Num­bers game

Sup­ply of skilled coders key to ICD-10 tran­si­tion

Modern Healthcare - - STAFFING - Ashok Sel­vam

It’s all about num­bers as hos­pi­tals, physi­cian prac­tices and health plans move for­ward with prepa­ra­tions to meet next year’s fed­er­ally man­dated switch from the cur­rent 36-year-old sys­tem of cod­ing for dis­eases, di­ag­noses and clin­i­cal pro­ce­dures to a new, more com­pre­hen­sive stan­dard. It’s not just the right code sets, but the right skill sets.

While hos­pi­tals and other health­care providers might dif­fer on the steps al­ready taken to­ward tran­si­tion­ing to the new ver­sion of the In­ter­na­tional Clas­si­fi­ca­tion of Dis­eases, known as ICD-10, they have un­til Oc­to­ber 2014 to achieve com­pli­ance. Readi­ness be­gins by de­ter­min­ing whether or­ga­ni­za­tions have the nec­es­sary staff. Ob­servers agree that find­ing qual­i­fied coders could be chal­leng­ing. With 16 months un­til the im­ple­men­ta­tion dead­line, few coders have the needed ICD-10 skill sets. And it’s still dif­fi­cult to de­ter­mine how many coders will be needed.

The U.S. La­bor Depart­ment projects nearly 38,000 more health in­for­ma­tion tech­ni­cian jobs will be cre­ated from 2010 to 2020, a 21% in­crease. Health in­for­ma­tion tech­ni­cians in­clude coders, as well as tran­scrip­tion­ists and clin­i­cal doc­u­men­ta­tion im­prove­ment prac­ti­tion­ers. But even with the pro­jected in­crease in jobs, of­fi­cials worry that there won’t be enough coders. In some cases, providers are al­ready out­sourc­ing work to cod­ing pro­fes­sion­als in other coun­tries.

The stakes are high. If the tran­si­tion doesn’t go smoothly, hos­pi­tals could suf­fer deep losses of rev­enue, since proper cod­ing is es­sen­tial in all clin­i­cal and billing data.

What’s driv­ing the con­ver­sion? The cur­rent sys­tem, ICD-9, is out­dated and of­ten has se­vere lim­i­ta­tions. The in­creased de­tail in the new sys­tem could lead to im­proved pa­tient out­comes be­cause the in­for­ma­tion, stored in elec­tronic health-record sys­tems, gets passed along to other clin­i­cians. The data are also use­ful for mon­i­tor­ing qual­ity mea­sures and in other sta­tis­ti­cal analy­ses.

The U.S. has used ICD-9 since 1977. The World Health Or­ga­ni­za­tion mod­i­fied the stan­dard in 1990, and U.S. of­fi­cials up­dated it once more in 1998. While ICD-9 has about 13,000 three- to five-char­ac­ter codes, ICD-10 al­lows for more de­tailed de­scrip­tions with about 69,000 codes be­tween three and seven char­ac­ters. The new stan­dard also al­lows the use of more let­ters, in­creas­ing the unique­ness of the codes and lead­ing to more pre­ci­sion.

Cod­ing pro­fes­sion­als are still study­ing the re­quire­ments of the new sys­tem, fig­ur­ing out how to han­dle new clin­i­cal sit­u­a­tions, says Nelly Leon-Chisen, di­rec­tor of cod­ing and clas­si­fi­ca­tion for the Amer­i­can Hos­pi­tal As­so­ci­a­tion. But with the launch still more than a year away, many hos­pi­tals are hold­ing off on ex­ten­sive train­ing. “Hos­pi­tals are just de­vel­op­ing their ed­u­ca­tional pro­grams,” Leon-Chisen says. “If you think about it, if you had to learn some­thing and then wait a year to ap­ply it, could you trust that you would re­mem­ber how to do it?”

While med­i­cal cod­ing might not be con­sid­ered a glamorous job, it’s vi­tal. Staffers trans­late physi­cian de­scrip­tions of pa­tient in­juries or dis­eases into codes and en­ter the in­for­ma­tion into the pa­tient’s EHR. Providers then use the cod­ing to file for payer re­im­burse­ment and to gen­er­ate pa­tient billing.

The most ex­pe­ri­enced coders are be­ing charged with train­ing newer staff mem­bers. But many vet­eran coders ap­pear un­will­ing to re­learn their jobs; in­stead they are choos­ing to re­tire, says Deb­o­rah Neville, di­rec­tor of rev­enue cy­cle, cod­ing and com­pli­ance at con­sult­ing firm El­se­vier. That leaves cod­ing in the hands of a younger work­force, and many hos­pi­tals aren’t com­fort­able with that sit­u­a­tion.

The advent of com­puter-as­sisted cod­ing also could be in­hibit­ing the sup­ply of ex­pe­ri­enced coders, Neville says. Some job-seek­ers might con­sider pay­ing for train­ing to achieve cod­ing cre­den­tials—a risky in­vest­ment if there’s an in­creas­ing like­li­hood of be­ing out­sourced to a ma­chine.

Some com­puter sys­tems al­ready as­sist coders by pro­vid­ing guid­ance, but Neville says it will be a long time be­fore au­to­ma­tion re­places hu­man coders.

Com­puter sys­tems “might aid in in­creas­ing pro­duc­tiv­ity and be­ing faster in terms of bring­ing forth the in­for­ma­tion,” Neville says. “But I think it’s got to be a com­bi­na­tion.”

U.S. health of­fi­cials pre­dict grow­ing pains once the con­ver­sion is com­plete, in­clud­ing a drop in pro­duc­tiv­ity among med­i­cal coders as they climb the learn­ing curve with the new sys­tem. Ac­cord­ing to re­search from the Cana­dian Coun­cil of Hu­man Re­sources As­so­ci­a­tions, coders at Cana­dian hos­pi­tals took three months to re­turn to pro­duc­tiv­ity lev­els seen be­fore their tran­si­tion to ICD-10, which oc­curred in July 2002. But given the dif­fer­ences in size and other as­pects of the Cana­dian and Amer­i­can health­care sys­tems, the

length of the tran­si­tion is an­other un­known.

“I wish I had a crys­tal ball. What keeps me up at night is that ex­act ques­tion,” says Lynne Thomas Gor­don, CEO of the Amer­i­can Health In­for­ma­tion Man­age­ment As­so­ci­a­tion. How long will it take for coders to be­come com­fort­able with ICD-10, she says.

There’s no short­age of can­di­dates in­ter­ested in cod­ing jobs, Gor­don says, again stress­ing the need for hos­pi­tal ex­pe­ri­ence. Many cer­ti­fied cod­ing spe­cial­ist job list­ings re­quire can­di­dates to have med­i­cal ter­mi­nol­ogy knowl­edge.

One way AHIMA is at­tempt­ing to help coders achieve the pre­req­ui­site ex­pe­ri­ence is through an up­com­ing paid ap­pren­tice­ship pro­gram, which will pro­vide job can­di­dates with a clearer ca­reer path and give them in­hos­pi­tal ex­pe­ri­ence.

This type of job shad­ow­ing will pro­duce more-qual­i­fied coders, Gor­don says. AHIMA and other or­ga­ni­za­tions of­fer cer­ti­fi­ca­tions, which make the job can­di­date more at­trac­tive to an em­ployer. Coders with cer­ti­fi­ca­tions also typ­i­cally earn higher salaries.

Stu­dents can also take spe­cialty code-set train­ing. That could help with med­i­cal ter­mi­nolo­gies, but isn’t needed. Cre­den­tials also aren’t manda­tory for ICD-10 work.

“It’s not nec­es­sary, but it’s cer­tainly some­thing that some­body would want to look for to show a cer­tain level of com­pe­tency,” says Stan­ley Nachim­son, prin­ci­pal of IT con­sul­tancy Nachim­son Ad­vi­sors, based in Reis­ter­stown, Md.

There’s a sub­stan­tial in­dus­try cost for the switch over to the new ver­sion of ICD. HHS projects that the changes, in­clud­ing the pur­chases of new IT sys­tems and staff train­ing, could cost $2.3 bil­lion to $2.7 bil­lion in­dus­try­wide over 15 years. The cost of ICD-10 coder train­ing alone could cost an or­ga­ni­za­tion from $2,405 to $46,280—de­pend­ing on its size—ac­cord­ing to Nachim­son re­search.

Some con­cerns re­main over the work­load of vet­eran coders dur­ing the tran­si­tion, be­cause many will not only be re­spon­si­ble for their ev­ery­day work, but also for train­ing les­s­ex­pe­ri­enced col­leagues. While some hos­pi­tals and health sys­tems may be well into their im­ple­men­ta­tion plans, oth­ers are just get­ting started with train­ing, Nachim­son says.

One prob­lem with train­ing too am­bi­tiously early on is the risk of staff los­ing key skills in the 16 months be­fore ICD-10 is im­ple­mented. Sys­tems such as Nor­folk, Va.-based Sen­tara Health­care and the Cleve­land Clinic are solv­ing that is­sue through dual cod­ing. The health sys­tems are us­ing both ICD-10 and ICD-9 at the same time. De­spite the time and bud­getary con­straints in hir­ing ex­tra coders, hos­pi­tals can use dual cod­ing to iden­tify ICD-10 rev­enue losses and claim de­nials. It also lets staff mem­bers prac­tice their ICD-10 skills be­fore the im­ple­men­ta­tion date and gives the sys­tems a chance and to iron out any prob­lems with less pres­sure.

Mean­while, some providers, in­clud­ing Chil­dren’s Health­care of At­lanta, have used con­tract man­age­ment firms to find coders. Dr. Jef­frey Linzer, as­so­ciate med­i­cal di­rec­tor of com­pli­ance for the hos­pi­tal’s emer­gency pe­di­atric group, says the ICD-10 tran­si­tion is a ma­jor is­sue for physi­cians be­cause most prac­tices don’t em­ploy coders. The ICD-10 tran­si­tion will cost a three-physi­cian prac­tice $83,290, ac­cord­ing to re­search from Nachim­son Ad­vi­sors. That cost cov­ers train­ing, new staff and tech­nol­ogy. The cost is $285,195 for a 10-physi­cian prac­tice and $2.7 mil­lion for a 100-physi­cian prac­tice, ac­cord­ing to the re­search.

Changes are also nec­es­sary at the na­tion’s med­i­cal schools, which Linzer says are not prop­erly train­ing physi­cians in ICD cod­ing. “They have to make sure their med­i­cal doc­u­men­ta­tion is ap­pro­pri­ate and gives a clear pic­ture of why they are see­ing their pa­tients,” Linzer says. “If we could im­prove physi­cian doc­u­men­ta­tion, it would make the coder’s life much eas­ier.”

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