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ICD-10 Coder Training on Island Time

Hospital General Menonita in Puerto Rico is one hour away, many months ahead.

Hospitals everywhere are predicting a financial hit when clinical coding moves from ICD-9 to ICD10. Recent studies suggest that up to 50 percent of healthcare leaders anticipate revenue loss and the move to ICD-10 has earned top position as a business priority.

None of the nearly 6,000 U.S. healthcare provider organizations are exempt from the pressures of ICD-10. All are bound to the October 2013 deadline and in addition must comply with CMS's MS-DRG based reimbursement model and recovery auditor take backs; even hospitals located in U.S. territories and commonwealths.

This article explains how the health information management (HIM) department at Hospital General Menonita in Puerto Rico is planning for the ICD-10 transition, predicting the financial impact and training coders -- well in advance of their mainland counterparts. Lessons learned and benefits realized through early coder training are explored and valuable tips shared.

Set Your Executive Mindset: Coding Equals Revenue
Located in the lush, central mountain range of Puerto Rico and only one hour's flight from Florida, Hospital General Menonita (HGM) gives stateside HIM directors a clear glimpse into the benefits of early coder training. The 153-bed acute care, community hospital is part of a two-hospital healthcare system and located in the college town of Cayey, approximately 30 miles south of San Juan, the island's capital.

HGM owns six trauma centers in Puerto Rico and serves a largely Medicare Advantage population with 11,000 total inpatient discharges annually. A new construction project will add 80 acute care beds in 2012. The hospital uses the Meditech hospital information system (HIS) and is implementing their electronic health record. HGM employs 18 full-time HIM staff including five in-house coders.

From a coding perspective, the hospital is an island leader and innovator. HGM was the first hospital on the island to adjunct in-house coding staff with remote, outsourced workers. They began using H.I.M. ON CALL outsourced coding via the company's web-based coding technology in 2005 as part of an overall, revenue cycle improvement project. The project was highly successful. Case mix index was improved and a $2 million annual loss was converted to sustained, multi-year profitability. Much of their success is attributed to H.I.M. ON CALL's outsourced coding service and revenue analytics software.

Also important was the strong support and underwriting provided by hospital CEO, Pedro Melendez. "HIM is an integral part of the revenue cycle. I totally rely on them and understand the money starts in coding," he states. Melendez is consistently open-minded about new approaches that increase productivity, reduce costs and are good for the hospital. So when the HIM director approached him with the option to begin ICD-10 coder training sooner rather than later, he was totally supportive.

Early Training and Predictive Modeling Help Set Expectations
The coding team at HGM has 4 to 10 years of coding experience and all have graduated from American Health Information Management Association (AHIMA) accredited programs. Just like stateside counterparts, coder shortages are rampant and the hospital continually struggles to find certified, qualified staff from the island's two AHIMA-approved schools.

HGM initially attempted to use free-lance, contract coders before turning to an outsourced coding company. Stability, reliability and quality were issues with the free-lance staff. Today the outsourced company covers Medicare DRG and all ambulatory coding with hospital staff supporting the remainder of coding needs.

With ICD-10 looming, HGM decided to get started early and established an ICD-10 assessment and training partnership with their coding firm. They also evaluated the ability to use existing case mix and DNFB analytics software to predict ICD-10's financial impact. Both steps have truly helped HGM get months ahead in their transition.

Benefits of Early Training
HGM's transition team includes the directors of IT, nursing, HIM, patient access, billing and the hospital's health plan. They began initial awareness training in HIM and billing. An immediate need in the area of anatomy and physiology was identified. Through subsequent, more in-depth coder training, executive management recognized that coder anxiety and fear levels would continue to climb as the 2013 date approached. With this in mind, the department budgeted for additional external training while also exploring internal educational opportunities. A partnership was formed between HIM and the Director of Nursing (DON) to offer internal anatomy and physiology training. Other external programs and offerings were also identified and budgeted. This ability to identify weaknesses and adequately plan for their remediation was the most important benefit of early awareness and assessment.

Training Step

Need Identified


High level awareness training

Anatomy and physiology is weakness

Partner with Director of Nursing (DON) for internal training

Introductory courses

Coder anxiety and fear as deadline approaches

Budget time and money for more coder training in 2011 and 2012 to relieve anxiety, give coders hands on experience.

Continue internal training with DON.

Enroll coders in PRHIMA sponsored training courses.

In-depth training

Productivity will drop.

Budget for more training and outsourced coding support in 2013.

Benefits of Predictive Financial Modeling
From a financial perspective, the organization plans to run predictive models through their coding and revenue analytics software to determine which MS-DRGs will be at greatest risk for revenue loss under ICD-10. Calculations will be performed through H.I.M. ON CALL software, which is currently used to provide executive-level, physician-specific reporting and predict revenue impact for annual code updates. "We are able to produce physician report cards including MS-DRG profiles that annually compare costs and case mix by physician," mentions Melendez. Already the most important report in the medical staff office, these reports will soon be ready for ICD-10 financial impact modeling. "Data is very important in making projections and strategic decisions," he stated.

Physician report cards are also used to design and guide clinical documentation improvement (CDI) initiatives. Overall the organization cares deeply about quality and this same commitment extends to their documentation. HGM works closely with their physicians and the hospital enjoys a strong, long-term relationship with most of them.

Stronger Physician Relationships Ahead
To further strengthen physician relationships, HGM supports affiliated practices through annual coding and billing audits, coding advice and PC technology. Melendez suggests that report-card type information be presented to physicians in a very positive light and as a way to help them boost practice revenue. "Find ways to work together: it really pays off and has been highly effective in gaining physician buy-in," he suggests. Melendez and his HIM team will need physician buy-in to ramp up documentation granularity and specificity in advance of ICD-10. Just like us all! Even on this lush, beautiful tropical island, some HIM issues remain the same.

Ruth Nater is HIM director, Hospital General Menonita, Cayey, Puerto Rico.

Articles Archives

I would like to know more about ICD-10-CM. Thanks for such an interesting article.

What do you think is most important for the ICD program?

Florida Alvarado,  Clinical Documentation Improve,  St John's Regional Medical CenterSeptember 23, 2011
Oxnard, CA


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