June 10, 2011

What Does It Take To Be a Healthcare Coder?

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With the approaching conversion from the ICD-9-CM classification system to the much more granular ICD-10-CM/PCS systems, there has been much talk about additional coder education to accommodate the level of necessary detail.

Many educational programs covering anatomy and physiology are being offered to beef up the skill set of the existing coding workforce. There has been much discussion and plenty of chatter on websites such as LinkedIn debating the need for such major training efforts. It made me think about the difference between what is being coded now by the staff now doing the coding, and what things might look like two years from now. What does it take to be a healthcare coder?

A coding professional requires clinical knowledge, but not hands-on clinical experience. The coder must be able to read the medical record and decipher what has been documented.  Through this analysis, a coder determines what diagnoses and procedures meet the requirements for coding. So along with possessing clinical knowledge, the coder must be a detective and have a curious mind.

A coding professional must apply the clinical facts they discern from review of documentation to the coding rules that apply to the medical setting. Since ICD-9-CM has been in place since 1979, an experienced coder knows all the rules and their many nuances. Although coding guidelines are updated on an annual basis, changes usually center on specific problematic areas (for instance sepsis or avian and novel H1N1 influenza virus), so even an experienced coder still must be able to stay current with the rules. A coder therefore also must be a list-maker, keeping track of updated rules and the dates the updates became effective.

Above all, coding professionals must know the medical record. They must know who documents what and where it all is documented. This is no less true in the electronic environment than in the world of paper. I personally mourned the loss of the many different colors that once were used to differentiate between different documents in the medical records back when all things were being printed directly at the nursing station – a development that made every form white. It is the coder’s role to identify and question any discrepancies in the documentation in order to clarify the diagnoses and procedures that ultimately are coded.

What, then, will be required to help these staffers attain this same level of proficiency with the new classification system? We have identified three primary areas in which the coder must be proficient: clinical knowledge, coding rules (as applied to their specific setting) and the medical record itself.

Clinical Knowledge

If a coder is working in a hospital setting, he or she probably already has had formal classes in anatomy and physiology, and coders apply this knowledge every day. No matter what type of facility, from a large teaching hospital to a small rural hospital, coders are familiar with the type of medicine that is practiced in their facilities. They build on their foundation of formal anatomy and physiology on a day-to-day basis simply by reading and coding. Unless there is a change in the services being provided, or if a new specialist joins the staff or new equipment is purchased, this level of coder most likely already has the clinical knowledge they need to move to ICD-10-CM-PCS. If any additional education is needed, it should be focused on new areas or wherever a coder has shown a weakness in the past. A program through which you can pick and choose the subject areas would work best here.

Knowledge and Application of Coding Rules

It would be simple if the same set of rules applied to all care settings, but the rules are different for facility coding of professional, inpatient and outpatient services. A coder who works in all three always must be aware of setting, because at times the rules are not just different but conflicting. Coding rules also are changing for all coders across all settings. This is the area where education should be focused most heavily. To understand this thoroughly let’s review the classification systems that are being introduced.

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is a classification of diagnoses only. There are no procedures. Because it is based on the World Health Organization’s ICD-10, the rules and conventions are similar to those we know in ICD-9-CM. Those areas that do exhibit significant differences also reflect improvements to the system made to clarify areas of longstanding confusion. For example, there are two types of exclusion notes in ICD-10-CM; one means “Do not code that here!” and one means “Not included here” (unless the patient has both conditions, in which case you may code both). In the current system, when there are conflicting exclusion notes there is always a debate. Yes, all the codes start with an alphabetic character, which is a change, and yes, you will not be able to code from memory, as all the codes are different. The basic concepts are still the same, and I think most coders will welcome the challenge posed by these new codes, including the level of specificity that now will be reflected in our code assignments.


 

ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Classification System) is a brand-new classification of procedures. As such, it has new rules, and most importantly a new language for coding procedures. Much debate has occurred regarding changing the physician documentation habits to better enable coders to assign the most appropriate codes. In this area I believe the coder must master ICD-10-PCS and fully understand the concept of the root operation. It is not the responsibility of the physician to change the language used to describe the procedure, but rather the coder who must review the clinical documentation and equate it to the ICD-10-PCS root operation. It is not just a matter of becoming accustomed to the alphanumeric codes or the definitions of the seven characters in the medical and surgical section; this is a whole new approach to procedure coding. The coder first must determine the root operation, a process that will require not only formal training but enough time prior to the ICD-10 implementation to practice and become proficient. For all facility coders who will be using ICD-10-PCS, this should be the main focus of their in-service training, and ample time must be allotted to practice.

Know the Medical Record

As previously mentioned, a coder must be completely familiar with the medical record. If you are implementing any changes to your system it would be wise to have that process completed well before the October 2013 implementation of ICD-10-CM/PCS. The last thing a coder needs is to be unsure about where they can find the information they need to identify what needs to be coded (in addition to mastering the new classification). If at all possible, the new record should be implemented long enough before October 2013 to allow users to work out all the bugs, and most importantly to become familiar with all new features and functions. This is also true if you are implementing a computer-assisted coding (CAC) system to ease the coding burden. Coders need ample time to become comfortable users with this type of new system and process changes before they have to address all of the challenges of ICD-10-CM/PCS.

About the Author

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.

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Read 65 times Updated on September 23, 2013
Rebecca DeGrosky, RHIT

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.