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What Does ICD-10 Really Mean to New Coders?

If you haven't heard yet, the coding system is changing on October 1, 2013 from ICD-9-CM to ICD-10-CM and ICD-10-PCS. I have told a lot of new coders and coding students that this gives them a more level playing field when it comes to getting hired on as a coder. But 2013 is still 3 years away. If you are graduating soon and will be looking for a coding position, what does ICD-10 really mean to you? Should you start training on ICD-10 now so that you are well-positioned for the coding switch?

Why ICD-10 is a Good Thing for Wanna-be Coders
I always start with the prerequisite disclaimer when I talk about coders: I am a coder, so I can poke a little fun at our idiosyncrasies. Many coders don't like change. And that's part of what makes them so successful as coders - the ability to work in a routine environment coding patient record after patient record. So to coders who really dislike change, ICD-10 is like an atomic bomb. I've heard some say they will retire or find a new line of work when ICD-10 is implemented. Add those open positions to the decreased productivity that is inevitable with the implementation of a new coding system, health care reform, and the current national coder shortage, and what we have is an awesome opportunity for new coders to enter the field.

Coders who learn ICD-10 in school will likely be called upon by their new employers to share their knowledge of the new coding system with more established coders. Getting into ICD-10 on the ground level means more opportunities for new coders in the future.

Why ICD-10 Coding Jobs Won't be Super Easy to Land
While the need for more coders trained in ICD-10 will be there in 2013 and the codes themselves will be different, the one thing that makes a coder truly special will not change: navigating the medical record, deciphering medical terminology, and applying coding guidelines. These are skills that are not easily taught in school - this is the "experience" that employers are looking for when they say they want two to three years of coding experience. And while new coders right out of school will have oodles of exposure to the ICD-10 code sets, experienced coders will have that other type of experience - the type that goes beyond looking up a code in a book. That skill will still be coveted by employers.

I talk to a lot of people who are pondering changing careers and getting into coding because of what they've heard about ICD-10 and the future need for more coders. But just because we're nearing this massive change doesn't mean that it will be any easier to get hired as a coder in 2013 than it is now. There are many considerations you need to make in determining when ICD-10 training is appropriate for you.

What Kind Of Coder Do You Want to Be?
I have been trained in ICD-10-CM and ICD-10-PCS. The only reason I am trained is because I intend to do a lot of ICD-10 training myself and those who are getting educated now are the educators. I recently had someone tell me she planned to wait a couple years to get trained in ICD-10 because she heard it was so different from ICD-9-CM and she didn't want to have to learn a dying coding system. So let's start with the first question you need to ask yourself: What kind of coder do you want to be?

This is important because ICD-10 is divided into two code sets: ICD-10-CM for diagnoses, which will be used by all health care settings, and ICD-10-PCS, which will be used only by hospitals for reporting procedures. CPT will not be impacted by ICD-10 implementation and the format of ICD-10-CM is very similar to ICD-9-CM (granted all the code numbers are different!). I see the transition from ICD-9-CM diagnoses to ICD-10-CM being relatively easy (notice I said relatively - it will still be a bear!).

ICD-10-PCS is a whole different story. The procedure portion of ICD-10 is set up like no codebook we've ever seen. There is no tabular listing - only a series of tables that allow the coder to "build a code." Furthermore, the level of detail and the coder knowledge required to code an ICD-10-PCS code as opposed to an ICD-9-CM procedure code is astronomical. For example, there is one ICD-9-CM procedure code for repair of an artery. In ICD-10-PCS, the coder will need to know which specific artery was repaired and how that repair was approached.

So when people say ICD-10 is very different from ICD-9-CM, I have to ask, which code set? While the code numbers and code format will be drastically different, the way we code will be the same for ICD-10-CM as it is now for ICD-9-CM diagnosis coding. But ICD-10-PCS is like... well, CPT on steroids. The level of detail in ICD-10-PCS coding is much more specific than what's required even by CPT standards.

Why the long explanation? Well, if you plan to code for a physician office, you won't need to learn ICD-10-PCS. So I say, go ahead and learn ICD-9-CM now because the main change for you will be the code numbers themselves (and a couple of coding guidelines). If you plan to code for a hospital, you need to be prepared for a whole new game with procedure coding when ICD-10 is implemented. The good news is, ICD-9-CM procedure coding really isn't very difficult, so I don't see anyone "wasting" time by learning it now until 2013.

Do You Want to be More Than a Coder?
Let's get one thing perfectly clear here and now. The implementation date for ICD-10 (both CM and PCS) is October 1, 2013. There will be no push on that date. Everyone will be expected to be up and running on October 1, 2013. Rumor has it that this date will get pushed back, but everything I have heard from government representatives says that there will be no push on that date. So spread the word!

Let me get something else perfectly clear: ICD-9-CM will not "die" out. There will be a need for people to know ICD-9-CM diagnosis and procedure coding after October 1, 2013. Particularly if you work in a hospital, data analysis is often performed based on codes and we often compare case loads from year to year to see which services are growing, which are waning, and which are needed in the community that aren't currently offered. In the calendar year 2013, we will have data from both ICD-9-CM and ICD-10. That means a need to be able to crosswalk between codes for data analysis. And someone within the hospital needs to understand both systems. That might be you.

Take the Next 3 Years to Get Experienced
The biggest complaint I hear from wanna-be coders is that all employers are requiring 2-3 years of experience. So if my math is correct, if you wait 3 years to learn ICD-10 and it takes another 2-3 years to get experience, you won't really be working as a coder for another 5-6 years. Why wait? While it doesn't make too much sense to get trained specifically on ICD-10 right now because you won't remember it in 3 years, it does make sense to get hired on as a coder and start positioning yourself to take on a coding position in 2013. This might mean taking an entry-level position where you are exposed to the medical record, codes, or billing. Don't wait till 2013 because there will be a mad dash and employers who have open positions in 2013 probably won't have time to train someone who is complete green. As a matter of fact, I have been encouraging facilities to make education a part of their organizational culture now to lessen the impact of ICD-10 implementation.

Now is the time to hone your skills in coder detective work - where you find information in the medical record, how the patient's symptoms come together in the disease process, anatomy and physiology, medical terminology, and pharmacology. And the good news is, learning this now means you can also apply it to ICD-9-CM now and it will make it easier to make the switch to ICD-10.

Talk to Your School
If you're enrolled in a coding or HIM program or plan to enroll in one, do your homework. Ask the program director or coding instructor what the school's plan is for the ICD-10 transition. They should be referencing timelines like the one posted on AHIMA's website. If they don't have a plan now, you should be concerned.

Don't Hurry Up and Wait
I suppose the best way to sum up this posting is to say this: think of your coding education as a journey rather than focusing on the destination. Go ahead and get trained in ICD-9-CM now - it will not be a waste of time or money. Yes, you will need to train in ICD-10, but if you're credentialed, you will have every opportunity to train through AHIMA and the AAPC. And if you're employed, your employer will be be focused on training as well. Plus, I really do believe that those coders who know both ICD-9-CM and ICD-10 and can analyze and compare data across both code sets will be hot commodities.

Why Wait?

Are you currently a coding student? Are you nearing graduation? Are you waiting until you graduate to look for a job? If you answered yes to any of the above, I ask you, why wait? Start applying for coding jobs now.

We all know it can be hard to get that first coding job or even to land in an entry-level position. So if you can make it work, I recommend applying for any job now that will boost your chances of moving into a coding position. That might mean working as a file clerk or scanner (someone who scans in medical record documentation into the hospital's imaging system). Anything that will get you closer than you are today to being a coder.

If you start now you will also find that you won't be competing with your fellow graduates for the same jobs come graduation day. And for all you kinesthetic (learn-by-doing) learners out there, you may find it will help you piece together the puzzle we call health care revenue. In other words, you'll get experience!

So take this time to get a leg up on your coding career and get started! Good luck!

The Shortcut to Being a Coding Professional

About 10 years ago when I was working as a coding supervisor in a hospital, I received a phone call from a woman who was asking me how she could get trained to become a DRG auditor. At that time, there weren't a lot of coding schools and the internet was just catching on, so I referred her to the local community college and their health information technology associates degree program. She went on to tell me that she had a masters degree in an unrelated field and she didn't feel an associates degree was necessary. She also didn't want to be a coder, just a DRG auditor. She had an acquaintance who became a DRG auditor without a degree in HIM, so she figured she could too. She heard there was good money in DRG auditing and she wanted to make good money. All I needed to do was tell her where to get the information.

Okay, a quick side note: DRGs are the result of the codes assigned on a single inpatient claim - adding, removing, or changing a code can potentially change the DRG. For example, I recently reviewed a record for a coder and changed just the fourth digit on one code and it changed the DRG. So wanting to know how to audit DRGs without being a coder is like wanting to perform surgery without knowing how to use a scalpel.

Anyway, at that moment, two things ran through my brain. 1) This woman wants the job I consider to be my next step in the career ladder and 2) She just insulted me by seriously underestimating what it takes to be a successful coder, let alone a successful coding auditor.

The Shortcut to Being a Coding Professional
Each week I jot down blog ideas and often the short snippets scrawled on my note pad show a common theme. This week, the theme is summed up by a quote from Randy Pausch in the Last Lecture (I'm almost finished reading!): "A lot of people want a shortcut. I find the best shortcut is the long way, which is basically two words: word hard." And last night as I watched the last night of performances on So You Think You Can Dance, I was further moved by a simple statement by judge Nigel Lythgoe: "People believe they can be a star without working hard."

Now I am not trying to discount this woman's abilities in her chosen field of study. And although I have 15 years of experience in coding, if tomorrow I decided to be a computer programmer, I wouldn't expect someone to hire me because I have 15 years of experience in an unrelated field. I would have to study and become and apprentice all over again. It's a long journey, but the shortcut really is the long way: work hard. Would there be skills I could bring from my background? Absolutely and I would advertise those skills. But if you take one thing away from this blog posting, let it be this. You could unintentionally insult your potential employer by discounting what it takes to get to their level. And insulted people don't hire the people who insult them.

Spending Time in the Trenches
I've been a consultant for over 9 years and the best compliment I receive from a client is when they tell me that they can tell I've worked in the hospital environment and understand the process and issues. It seems simple, but in health care, we do everything differently - especially the business side of health care. Hospitals and physicians have been in business for centuries treating patients. But it's only been the last few decades that it's become necessary to combine the human health care aspect with the concept of running a facility like a business. And that's due to the increase in health care costs and the attempts to try to control those costs. The result is an industry built around human care and retrofitted for finance. How many businesses do you know that operate that way?

When I took a health care finance class a few years ago I already had several years of coding experience and was well versed in how a hospital's revenue cycle works. So as our professor talked about the process, I decided to observe the other students in the class that came from other industries - in particular, an attorney. And as the professor talked about the charge master and codes coming from different departments and payer mixes, the attorney thought it was crazy and unreasonable. It was a completely foreign concept to her. And it will be a completely foreign concept to you too until you get your foot in the door and start observing.

The woman who called me about how to be a DRG auditor eventually got frustrated with me and hung up. I wasn't the first person to give her the community college answer.

Within a few years I was a DRG auditor and I have to say it was one of the hardest experiences I've ever had. We traveled in teams of auditors (safety in numbers!) with our laptops and portable printers. Each time we finished a record that had a coding or DRG change, we printed out an audit sheet and sent the record and audit sheet back to the original coder. At the end of the week, we sat down with the coders and they had the opportunity to refute our findings. It took a few exit interviews and a lot of tough skin to build my abilities as a coding auditor. The terrific thing about coders is that they will dig to find an answer until they can prove they're right. Some of the coders I audited were right. And sometimes (I like to think more often than not!) I was right. My point is, I worked hard and I have a lot of confidence now in my ability to both conduct and defend a DRG audit.

That Annoying Overqualified Coder
I'll never forget my first encounter with a coding auditor. She was very qualified. As a matter of fact, all of my coworkers thought she was overqualified. She was brought in to do an audit of our work and then do some education. We all sat around a table at our first meeting and introduced ourselves. She started. She listed off her years of experience, degrees and credentials, and a long list of states she'd visited and audited. It took her about 5 minutes. And then she turned to her left and looked at me and asked me to introduce myself. My introduction went something like this, "Uh, hi. My name is Kristi and I just graduated and will sit for my ART [now RHIT] exam in October... That's it."

I was humiliated that I didn't have the credentials this woman had. I sounded ridiculous after her 5 minute speech about her experience. Afterward, my coworkers said they found the whole thing hilarious. They were not happy about being audited and most of them thought the consultant was overbearing and way to focused on credentials. They thought my response was perfect. And they all reassured me that no one could possibly expect me to have any experience - I had just graduated!

Now I think back to that consultant. Was she overbearing? Maybe. Did she have experience? You bet. Was she good at what she did? Absolutely. She taught me 2 things: 1) even if you have an encoder, you should always have a CPT code book on your desk because, "The encoder took me there" is not a valid response to why you coded something the way you did, and 2) how to code bunionectomies. That first introduction sticks with me too because now I'm the consultant who to some may seem overqualified. But I will tell you this. It feels so good when someone asks me a question and my answer includes the phrase, "When I was... [a coder, a coding manager, etc]." And I know it gives me credence with the people I'm talking to.

The Brick Walls are There for a Reason
The Randy Pausch quotes will be with me for awhile because so often as I've read this book, I find myself pumping a fist in the air and saying, "Yeah!" I spend a lot of time on thinking and self reflection and much of what Pausch wrote is in line with my thinking. Anyway, another favorite quote is this:

"The brick walls are there for a reason. They're not there to keep us out. The brick walls are there to give us a chance to show how badly we want something."

Yes, it's a quote worth bolding. I have no doubts that if you really want to be a coder and have the skill and talent for it, you will be a coder. The question is, how hard are you willing to work to scale that brick wall? We all started somewhere. People have asked me how I got so far in such a short time frame (15 years). I think I like the answer that Randy Pausch gave whenever someone asked him how he got his tenure so early: "It's pretty simple. Call me any Friday night in my office at ten o'clock and I'll tell you."

Top Ten Reasons to be a Coding Professional

I would love to take credit for making up this list of reasons to be a coder, but I can't. It's a list that came out about 15 years ago and I believe it was published in The Journal of AHIMA. This list was popular when I first started coding in the mid-90s. I have yet to see an electronic copy of it, but found a photocopied list in a scrapbook (er, chart) my coworkers gave me when I left my first coding job. This list graced my bulletin board for a long time!

Some of these are a bit dated, but most still ring pretty true and I updated Ms. Scichilone's credentials as she is still a well-respected practicing HIM professional. I hope you enjoy this little bit of levity!

Top Ten Reasons to be a Coding Professional
by Rita Scichilone, MHSA, RHIA, CCS, CCS-P, CHC

10. You love to read really small print.

9. Carrying around code books is better weight training than those cute little dumbbells you buy at the fitness store.

8. Classification systems and nomenclatures make great party conversation. "I'll bet you don't know what SNODO* is!"

7. If a patient can do it, get it, or hurt it, you can code it.

6. You love explaining what you do each day - "Oh, I typically transform sixty-five or so pages of complicated clinical information written in a foreign language (medical terminology) into numeric codes that will fit on a one-page form."

5. When you get carpal tunnel syndrome from turning those pages and burning up a computer keyboard, you'll know how to code it for your insurance company.

4. You can impress your friends by saying you'll meet them after work for some 94.38 at your favorite hangout."**

3. You are passionate about acronyms (DRG, APG, HCPCS, HCFA, HEDIS, CPT, UHDDS, ICD-9-CM, CHMIS, WEDI, UB-92)***

2. When you hear "The AR days dropped again today," you get goosebumps.

1. The eternal mysteries of ICD-9-CM and HCPCS CPT-4 are transformed at your touch into essential mastery of critical clinical data indexing that can change the health of America!


*Standard Nomenclature of Disease and Operations (SNODO) was a coding system that predated ICD-9-CM

**94.38, Supportive verbal psychotherapy

*** Ambulatory patient groups (APGs) were proposed prior to the use of ambulatory payment classifications (APCs); the Health Care Financing Administration (HCFA) was renamed the Centers for Medicare and Medicaid Services (CMS) in 2000, the uniform bill 1992 has been updated and replaced with the uniform bill 2004 (UB-04)

What Are You Going to do About It?

I will be the first one to admit when I’m bad at something (like math), but as far as joke-telling goes, I think I’m actually quite good. It’s the remembering part that’s tricky. But I do have a few favorite jokes in my arsenal – a blonde joke or two (it’s okay, I’m blonde!), a couple of jokes that are only truly appreciated by kids under the age of 8, and one joke that teaches a lesson. I am going to share the latter with you now.

A damn broke uphill from a town and the entire town had to be evacuated before the eventual flooding and devastation that was going to occur. One man began to pray and asked that God protect him from the flood. The police came to his door and told him to evacuate and he said, “No thank you. I believe and have faith that the Lord will provide.” The police left. Soon the flood waters were starting to make their way into the town and the man was forced to move to the second story of his home. He prayed again and asked God to protect him. A motor boat with rescuers came by offering to take the man to safety but again he said, “No thank you. I believe and have faith that the Lord will provide.” The rescuers sighed and shook their heads and moved on. Soon after that, the flood waters were so high the man had to take refuge on his roof. He maintained his prayer for safety. In one final attempt to clear the town, rescuers came by in a helicopter but the man refused to get on board. He said, “No thank you. I believe and have faith that the Lord will provide.” Soon there was no place left to climb and the unfortunate man drowned. When he got to heaven and spoke to God he said, “Lord, I believed in you and had faith that you would save me. Why did you let me drown?” And God said to him, “I provided you with the police, a motor boat, and a helicopter. What else was I supposed to do?!”

I’ve heard the joke many times – sometimes as part of a sermon, sometimes as an anecdote to get people to realize they have more control over their lives than they think. I receive many phone calls and emails from students and novice coders who are frustrated with the hiring process. And since I’ve committed to mentoring, I try to find time to respond to each of those emails. I am always happy to give a little pep talk or give a little advice that may guide them in the right direction. But occasionally, I get an email that is a series of complaints and blame games and all I can think is: what are you going to do about it?

Don’t get me wrong. No one loves a good venting session more than me. I even have friends that I can email and rant to and they won’t take it personally. I can type a 2 page email and usually get the response, “Feel better now?” and usually I do. I am all for venting frustration. But at some point, you have to make a decision to do something about the problem or change course. Otherwise you’ll go crazy. Think of Einstein’s famous quote about the definition of insanity: “doing the same thing over and over again and expecting different results.” So if you’re stuck in venting mode or you haven’t tried a different attempt at getting what you want, it’s time to break the monotony and move on.

I recently started reading The Last Lecture by Randy Pausch with Jeffrey Zaslow. I don’t get a lot of time to read and I am by no means a speed reader, so it will probably take me at least a week to get through this “quick read.” The story, if you are unfamiliar, chronicles the last lecture given by Randy Pausch, a professor at Carnegie Mellon University before he succumbed to pancreatic cancer. He was 47-years-old and left a wife and three young children behind. His lecture entitled “Really Achieving Your Childhood Dreams” was really directed at his children (the lecture was recorded) and is so inspiring, it yielded a spotlight on a national TV news program, the book, and countless videos on YouTube.

In the book, Pausch dedicates an entire chapter to his parents and their parenting skills. One of the things his parents did for him was to encourage him to find answers to the unknown. This is something I felt I had in common with him – my parents were always telling me to “look it up” if I didn’t know an answer. In fact, my mother always told me, “Knowledge isn’t what you know; it’s whether or not you know where to find the answer.” And as much as I hated the look-it-up-response (I actually thought they were lazy), I appreciate it now because now I don’t rely on someone else to figure everything out for me.

I am at a point in my life where I am probably the happiest I’ve ever been. And I’ve noticed that as a happy person, the last people I want to be around are unhappy people. Unfortunately, I have a few in my life – friends, acquaintances – who every time I talk to them dump every last problem on me and then wait for me to speak. Sometimes I mess up and give them advice. What I’ve found to be more effective is to ask them what they plan to do about it. If all they want to do is complain about their situation and aren’t willing to do anything about it, there’s really not much else I can do other than listen and wait it out until they’re done. But every once in awhile, I see something flicker in their eyes and I can tell they haven’t really thought what they would do about it. And I sometimes suspect they’re waiting for someone to tell them what to do. My hope is that my question is a virtual slap-in-the-face to get them past the complaining stage and onto the fixing stage.

Are you one of these people? Are you waiting for the magic opportunity that will get you into the coding profession? Have you really tried everything to get into the industry? I defer again to Randy Pausch, who created a list of childhood dreams. On that list was “being in zero gravity.” His students won a contest that enabled them to experience NASA’s plane “The Weightless Wonder,” which helps astronauts get used to a zero gravity environment. Unfortunately for Pausch, no faculty was allowed. So he found a loophole and withdrew his application as faculty and resubmitted it as press (for which he had to do some additional work to get the story into the media). It worked and Pausch was able to cross one thing off his childhood to do list. So I ask you again, if you’ve tried to get a job and have failed, what are you going to do about it?

Happy Summer!

You may have noticed a blatant absence of new blog posts. I've been busy with a new client and taking advantage of summer, which, I'm sad to say, is almost over (boo!). That's meant a break from my Coder Coach events and, yes, my blogging too.

But fear not! I will be posting some small blog posts to tide you over until September and I just submitted a couple of blog posts to AHIMA's HI Careers website, so you won't miss out. Be sure to check out my latest HI Careers post entitled "Experience for the Inexperienced" at www.HICareers.com and be sure to also check out the other blogs and offerings the website has to offer.