By Clark Chaffin, MBA, RHIA, CCS
Health information management (HIM) departments across the United States, whether small or large, are experiencing a multitude of challenges and growing pains in today’s healthcare landscape. As more experienced members of the workforce are retiring, an increasing number of workforce members are training for expanded areas of HIM not focused solely on coding. And HIM professionals are also navigating constant demands of lowering current discharged not final billed (DNFB) with simultaneous scrutiny aimed at achieving and maintaining high quality coding despite incomplete documentation. This article will discuss how the HIM department at one healthcare organization—CoxHealth, a six-hospital system in the Midwest region of the US—has approached the task of managing a growing coding workforce while meeting all organization expectations for the department.
In the past five years, the coding department at CoxHealth in Springfield, MO has almost doubled its staffing due to the addition of new hospitals, increased inpatient volumes, and growth in outpatient markets. To successfully manage the demands of this changing environment, the department developed a coding project plan to address all aspects of coding, including DNFB, to manage not only employee retention but also recruitment, coding productivity, and internal/external coding audits.
Healthcare is a business and just like other successful businesses there must be a project plan in place in order to achieve goals and successes. As such, it is important for HIM departments to have goals in place as well, and the implementation of a clearly defined coding project plan has proven key to CoxHealth’s HIM department achieving success.
What Should the Coding Project Plan Address?
The coding project plan should address all areas that affect the management of coding-related activities. The coding project plan at CoxHealth addresses the following:
- Coding education (How often should it be done? What topics should be covered?)
- Coding productivity (How is it measured for inpatient and outpatient?)
- Coding quality (How often is it checked? What are steps for improvement?)
- Coding recruitment/retention (What is the best way to attract and retain coding staff?)
- Coding training programs (What is being covered in training? What professional organization will provide the best foundation to train future coders?)
The following sections of this article take a closer look at each of these elements.
The type of education approach that works best can vary widely for individual employees. Keeping this in mind, CoxHealth provides coding education in various forms, including quarterly coding audits/training meetings, online training tools, webinars, email communications like the “Monthly Coder Notes” newsletter, and a monthly department-wide newsletter.
Although there are coding productivity standards in the industry, the set coding productivity measures should be based on the systems/functionality of the electronic health record (EHR) within each health system. An assessment of coding productivity at 10 different hospitals would yield widely varied results.
CoxHealth conducted extensive measurements of what codes are captured, how the EHR is set up, and clinical documentation in order to set the standards across the system. Using available industry standards as a foundation, CoxHealth customized their standards based on coding productivity studies conducted at the organization after ICD-10-CM implementation. Consistent monitoring of coding productivity is necessary for all organizations in order to maintain adequate staffing and meet goals, such as those related to DNFB directives.
The CoxHealth standard for coding quality is greater than 95 percent accuracy, which is the common industry standard. Primary focus on coding quality should be emphasized over coding productivity. The accuracy of coding is a top priority and affects reimbursement, quality outcomes for patients, and hierarchical condition category coding on the physician’s side.
As the “Baby Boomer” generation gets older, hospital coding departments are seeing their seasoned coding professionals either retiring or nearing retirement. It is important to plan ahead now and craft succession plans for those coding professionals exiting the field. The HIM profession should be utilizing these seasoned coders to provide the training for new incoming coding professionals. They are the best source of knowledge of what it takes for a solid foundation in the complexities of coding. This is an emerging issue that must be on the radar of any coding project plan in order to avoid the necessity of using additional coding resources to aid with the potential staffing shortage.
Thinking outside the box is fundamental for the most effective recruitment techniques to attract new coding professionals to an organization. Coders working remotely want autonomy with their work schedules, less traveling to the office for meetings, and the ability to advance within the coding department. Coding professionals want the opportunity to learn everything very quickly, and keeping up with that demand means leveraging experienced/seasoned coders to become auditors or trainers to aid in successfully moving the next generation of coders into the workforce.
CoxHealth decided to undertake recruitment efforts beyond the usual tactics in order to find and recruit new coders. For example, internally, document imaging and discharge analysis assistants were sent to online and in-person training on outpatient coding to get a foundation on the basics of such concepts as coding guidelines, how to use code books, and code assignment. CoxHealth invested in this group of clerical staff in order to grow the outpatient coding program internally.
Retention of current coders is also constantly on the radar in the coding project plan. It is costly for any organization to effectively train coders in-house. Organizations must have outside-the-box coder retention tools. For example, coder retention bonuses that are separate from the employees’ annual salary is one way to reward coders. Quality bonuses are a great incentive to reward coders for their quality of coding and meeting established standards. Providing ongoing continuing education opportunities is a must in today’s coding environment to ensure coders are staying abreast of current coding trends. Lastly, look at the current workforce and see what it is that makes sense for your particular market. Not every worker is incentivized solely by monetary measures.
Coding Training Programs
CoxHealth currently has two training programs in place—an inpatient and outpatient coding training program. The inpatient training program was put in place prior to the implementation of ICD-10-CM/PCS and started in January 2015. It was set up to internally train more inpatient coders to reduce the need for long-term contract coding. There was a growing need to bring some of that coding back in-house and internally move coders from outpatient coding to inpatient coding to achieve proper coverage of inpatient coding needs.
The inpatient coding program began with two inpatient coding auditors and nine inpatient coder trainees. The program started with dividing those nine inpatient coder trainees into medical service line training so they were learning at different levels and distributing the workload out evenly amongst the nine trainees and five seasoned inpatient coders. The goal of the program is to graduate inpatient coders within a two-year period so that all medical service lines are covered. New inpatient coders start in January each year with the goal to complete the training period within two years. There was a delay with ICD-10-CM implementation, which prolonged the first group of graduates. Additionally, an inpatient coding auditor/trainer was added during this process to assist with further training.
The outpatient coding program began in spring 2017. Online/in-person training for new coders with no hands-on experience taught basic skills and then moved to teaching outpatient coding at a designated coding level, such as ancillary and/or emergency department coding, to build a strong foundation of coding a variety of different types of cases. Under the direction of the coding auditor/trainer, the coder is assigned cases to code and coding is reviewed for a period of time and then released when the coding meets 95 percent accuracy or greater. The coder progresses to monthly quality review by the assigned coding auditor.
Clark Chaffin (Clark.Chaffin@coxhealth.com) is system director, coding and health information management at CoxHealth.
Chaffin, Clark. “Effectively Managing a Growing Coding Workforce.” Journal of AHIMA 90, no. 2 (February 2019): 48-49.