On the Floor and Maintaining Contact
By Gretchen Berry
OF THE MULTITUDE OF soap operas set in hospitals, not one has ever featured a torrid romance between a doctor and a coder, a kidnapping plot hatched by a nurse and a coder, or a coder with an evil twin who terrorizes the medical staff. Plots like that are too unbelievable. Everyone knows that coders don't have that kind of contact with the medical staff!
Unless, of course, they are concurrent coders.
"Concurrent coding is reviewing patients' records during their stay and assigning the diagnostic and procedural codes at that time," explained Eve Van Sickle, RRA, director, health information services, Shriners Hospitals for Children, Cincinnati Burns Hospital. The practice has been in use for decades, but seems to have waned in popularity over the years. Some institutions, however, are still using concurrent coding programs and achieving excellent results. Still others have adapted and re-engineered these programs to suit their changing needs.
In 1993, Van Sickle helped implement concurrent coding while she was the assistant director of medical records at Christ Hospital, a 550-bed facility in Cincinnati. "Administra-tors at the time looked at the big picture," she recalled "They decided that the only way to get good quality data reflecting the severity of our patients' illness was for our coding to be really good. And the only way for our coding to be thorough, accurate and comprehensive was to do it concurrently."
Proponents point to several advantages to concurrent coding. First, it decreases the amount of time the hospital must wait to be reimbursed, because the bulk of the coding is done before the patient is even discharged. In addition, the coding is more accurate because coders are in a better position to seek clarification from clinicians.
"Better documentation really does lead to better patient care," added Van Sickle. "The payback for the hospital is that it gets every dime to which it is entitled."
Case mix was one of the concerns that lead Franciscan Hos-pital Mt. Airy, in Cincinnati, to try to increase and improve documentation through concurrent coding. Rather than undertake the huge change themselves, Franciscan contracted with St. Anthony's Consulting to ensure that the transition would be as smooth as possible.
June Gatzke, RRA, manager of medical records for Franciscan, detailed how the program works. "Basically, we have coding stations on our acute floors. A coder is assigned to an individual unit and works right there on the floor," explained Gatzke. "They are responsible for anyone who is admitted to that floor from admission to discharge and until the bill is finally sent."
Franciscan coders begin with an initial admissions review and then review the chart again as often as required based upon the patient's care. "Then they perform a final discharge re-view," Gatzke concluded, "making sure that everything is in place and the proper DRG is assigned. Hopefully, we can release the bill at that time."
When the bill is released, it may contain charges that would not be possible had the coding been done retrospectively.
"For example," offered Van Sickle, "let's say you notice an antibiotic or a respiratory treatment noted that leads you to believe that a patient has gram negative pneumonia. But the physician has not diagnosed it because he or she does not have a culture that says that." With concurrent coding, the coder can query the physician and ask that the suspected diagnosis be included in the progress notes. "The coding rules allow you to code gram negative pneumonia, which pays significantly more than simple pneumonia."
This type of interaction with the medical staff, however, is not desired by all coders. Van Sickle recalls encountering some resistance at her facility. "It takes a certain type of person to do this. You have to be able to walk up and say, 'Excuse me Dr. Smith, can I talk to you about this case?' And that can be very hard."
What can make it even harder, according to Karolyn Broussard, MBA, RRA, vice president, health information/patient fi-nancial services, Quorum Health Resources Inc., Brentwood, TN, is being viewed as an intruder. "Nursing tends to resent having nonclinicians in their nursing unit. It is such a high-traffic area that many times nurses may feel that coders are in the way."
Broussard believes that al-though concurrent coding makes sense in theory, the process actually wastes more time and effort than it saves. "The concept is wonderful," she conceded. "But there is a lot of down-time to be considered. There are a lot of hands going after that chart and it may not be available when you need it. There's a lot of time wasted traveling to and from the nursing units. It's very different from being stationed at a desk where you have all your coding resources at hand and space to do your work."
Quorum, which owns, manages and consults in hospitals in 44 states, utilizes concurrent coding in very few of its facilities and advises clients against its use. "Coders are hard to find," Broussard observed. "You don't want to waste their time and expertise traveling in elevators and waiting on charts."
Quorum hospitals employ what Broussard refers to as "concurrent documentation." "In our hospitals, we have case managers who are working with patients, physicians and documentation, so it doesn't make sense to have another set of hands going after the chart while the patient is in house. Our preference is to equip the case managers with DRG knowledge so that they understand what documentation is necessary to support accurate coding and DRG assignment. The case managers then transmit their worksheets, manually or electronically, to the coders who in turn update the codes and respective DRG."
It was problems like these that lead Christ Hospital to abandon their concurrent coding program after two years. "Work load was one of those fluctuating things that was very hard to deal with," Van Sickle admitted. "If the census was down, what did you do? That was one of the biggest problems with concurrent coding. We never got a handle on productivity."
According to Gatzke, Franciscan has not had a major problem with productivity. "The way the workload is distributed, if a coder has no work, they go to another inpatient coder and ask if they need help. If not, they help with outpatient coding." Franciscan, in fact, has had few problems at all. Their five-year-old program has been extremely successful.
Crozer-Chester Medical Center in Upland, PA, has created a hybrid pro-gram, incorporating Franciscan's successful approach to concurrent coding, while addressing the concerns expressed by Broussard. The facility employs "concurrent analysts."
"They are like case managers," explained Walt Bisbee, RRA, assistant director of medical records. "Approxi-mately half of their function is coding and the other is performing concurrent third party reviews."
Case managers, who are RNs and work out of the utilization department, do the initial reviews and precertification. They then give the names of the admissions and the corresponding insurance information to the coding staff. "For example, the RN precertifies with the insurance carrier a patient who is admitted into the hospital. The insurer may agree to admit the patient, but asks to be called back with clinical information in a day or two. After two days, a concurrent analyst will call back and give the concurrent review. The analyst will comb the chart and indicate the particulars regarding the patient's medical condition or answer any question from the insurance carrier concerning the patient's treatment or clincial standing."
Crozer's use of concurrent analysts meets managed care's requirement for third-party reviews. Rather than certain insurance companies utilizing their own staff for the on-site reviews, Crozer needed to do the reviews internally. With their clinical knowledge and routine review of the chart for coding, the analysts/coders seemed the natural choice.
Crozer also has concurrent analysts who assemble and analyze the charts after discharge while the chart is still in the nursing unit. The chart is then sent to the medical records department completely assembled, analyzed and coded. There, it is scrutinized by concurrent chart DRG coordinators who review the chart for coding and DRG accuracy.
The program has been in use for at least six years and Bisbee classifies it as very successful. "Most of the analysts enjoy working this way," he said. "For people who want change in their activity every day, who want to be interacting with the physicians and nurses, this is perfect."
Van Sickle agrees, despite the discontinuation of Christ's program. "That's the way I would want to code," she said. She does not hesitate to praise concurrent coding and believes that with more time and better planning, Christ's program may have lasted longer.
"I wouldn't say that our program was unsuccessful," Van Sickle offered. "In reducing our accounts receivable it was very successful. We needed more lead time, better planning and better education."
"Whatever works for your institution," concluded Bisbee. "That's what you need to do."
Gretchen Berry is an editorial assistant at ADVANCE.