|
HIM directors-under pressure to do more with less-are looking in every nook and cranny to find options to maximize the use of skill sets, increase productivity and equitably distribute work. Coding professionals have a unique skill set and if utilized effectively, these abilities can help them evolve in any number of the positions described in AHIMA's Vision 2006.
Back in 1993, I wrote, "Coding professionals hold a unique position in health information management (HIM) and institutional fiscal solvency. The focus on their performance includes scrutiny by some external agencies to enhance the codes assigned, while others simultaneously question excessive coding."
My opinion has not changed, but the health care industry has certainly accelerated the surveillance of coding-related activities. Meanwhile, HIM directors-under pressure to do more with less-are looking in every nook and cranny to find options to maximize the use of skill sets, increase productivity and equitably distribute work. Coding professionals have a unique skill set and if utilized effectively, these abilities can help coders evolve in any number of the positions described in the American Health Information Management Association's (AHIMA) Vision 2006.
Based on a 1993 nationwide survey of HIM professionals, I previously suggested a set of coding standards and position descriptions for coders. Recent data, however, have reflected some interesting changes and influences impacting productivity for coding staff. For example, technology may actually slow coding professionals down. Also, the development of numerous registries has increased data collection requirements by skilled professionals. In addition, new technology may replace the search and read functions by coding professionals. Other changes include the evolution of super coders and incentive plans that compensate professionals for the value they produce.
Regardless of these changes, good coding professionals are those who have decided that coding and classification is a career-not just a job. This article is intended to augment that 1993 survey and identify opportunities to enhance performance.
What's Happened Since 1993?
Encoders: Some of the survey respondents have recently indicated that using groupers and encoders have, in some cases, negatively impacted productivity. On the other hand, the same software products have increased coding accuracy and, for some organizations, case mix and reimbursement. Professionals who maintain their "book skills" and study Coding Clinic and other coding rule publications believe they can code as many, if not more, than their counterparts who pledge the same about their skills linked with encoders.
Super coders: These are the coding professionals who produce more than 50 inpatient records (all types) a day. Truly talented professionals have been sought out by coding firms because they have demonstrated their talents by concentrating on coding for accuracy and volume. Recognizing that clients expect quantity and abhor poor quality, these coding professionals have found a way to groom loyal clients and make an enviable salary.
|
TABLE 1:
Suggested Productivity Levels* for Coding Career Ladder
Coding Specialist I:
> 45 inpatient records** daily
2 min/chart or 250/day outpatient and ER records
3.5 min/chart or 130/day ambulatory surgery records
Coding Specialist II:
> 32 inpatient records** daily
2 min/chart or 250/day outpatient and ER records
4 min/chart or 120/day ambulatory surgery records
Coder II:
> 23 inpatient records** daily
3 min/chart or 160/day outpatient and ER records
6 min/chart or 80/day ambulatory surgery records
Coder I:
> 15 inpatient records** daily
4 min/chart or 120/day outpatient and ER records
8 min/chart or 60/day ambulatory surgery records
* For coding and light abstracting. Assumes an eight-hour day/40-hour week.
**Regardless of payer type and case complexity
(table/courtesy Rose Dunn) |
One may ask, "Why don't we see these 'super coders' in our departments?" In my opinion, it's a combination of "I's"-interruptions and incentives. A coding consultant avoids interruptions because every minute lost is compensation lost. Employed staff have a variety of interruptions that interfere with their ability to maximize their time for productive activities. Interruptions can include educational programs, department parties and socializing with co-workers.
Coding professionals should be given an incentive to learn and retain coding rules and tidbits that will optimize their coding and reduce the time spent using references or depending on technology. Further, coders should be compensated as highly skilled professionals for the actual quantity of work produced.
This method of compensation is commensurate with the value obtained by the organization from billings from the professional's efforts. Paying coders a straight hourly wage, regardless of quantity produced, does not provide the incentive to be a "super coder," and there's usually just enough room for one "lead" coder at any given facility.
But what about those professionals who can't produce more than 30 records? There may be circumstances beyond their control. Consider the "I's" and look at the "other duties as required." HIM directors must also be sure to use the coder's skills where they are most required (coding) and focus the staff's efforts on those activities that will benefit the organization most (coding).
Maybe your coding department has a lack of resources-reference materials, coding guidelines, coding inservices and well constructed encoding products. Or it may be excessive abstracting of data that are rarely or never used, but have always been abstracted. Or it could be cumbersome processes that hurl barriers in the coder's way. Such a process could be the lack of adequate interfaces between groupers, encoders and abstracting systems, thus requiring redundant data entry or logging in and out of multiple systems.
Incentive Plans: While only a few organizations have implemented incentive plans, these facilities have seen increased productivity. But increased productivity is not the only change in behavior. The coding staff has an increased interest in reference material availability, they read updates and guidelines on their own time and they attend coding seminars, often on their own time as well. HIM directors utilizing incentive programs have also noted a reduced dependence on external coding support agencies and a reduced amount of absent and tardy time.
However, there are some downfalls to an incentive program, including:
Unions see "paying for performance" as a threat to their seniority philosophy;
There may be less willingness to respond to questions from co-workers because they are perceived as interruptions;
Quality may drop without adequate checks; and
Only conditions that count toward establishing the DRG are captured-not every condition that may have been present.
Establishing an Incentive Plan
If you are thinking of establishing an incentive plan, keep the following points in mind:
1) Records must be distributed equitably: consider assigning records by terminal digit number, not day of week. This eliminates the complaint that one coder receives all the big charts and prohibits coders from "picking" the easier charts from the stack.
2) Points need to be taken away for errors. A record whose DRG is affected by a coding error, whether it's due to one or five errors, must be subtracted from the coding volume produced.
3) Time flexibility should be considered. Does it really matters whether coders start to work at 6 a.m. or 11 a.m.? Some coders may find they are "afternoon" thinkers, while others have biological clocks that allow them to produce more in the early hours.
4) Absent, sick and holiday time should be paid at the regular hourly rate.
5) Allowances for assignments other than coding (e.g., teaching ICD-9 coding to a physician's office staff) should be made.
Coding Career Ladders
If an incentive plan is not for your facility, you should consider a coding career ladder, consisting of "Coder I," "Coder II," "Coding Specialist I," and "Coding Specialist II." Table 1 explains the productivity level for each position.
The productivity volumes found in Table 1 were based on the results of a survey conducted in 1993 and recently updated this past June. Respondents were from approximately 28 organizations including clients of First Class Solutions Inc., coding professionals associated with that firm, facilities that had participated in the 1993 study and several other hospitals. Of note is that the productivity volumes expected from staff members are consistent with other studies recently published (see Table 2).
TABLE 2:
Productivity Levels According to Other Sources
Productivity Level
3 to more than 10 inpatient
records/hour with the majority at 4-7 records per hour |
Source
Medical Records Briefing, Where Do You Stand? A Collection of Benchmarking Articles, 7/98 |
| 10 to more than 31 outpatient records/hour with the majority at 11-20 records per hour |
Medical Records Briefing, Where Do You Stand? A Collection of Benchmarking Articles, 7/98 |
20-60 inpatient records/day
36 Medicare records/day
46 non-Medicare records/day
53 ambulatory surgery cases/day
140-344 ER/outpatient tests/day |
Journal of AHIMA, Productivity
Standards: A survey of HIM professionals, Part II, 6/96 |
Suggested Performance Evaluation Criteria
Quality indicators that HIM directors should use to evaluate coders at all levels includd:
Coder accurately codes all diagnoses and procedures.
Documentation is present to substantiate codes assigned.
Sequencing is correct according to coding guidelines.
Codes are accurately entered into the computer abstracting system (if applicable).
Blood, Tissue and Surgical Case Review, Medical Record Clinical Pertinence Review, or other PI/JCAHO studies are completed accurately (if applicable).
Coder accurately enters coding and abstracted data into computer system.
Coder accurately completes registry forms when applicable.
Other possible evaluation factors includd:
Attendance.
Participation in career development activities, such as reading journals and coding articles and participating in educational seminars and in-services.
Ability to aid other workers in the completion of their work during periods of heavy workload.
Ability to use good judgement and demonstrate flexibility by conforming to unusual situations.
Use of free time between workload assignments to complete special assignments, file loose reports, update code books using reference material and assist with any registry abstraction.
Positive interpersonal relations in dealing with fellow employees, so that departmental productivity and positive employee relations are maximized.
Positive interpersonal relations in dealing with physicians and all health care professionals to project a favorable image of the HIM department and hospital.
Registry Requirements
One interesting finding from the latest survey is the surge in registry requirements. Historically, HIM departments have contributed to the efforts of an accredited cancer registry, but now many states are mandating cancer reporting. In addition, there are registries for trauma, spinal cord injury, fetal death, congenital anomaly, and the list goes on. Often, the abstracting efforts for these registries falls on the HIM department.
Management must weigh the time it takes to complete registry data at the time of coding with the delay it may cause in processing records to the incomplete area and/or the delay it may cause in processing an uncoded record for billing. Some facilities have found the "colored sticker" approach effective-that is, placing a colored sticker on the folder to signify a record requiring attention for registry data collection. Once the record is completed and before it's placed back in permanent file or on optical disk, the record is abstracted for the registry.This approach allows "coders-in-training" to perform the registry functions and get their feet wet with reading medical records and finding pertinent data. At the same time, experienced coding staff are moving the uncoded records through the process without interruption, and the registry reporting is still in line with state mandated timeframes.
New Technology on the Horizon
Laguna Medical Systems Inc. and MedDiscern Inc. have partnered in the development of a software product utilizing artificial intelligence to read all electronically generated documents contained in patient records (e.g., laboratory data, pathology report, EKGs, dictated reports, etc.). Tentatively, Dictaphone Corp. has been chosen to distribute this software.
The artificial intelligence software applies intricately designed rules to determine whether words, phrases or values within a given report or those that are linked to other reports (such as operative reports, post-operative diagnosis, and a pathology report's diagnosis for the same dates) should be captured as one of the diagnoses for the given patient. These phrases or words are then highlighted and linked to the diagnosis displayed for the coding professional to now review. The coder can edit out those that don't apply and those that should remain, and sequence them accordingly to establish a DRG. Laguna executives indicate that team members using the software experienced inpatient record coding productivity of up to more than 20 records per hour with a better than 98 percent accuracy rate on audit.
What does this mean for the coding professional today?
It means that the mundane combing through assembled or unassembled records will be history and that your role will be one of clinical editor and analyst. Does it mean that your books and encoder will go away? Not necessarily, because both may still be required to make a determination from time to time.
It's clear that the field of coding and classification continues to experience dynamic change, not to mention the recent addition of modifiers and ICD-10 on the horizon. Those health information professionals who have chosen the specialty of coding should be commended for their talents. They are an integral part of any successful health care organization.
Rose T. Dunn is a past president of AHIMA and vice president of First Class Solutions Inc., a health care consulting firm based in St. Louis. She has written more than 200 articles and is often sought after for public speaking engagements. Ms. Dunn extends her sincerest thanks to those who contributed to this article. Normally, she would send a personal letter to each survey participant. However, on July 11, her company was burglarized. The original survey data, participant names and addresses, and the original version of this article were just a few of the many items that were taken when her computer and briefcase were stolen, along with much of her office technology. Fortunately, no one was hurt and she has restored to status quo, less the data that were on stolen computers.
|