Recovering Encoderaholic

Most coding students spend semesters learning to navigate ICD-9-CM and CPT code books and maybe a little class time plus internship experience learning how to code using an encoder. And then they graduate and, if they move on to a position at a hospital, they start using an encoder almost exclusively. In fact, many hospitals don't purchase code books for their coders because they pump so much money into encoders. The result can be coders who forget how to use their code books all together.

In case you aren't familiar, encoders are software programs that automate the code book. This makes coding faster for the coder and also allows for inclusion of coding and billing edits and coding guidelines and advice. Not to mention, it helps us remember to put fifth digits on all those diagnosis codes! There are two types of encoders: logic-based and book-based. Logic-based encoders are probably the most popular. They ask the coder a series of questions that ultimately lead to code assignment. Book-based encoders are computerized code books in which the coder looks up codes just like in a hard copy book with a few enhancements. Both types tend to include crosswalks from ICD-9-CM to CPT and vice versa.

Sounds great, right? What could possible go wrong?

Well, a lot, actually. And I speak from experience as a recovering encoderaholic.

Don't get me wrong, I like encoders - love them, actually - and can't do my job efficiently or completely without them. But even when I have my encoder up and running, my code books are at my finger tips. And when I teach, I prefer to teach from the book. This was a hard won lesson for me. I remember a coding auditor coming to audit my coworkers and me and, in her exit interview, she made an example of me. She asked me how I came up with a CPT code and my response was "the encoder took me there" and she asked me where my CPT book was and I pointed to the enclosed bin over my desk. And she read me the riot act for not having my CPT book on my desk - and I was coding day surgeries. She then told me what I tell the coders I audit now - "the encoder took me there" is not a valid excuse.

If you're wondering why you have to spend so much time becoming familiar with using the code book, it's because it's the fundamental of coding. If your elementary learning experience was like mine, you had to learn how to do long division before using a calculator and you had to learn to tell time on a clock face before you got a digital watch. Learning to use the code book is important because you need to know the logic behind the encoding programs in order to "check your work" - to steal a phrase from math class! How will you know the encoder led you wrong if you don't know the logic?

If that's not a good enough reason for you, then chew on this. Many people are not passing coding certification exams these days and it's not because they don't know how to code. Many of them have been coding for years - with encoders. And since they have to use books on the test and they aren't efficient in looking up codes in the book, they are unable to finish the test.
You may be asking if encoders will replace the need for coders and many industry experts agree that while there is some limited application to computer-assisted coding (e.g., radiology), the skill of reading a medical record and translating it into code is a subjective skill that requires a human. So don't worry about there being no future in coding due to computerization; just worry about how you will use coding software to enhance, not replace, your coding knowledge.

There's No Future in Coding... or is There?

When I graduated from college 15 years ago, there was a big local trend in my area to train RHITs to become utilization review (UR) case managers. In case you haven't heard of UR, they are typically nurses who review medical record documentation against criteria from insurance companies to help the doctors know when it would be best to discharge patients and they help arrange post-hospitalization care if needed. There was a local company created by an RHIT who received her first post-grad job from none other than my mom (also an RHIT) and she promised me an interview when I graduated. See? Networking is important!

Once I graduated, I called in the favor and met with her HR recruiter. The only problem was, I had just finished doing a lot of coding at an internship and I had fallen in love with it. Believe it or not, at that time there were no open coding positions. I used to joke that the only way I would get hired as a coder is if someone moved out of state or retired! So I took the interview at the UR company and it sounded okay. It sounded like something I could do and they were willing to train. They were even willing to give me raise once I passed my RHIT exam.

And then I got the call from my internship supervisor. She was excited to tell me that they had just run the numbers and decided they needed another outpatient coder. She really wanted to hire me as an inpatient coder, but this is what she could offer me to get my foot in the door. It was more money than the starting position at the UR company, but less than I would make at the UR company once I passed my RHIT. But I didn't care about the money, I wanted to code. So I took the coding job and graciously declined the UR position. And I was told by the HR recruiter at the UR company that there was no future in coding - the future was UR.

I'm sure there are still some RHITs out there doing UR, but within a few years of beginning my coding career, the coding industry exploded. We had OIG investigations and new code-based payment systems and a seemingly endless list of things to keep the job new and fresh. Now I look back on that time 15 years ago when I wondered if I was making a mistake because I followed my gut rather than looking at trends. And then I look forward at the challenges we're facing in the future of coding and can say with a resounding "hooray!" - I think I made the right decision!

Is the Future EHRs?
These days I'm starting to hear it again - "Go into electronic health records (EHRs), there's no future in coding." What?! That's absurd! I'm not here to tell you there is no future in EHRs, but don't let anyone tell you there's no future in coding either. The health information management (HIM) field has historically been divided into operations, i.e., managing patient health information, and coding.

These days the most innovative thing to hit operations is the EHR. More hospitals are moving toward EHRs that will allow for better accessibility to patient health information for continuity of care. There are programs popping up everywhere to close the education gap between HIM and information systems and the term "health informatics" is the new buzz term for the early part of the 21st century.

I have a lot of colleagues who are are firmly embedded in EHR implementations. As a matter of fact, my company is an EHR implementation company. But most of us currently working in the field know that while there is an absolute future in EHRs for any HIM professional, coding is not and never will be a dead-end career. And if you can understand how coding relates to EHRs and vice versa, you can be very marketable.

RHIT vs. RHIA
When I received my RHIT, I assumed I would go into management like my mom. She was an RHIT who had been everything from a coder in her early career to director of HIM and quality for a small psych hospital. RHITs are not typically managers, though, they are usually more ingrained in technical work. The associates program for HIM that precedes the RHIT certification exam is loaded with classes on the technical aspects of managing patient information - including coding - with a few management classes thrown in. The bachelors program that prepares one to sit for the RHIA exam is less technical and more management.

What we tell folks is, if they want to manage an HIM program, become an RHIA. If you want to be a technical worker, like a coder or cancer registrar, become an RHIT. But this isn't a hard and fast rule. I recently talked to an RHIA student who really thinks she wants to be a coder, but her fellow students are telling her there is no future in coding, the future is in managing EHR implementations. She really wants to pursue coding, though.

Follow Your Bliss
I'm not really one for corny sayings like "follow your bliss" but this is your career we're talking about. No matter what your educational background - RHIT or RHIA - if you're trying to decide between coding and EHRs, don't let anyone else influence your decision. Even if you're an RHIA who wants to be a coder or an RHIT who aspires to manage some day (it can and has been done!), go after what you want.

And don't let anyone tell you there is no future in coding or EHRs. All I see for the future of HIM is opportunity in every direction I look.

Not Sure What to do? Do Something.

I know, I know. It's been a long time since I've blogged - I once again defer to my blog entitled "It's Coding Season" for my excuse! Like many I am back at work today after a long weekend - the kind of weekend that makes you forget about reality and work and you're embedded in a euphoric state of holidaydom with family and friends. But this morning it was back to the dreaded reality that I really have a lot to do. Darn it.

Like many Monday mornings, I grabbed a cup of coffee and padded into the office where stacks of virtual work awaited me. I was instantly grateful that I took the time last week before the holiday to clean off my desk and get the real stacks of paper off my credenza. But that ended once the computer was on, email was open, and my to do list was blaring at me. And so I sat here at my desk for a bit, not really knowing where to start, all the while knowing I needed to do something - no matter how seemingly small - to whittle down that to do list and make it more manageable.

By mid morning, I was starting to feel like I was accomplishing something. It reminded me of some of the students and novice coders I talk to who are so overwhelmed by prospects and job requirements that they're paralyzed by the fear of starting a new job. So if you're not sure what to do, here's my advice - do something. Eventually you will stumble onto something valuable that will help you get your foot in the door.

Does this sound familiar? The job description has a list of job requirements that you know you can do if given the chance, but you don't have experience. They call for coding experience, and you only have classroom hours. In addition to all the things you've trained for in school and basic office duties, they also want you to be a phlebotomist or rocket scientist. My point is, they probably aren't going to find a rocket scientist who can code and fix the copier, so stop focusing on what you can't bring to the table, and let them know what you can do. Are they looking for a team player? Are they looking for someone with project management skills? If your background and education (not just coding) brings additional skills to the table that they're looking for, this is the time to flaunt them. And be sure to let them know how passionate you are about learning coding too. With perseverance and hard work, by mid-morning, you might feel like you've accomplished something.

Coding From Home

Wow, I've been busy - see "It's Coding Season" for details!

Maybe this link will tide you over until I can come back up for air. This is a link to my HI Careers blog about the realities of coding from home.

"FAQ: Can I work from home as a coder?"

Catch you later,
Kristi

What Maslow's Hierarchy of Basic Needs has to do With Coding

By high school, we all had learned about Maslow’s hierarchy of needs, which states that if basic human needs are met, people are motivated to achieve more. And if those needs aren’t met, people can’t be expected to aim higher. I’m paraphrasing, of course, but lately I’ve witnessed a trend that seems to be upholding Maslow’s theory. The base of the Maslow hierarchy is the physiologic needs we all require to sustain life with safety following close behind. And when these two base needs are threatened, people don’t have the confidence they need to move into the self-actualization phase.

In case you need a refresher, here is Maslow’s hierarchy starting with the most basic needs:

· Physiological – breathing, food, water, sleep, homeostasis, excretion

· Safety – security of body, employment, resources, morality, family, health, and property

· Love/Belonging – friendship, family, intimacy

· Esteem – self-esteem, confidence, respect of others, respect by others

· Self-actualization – morality, creativity, problem solving, lack of prejudice, acceptance of facts

I think the best demonstration of Maslow’s needs is observing human reaction to environmental chaos – such as Hurricane Katrina. You witness people fighting for food and water and anything else they need in order to survive. It is, in my opinion, why we need the mobilization of external resources – people whose general well-being isn’t in jeopardy – to come to the rescue. Because when your basic needs are threatened, you aren’t really thinking about how to help other people.

Basic Needs and a Coding/HIM Career

By now, you may be wondering what this has to do with a career in coding. Well, although not as drastic as Katrina, the current economic environment has taken its toll on many. People have lost jobs and that has led to losing homes. People are seeking new professions and going back to school as they’ve seen their old jobs either dissolve or be outsourced to another country. And to come into a field, like coding or health information management (HIM), which has a need for workers only to find it hard to get a start, how are those people supposed to achieve the top level of self-actualization?

I’ve read message boards on coding and HIM career websites and talked to countless novices who are trying land their first job – some who are scared for their basic needs. I’ve talked to managers and debated the issue of hiring new grads. And although I’ve been accused of being a hopeless Pollyanna, I really do get it – times are tough and employers don’t always want to take a risk on a new student. From the novice perspective, it’s very difficult to understand how an industry with a need for trained workers isn’t more welcoming. From the employers’ perspective, everything we do in HIM and coding is surrounded by risk – whether related to submitting claims for reimbursement or releasing protected health information. Employers have been hit by the recession, even in health care, so they will cut dollars where they can in order to cut down on layoffs. One of the first things to go is education and training programs. The good news is there will be increased demands for HIM and coders over the next few years. The hard part is getting started.

That said – and here comes the hopeless Pollyanna part – you must be persistent. If this is what you really want to do, you will find a way to get the experience you need for the dream job you covet. I’ve blogged about it before, but it bears repeating: start networking. Who you know is so very important.

Ready to go Viral?

While you’re working hard and networking to get the recognition you deserve, here is something not to do. Don’t spill your feelings in an online forum. I see it all the time. People are frustrated and they want to lash out and vent, but an online forum isn’t the right place. You may be sitting alone in your home typing your feelings, but once you submit it online, it’s there for the world to read.

And the world includes potential employers.

And they read these sites.

And they don’t hire hot heads they think might be HR risks.

Plus, you never know when your post will go “viral.” Seemingly innocent communications can turn controversial quickly. This morning’s news was about a college student who wrote a thesis-style paper with graphs accounting her romantic encounters with other college students. And she named names. She only emailed it to three friends, but it didn’t take long for everyone on campus to see it and now that the story ran on national television, more people will read it. Do you want that kind of exposure?

Don’t get me wrong, though, I’m all for venting. Find someone you trust to spill your guts to or vent your frustrations in a private journal. I once knew someone who was under immense pressure and had to maintain a pleasant demeanor in public at all times. She coped by purchasing some juice glasses with happy faces on them and driving to a remote area with a cliff. She would scream and throw the glasses over the cliff and listen to them smash. I have the benefit of being a second generation HIM professional. Even though my mother is retired, she’s one of the best sounding boards for me in venting my professional frustrations because she understands the field.

Matchmaking for the Professional

I recently read a novel in which the heroine ran an executive recruitment company. She had a romanticized vision of her job. She saw it as a matchmaking business – except instead of matching two soul mates, it’s about matching the person to the right employer. Her colleagues thought she was shallow and nuts. I thought she was brilliant. If you think about it, interviewing is like dating, albeit a lot less personal. And the same traits that make a person a miserable dater make them a miserable interviewee. You want to come across as confident (not desperate), intelligent (but not cocky), and knowledgeable about who you are, what strengths you can bring to the relationship, and where you want to be in the future. At the same time, you don’t want to tell them everything about your history in the first meeting.

So do what you need to do to maintain your basic needs so you can find your employment soul mate – or at least the employment version of Mr./Miss-You’ll-Do-For-Now. That may mean taking a non-health care related job to make money and keep a roof over your head while you search for the job you want, but remember to take care of yourself so you can acquire the confidence you need for self-actualization – and remain positive!

Have a Smurfy Career

One of my favorite cartoons as a child was the Smurfs. And although I have strong opinions on my perceived unoriginality of remakes and the making of TV shows into movies, I admit, I was oddly excited when I saw a photo of Hank Azaria donning a Gargamel costume for next year’s Smurfs movie. I then read that the Smurfs have been around for more than 50 years. I’m not good at math, but I’m good enough to realize that means Smurfs were around long before I first started watching Saturday morning cartoons. So I did what I always do when faced with a potential trivia question. I googled Smurfs.

I was surprised to find out that the Belgian creator, Peyo, was faced with two job prospects after his schooling: one in dentistry and one as an illustrator. He applied for the job at the dentist first, only to find out the job had been filled 15 minutes earlier. And to think, had Peyo gotten started earlier that morning, I would have led a Smurfless life. Devastating. Peyo began illustrating for Le Journal de Spirou in 1952, but it wasn’t until the Smurfs made their costarring appearance in Peyo’s Johan and Peewit comic in 1958 that he was launched into cartoon fame. And the world has had an obsession with these lovable little blue creatures ever since.

The obvious lesson to be learned here is that the early bird doesn’t always get the worm – something I am ever so grateful for considering my solid existence as a non-morning person. Okay, so that’s not really the lesson. I also believe in the “you snooze you lose” mentality as well. I meet a lot of aspiring coders who are looking for an “in” into the industry. And those ins are not always glamorous. Or well-paid. Even with the right credentials, you may have to take a lower paying position to get your foot in the door or take a position close to the one you really want. But who knows? With the right mix of hard work, divine intervention, planetary alignment, or just plain luck, you may find yourself on a career path you never expected. And like Peyo, it could lead you to great things.

It's Coding Season!

I'm sometimes asked if there's a busy time of year for coders or if it's pretty much status quo. As a matter of fact, there is a busy time of year for coders and this is it!

Every year, we gear up for all the upcoming year's coding changes. That means letting coders know which codes have been deleted, expanded, and added and letting coders, physicians, administrators, and revenue cycle personnel know how code-based reimbursement will be affected in the coming year. This may seem rather straightforward, but since we work with more than one code set with different implementation dates, fourth quarter of each year can be pretty crazy!

ICD-9-CM Codes
The ICD-9-CM diagnosis and procedure codes are updated annually with the Center for Medicare and Medicaid Services' (CMS) fiscal year (FY), which begins October 1. These codes are used to report diagnoses for all health care settings and procedures for hospital inpatients. Right now, you will find coders acquiring their FY 2011 ICD-9-CM code books and attending seminars on the code updates. Some of this year's highlights include:

Diagnosis Codes:

• A new code for obesity hypoventilation syndrome
• Expansion of fluid overload code to differentiate between transfusion-associated fluid overload and other causes
  
• Expansion of the avian flu codes to include manifestations of the disease
• Expansion of the blood transfusion incompatibility codes to differentiate between ABO and Rh incompatibility
• Additional personal history codes
• Expansion of the body mass index (BMI) codes up to allow for classification of BMI in varying increments up to 70 and over
• A new section of V codes to report retained foreign body fragments
• A new section of V codes to report the number of placentae associated with multiple fetal gestations

ICD-9-CM diagnosis codes are within the public domain and the 2011 revisions can be found on the National Center for Health Statistics' (NCHS) website.

Procedure Codes:

• New code for placement of a central venous catheter under imaging guidance
• New codes for carotid sinus stimulation components and devices

Changes to the ICD-9-CM procedure codes are within the public domain and are available on CMS' website.

IPPS and MS-DRGs
The inpatient prospective payment system (IPPS), the system used for Medicare payments for inpatient hospitalizations, is also updated each year on October 1. This includes recalibration of the relative weights for the classification system used under IPPS - the Medicare severity diagnosis related groups (MS-DRGs). This year, the major changes to the MS-DRGs include:

• A documentation and coding adjustment of -2.9%, wherein CMS will discount payments in FY 2011 to hospitals by 2.9% in order to remain budget neutral. The attempt to remain budget neutral is to counteract the financial impact of implementing a severity-based DRG system 3 years ago.
• The addition of 12 new quality measures to be reported by hospitals under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
• A revamping of Medicare's 3-day rule, which bundles payment for outpatient services provided within 3 days of inpatient admission into the inpatient payment.

Changes to the IPPS and MS-DRGs are available in the public domain through CMS' website as well as the Federal Register.

CPT Codes
Changes to CPT codes become effective with each calendar year on January 1. These codes are used to report procedures and services for physicians and hospital outpatients. Because CPT codes are owned and maintained by the American Medical Association (AMA), they are not available in the public domain. As such, finding a list of upcoming CPT code changes is often a closely guarded secret until the CPT book is published, generally around November or December each year.

The best way to get updates on upcoming CPT codes is to attend either the AHIMA's Annual Clinical Coding Meeting (September 25 and 26, 2010 in Orlando) for the national code update or the AMA's CPT and RBRVS Symposium (November 10-12, 2010 in Chicago). After the AMA's Symposium, it's common to see articles appearing in coding journals and publications discussing the upcoming coding changes.

HCPCS Codes
HCPCS codes are developed and maintained by CMS to report services, supplies, and procedures that are not found in CPT. They are utilized by physicians and hospital outpatient reporting. HCPCS codes are potentially updated quarterly, although an update isn't always required that frequently. HCPCS codebooks may be purchased on an annual basis with the calendar year and quarterly updates are found on CMS' website. HCPCS codes are in the public domain and general information about their use can also be found on CMS' website.

OPPS and APCs
The outpatient prospective payment system (OPPS) is the payment system utilized by Medicare to pay for hospital outpatient claims. This is updated on January 1 each year, along with the CPT and HCPCS codes. The proposed rule was published in the Federal Register on August 3 and CMS accepted public comment on that proposed rule through August 31. CMS will review the comments, make final determinations, and finalize the rule by November 1.

OPPS changes include recalibration of the relative weights for ambulatory payment classifications (APCs), the categories used to group similar procedures for payment.

Some highlights of the proposed rule include:

• Two areas that have undergone frequent changes or requested changes will remain static for 2011: drug and substance administration and hospital outpatient evaluation and management visit guidelines
• Establishment of a list of services that must be performed under physician supervision
• Removal of three orthopedic codes from the inpatient-only list, making them reimbursable as outpatients under Medicare
• A new method of paying for separately payable drugs
  

Information about OPPS and APCs can be found on CMS' website.

Physician Fee Schedule and RVUs
Physician payment, as outlined in the physician fee schedule, is updated annually on January 1 by Medicare. The proposed rule was published in the Federal Register on July 13 and the comment period ended on August 24. The physician fee schedule outlines the relative value units (RVUs) for each CPT code based on the amount of work the physician performs. Information on the Medicare physician fee schedule and RVUs is within the public domain and can be found on Medicare's website.

Too Much Information?
It sounds like an awful lot of information, but remember this - not every coding professional needs to learn the ins and outs of every coding and payment system. Because I work with hospital clients, I will be focusing on everything but the physician fee schedule. And those who work in physician offices will focus on ICD-9-CM diagnosis code changes, CPT/HCPCS code changes, and the physician fee schedule only. Even so, it's enough of an impact to call fourth quarter "coding season!"