting and retaining these key members of their team.

The ability to work from home and the use of flexible scheduling, along with offering competitive salaries and a low-stress work environment, are among the most effective recruiting strategies that healthcare facilities use to fill vacant coding positions.

Sarah Glass, MA, RHIA, assistant director of HIM at St. Luke’s Episcopal Hospital in Houston, has experienced firsthand the difficulty of filling open coding positions. Besides being a 912-bed nonprofit hospital, caring for more than 30,000 inpatients and 220,000 outpatients each year, St. Luke’s is also a teaching hospital with a medical staff of 605 physicians that uses a centralized coding staff.

“For the amount of procedures done at St. Luke’s, the staff is kind of small with 12 full-time coders, five part-time coders, and two quality coordinators who do internal coding reviews,” says Glass.

“Prior to 2005, we had several openings that we had difficulty filling. A lot of people don’t want to drive downtown to the medical center,” says Glass. But since St. Luke’s had an electronic medical record (EMR) in place at that time, she says administrators were supportive of enabling coders to work remotely. “We planned to have the coders ‘sent home,’ and as soon as that initiative was put in place, we were able to fill the last two positions,” says Glass.

In an effort to relieve traffic congestion, the city of Houston enacted “Flex in the City,” which suggests that there is a measurable effect in productivity when the right employees in the right jobs practice the right flexible work options, such as telecommuting or flexible scheduling. By moving a relatively small number of cars off the roads during peak congestion periods, the city experienced a measurable improvement in downtown traffic. St. Luke’s was one of the first hospitals to participate in this venture.

This strategy has worked well for Glass and her staff, with a 100% retention rate since making the switch to remote coding. “Knock on wood, we’ve not had to hire new staff because the coders are so productive,” says Glass. So productive, indeed, that although the coding workload has increased at a steady rate, the current staff is able to handle it, and there hasn’t been a need to hire additional staff over the last two years. “The EMR made it possible for us to do this, as well as a very supportive administration,” says Glass. The EMR gives the coding department more flexibility with its work list and makes it possible to maintain consistency throughout all facilities within the system.

To achieve a functional remote operation, St. Luke’s IT department duplicated everything that was done on site at the coder’s remote office. It was done so thoroughly that Glass says the coders really haven’t needed additional technical support.

From an organizational standpoint, St. Luke’s has seen additional benefits by moving the HIM department out of the hospital and into a building in a business park, which freed space and furniture for the hospital to use elsewhere. Having the coders work at home eliminates concerns about power outages or even something as simple as having a coder miss work because of car trouble. Glass says the project has increased job satisfaction and productivity.

To assess coders’ level of satisfaction, St. Luke’s surveyed the staff, assuming that most would cite the money they saved on gas and parking fees as the biggest perks. What they found, however, were employees who said they most enjoyed having a better balance between work and home because of less stress and more time to exercise and cook healthy meals rather than sitting in Houston’s rush hour traffic. “We noticed less absenteeism due to illness as well,” says Glass.

New Opportunities
Rita Bowen, MA, RHIA, CHPS, enterprise director for HIM at Erlanger Health System in Chattanooga, Tenn., has also seen an increased demand for coders. She attributes part of this trend to the variety of jobs that have opened for medical coders over the last several years. “There is a larger demand for data collection and data analysis. Plus, with compliance issues, more companies are doing retrospective analysis. Coding offers a wider variety of employment opportunities than ever before,” says Bowen.

Last year, 800-bed Erlanger lost six coders who chose to advance their careers within the facility. Three went to outpatient compliance teams, one became a data analyst for reimbursement, and two joined the internal audit department. “You need the coding skill sets to move to the next level,” says Bowen.

“The demand is so great, when you can offer people the opportunity to work from home, you have a better chance of recruiting them,” she continues. Currently, approximately 75% of Erlanger’s coders work from home.

Bowen says it takes roughly six months to fill a general coding position, but for a more advanced position—for example, someone who works in compliance—it can take up to one year because those positions require the employee to be on site.

Flexible Scheduling
Janice Lynn, human resources manager for allied health recruitment at Sinai Hospital of Baltimore, and Joan Montgomery, human resources business partner at Northwest Hospital in Randallstown, Md., share many similar challenges when it comes to recruiting and retaining coders. As part of the LifeBridge Health System, both facilities have witnessed the growing need for coders; however, because of differences in size and location, the facilities recruit coders a bit differently.

Lynn also recruits for Practice Dynamics, Inc., (PDI), the professional physician billing organization for the LifeBridge Health System. “A huge factor that attracts applicants is that we offer flexible schedules,” says Lynn. For example, she has some coders that might work from 5 am to 2:30 pm. Since the coders are accountable to complete a certain amount of work, the time of day in which they perform the work is inconsequential and, in fact, improves productivity, according to Lynn.

Montgomery also uses flexible scheduling with the coders she recruits at Northwest Hospital, a 250-bed community hospital serving greater northwest Baltimore. “It works well for moms and for avoiding high-traffic times,” she says.

In addition to flexible scheduling, both Sinai and Northwest ensure coders are well compensated and salaries are market competitive. Because of its size, Sinai is able to offer quarterly bonuses if productivity is maintained. “We also offer free parking,” adds Montgomery. “It may not seem that important, but in healthcare, it’s a big deal.”

For Lynn and Montgomery, referrals have been the single most effective source for recruiting coders. As a 467-bed acute care facility, the largest of the LifeBridge Health facilities, Sinai also offers a sign-on bonus, as well as for a referral if the hired applicant remains at the facility for a specified period.

In addition to tangible benefits such as a competitive salary and flexible scheduling, Lynn and Montgomery have the benefit of touting LifeBridge Health as the area’s best place to work as determined by the Baltimore Business Journal. To qualify for the award, at least 300 employees had to complete an online survey about the company. “This honor means a lot because it was the LifeBridge Health employees who voted their workplace as the best,” says Montgomery.

What Do You Look For?
The credentials and experience needed to fill hospital coding positions can depend on several variables: whether the facility is rural or urban, a teaching hospital or research center, as well as the facility’s specialty areas.

“More than 90% of our coders have coding certification specialist (CCS) or multiple AHIMA credentials because we are in acute care,” says Glass about St. Luke’s.

“Erlanger is a Level 1 trauma center, so we look to hire coders with CCS certification,” says Bowen. As an employee of a large facility associated with research hospitals, Erlanger coders encounter a variety of healthcare specialties and diagnoses that would not be seen in a rural hospital. “If you can code here, you can code anywhere,” adds Bowen.

Lynn echoes the need for coders with hospital experience. “Coding depends on a wealth of information to do the job,” she says. At Sinai and Northwest, coders must have inpatient coding experience and are required to be certified. “While applicants come accredited with their CCS certification, some might only have experience from the physician side but not the acute care side,” says Lynn.

“We give all applicants a coding test,” says Montgomery, adding that even if the applicant is experienced and certified, if they don’t pass the test, they can’t be hired.

Because PDI handles the professional physician billing for the LifeBridge Health System, Lynn needs knowledgeable and experienced coders who can handle the various diagnoses and terminologies that are used in specialty care facilities. In contrast, as a smaller community hospital, Northwest doesn’t need to recruit coders with extensive specialty experience, according to Montgomery.

Having “The Right Stuff”
Grider believes the educational process has played a significant role in the current coder shortage. “They’re not being trained fast enough to fill the need,” she says. In the meantime, she notes that organizations such as the AAPC and the AHIMA are combating the shortage by offering opportunities for e-learning. Also, local colleges throughout the country are creating coding and degreed programs.

When looking for a coding program, Grider advises prospective students to carefully examine the curriculum, which should include courses in anatomy, law and ethics, coding, and billing. “Coding and billing work hand in hand in light of today’s compliance and regulatory issues as well as Medicare and Medicaid issues,” she says.

Many of Sinai’s and Northwest’s coders come from local colleges, and last year, the facilities began accepting applicants from coding certification courses. However, “Sometimes programs are limited and only certify a person to work on the physician side,” Montgomery says. She recommends examining a school’s curriculum to determine what is offered. Lynn adds that having specific specialty experience makes a coder more marketable to some organizations such as Sinai and PDI.

At Erlanger, Bowen has partnered with the local community college, where she finds potential coders from among the technology program graduates. She has also found that many experienced healthcare professionals are turning to coding as a way to use their healthcare background in a new way. For example, many who’ve been in ancillary care or nursing often cross over to learn coding skill sets because a coding position offers greater schedule flexibility.

In addition to recruiting recent graduates, Lynn and Montgomery also have tapped into nurses who want a schedule change or to move out of patient care.

The Future
Lynn and Montgomery stress the importance of the coders’ roles in a health system. Breaking down the coder’s value to its most basic, Montgomery says, “If a coder didn’t do the job, our facility wouldn’t get paid.” They view coding as one of the up-and-coming “hot jobs” and believe it’s important to educate people that there are other healthcare fields besides patient care where you can make an impact.

Grider says as EMRs become more commonplace, the need for coders will continue but may not necessarily increase. “But the roles may change, and it will take a higher level of experience and know-how to accomplish the job,” she says.

— Annie Macios is a freelance medical writer based in Doylestown, Pa.