ICD-10 Remix: What the Heck is a DRG and Why Should I Care About Case Mix?

I originally penned this blog post in 2011 and while the essence of DRGs hasn't changed much, the coding system has.  So here is the ICD-10 update to one of my most popular blog posts of all time.  Enjoy!

So you want to be a coder. And not just that, you want to be a hospital coder because, on average, they make more money than physician coders. And you don't just want to be a hospital coder, you want to be an inpatient hospital coder because then you get to look at the whole chart and piece together the patient's clinical picture. If this is your goal, then everything you need to know you will not learn in school. And that's mainly because there is so much to learn and practical experience is key.

Most of all, if you want to be an inpatient coder, you need to know diagnosis-related groups (DRGs) because in hospitals, it's all about DRGs and case mix - and compliance. If you have no idea what I'm talking about, fear not - here's a primer on DRGs! I wish I could say I cover it all here, but this is just a beginning!

What is a DRG?
The ICD-10-CM coding systems contains over 72,000 codes. Imagine trying to determine a payment amount for each individual condition. And that doesn't include accounting for procedures (over 78,000 ICD-10-PCS codes). The most logical solution is to create a system that allows for broader classification of conditions and services for easier comparison and assignment into payment categories. DRGs were created for this purpose. I look at DRGs as a way to "organize the junk drawer" where patients are grouped into different categories based on similar conditions and cost to treat the patient.

History
DRGs were first developed at Yale University in 1975 for the purpose of grouping together patients with similar treatments and conditions for comparative studies. On October 1, 1983, DRGs were adopted by Medicare as a basis of payment for inpatient hospital services in order to attempt to control hospital costs. Since then, the original DRG system has been changed and advanced by various companies and agencies and represents a rather generic term. These days, we have various DRG systems in use - some proprietary and some a matter of public record - all of which group patients in different ways. Two of the main DRG systems currently in use are the Medicare Severity DRG (MS-DRGs) and 3M's All Patient Refined DRGs (APR-DRGs). Different DRG systems are used by different payers.

How to Get a DRG
All DRG systems are a little different, but the basic premise is the same. DRGs are based on codes. In effect, DRGs are codes made up of codes. The following elements are taken into consideration when grouping a DRG:

• ICD-10-CM diagnosis codes
• ICD-10-PCS procedure codes
• Discharge disposition
• Patient gender
• Patient age
• Coding definitions as defined by the Uniform Hospital Discharge Data Set (UHDDS) - in other words, the sequence of codes on the claim

Back in the 80s, DRGs were grouped manually using decision trees. These days, DRGs are grouped with the touch of a button and DRG groupers are a big part of encoding software. But I would be doing you a disservice if I didn't at least give you an idea of the grouper logic. As I mentioned, there are different DRG systems and probably the most popular is the MS-DRG system, so I will explain how MS-DRG grouper logic works.

MS-DRG Grouper Logic
The first step in assigning an MS-DRG is to classify the case into one of the 25 major diagnostic categories (MDC). These MDCs are based on the principal (first) diagnosis and, with a few exceptions, are based on body systems, such as the female reproductive system. Five MDCs are not based on body systems (injuries, poison and toxic effect of drugs; burns; factors influencing health status (V codes); multiple significant trauma; and human immunodeficiency virus infection). Organ transplant cases are not assigned to MDCs, but are immediately classified based on procedure, rather than diagnosis. These are called pre-MDC DRGs.

Once a case has been assigned into an MDC (with the exception of the transplant pre-MDCs), it is determined to be either medical or surgical. Surgical cases require more resource consumption (that's industry speak for "costs more!"), so they must be separated from the medical cases. If there are no procedure codes on the case (e.g., a patient with pneumonia may have no procedure codes), then it's simple - it's a medical case. But if the patient had a procedure, that procedure may or may not be considered surgical. For example, an appendectomy is quite clearly a surgical procedure. But something like suturing a laceration is not. It's all based on resource consumption - the cost of performing the procedure. For the most part, anything requiring an operating room is surgical.

Okay, so now that we have our MDC and a designation as medical or surgical, we need to look at the other diagnoses on the claim. Right now, Medicare is able to process the first 18 diagnoses on the claim. These other diagnoses, depending on their severity, may be designated as complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Medicare maintains lists of CCs and MCCs and updates them annually. CCs and MCCs are conditions that have been identified as significantly impacting hospital costs for treating patient with those conditions. For example, it's been determined that congestive heart failure without further specification does not significantly impact costs and it is not a CC/MCC. However, patients with chronic systolic or diastolic heart failure do have slightly higher costs, so those conditions are CCs. More so, patients with acute systolic or diastolic heart failure have even higher costs, so they are designated as MCCs. Are you beginning to see how slight changes in a physician's diagnostic statement impact coding and thus payment?

DRG Weights
Now that we know the MDC, whether the case is medical or surgical, and whether or not there are any CCs or MCCs, how does that translate into reimbursement? Well, if you're using an encoder (and if you code for a hospital, you will), you hit a button and presto! You have a DRG with a relative weight. Now if only you knew what that relative weight meant. The DRG relative weight is the average amount of resources it takes to treat a patient in that DRG. Huh?

Let me demonstrate. The baseline relative weight is 1 and represents average resource consumption for all patients. Anything less than 1 uses less than average resources. Anything above 1 uses more than average resources. So let's compare some respiratory MS-DRGs:

• MS-DRG for lung transplant has a relative weight of 10.7863
• MS-DRG for simple pneumonia (no CC/MCC) has a relative weight of 0.6821
• MS-DRG for chronic obstructive pulmonary disease with an MCC has a weight of 1.144

You can see how different combinations of codes lead to different MS-DRGs with different relative weights. In order to convert that into monetary terms, we multiply the relative weight by the hospital base rate. Now I'm sure you want to know how to get that hospital base rate. Me too. Well, up to a point. The base rate is exclusive to each hospital and takes a lot of historical, facility-specific data into account, like what they've been paid in the past, whether they are an urban or rural hospital, and how much the hospital pays out in wages. That's just more math than my poor little head can comprehend! So for the purposes of this exercise, let's pretend like this hospital - we'll call it Happyville Hospital - has a base rate of $5000. So if we multiply the relative weights above by $5000, our reimbursement for those cases, respectively, is $53,932, $3,411, and $5,720.

Case Mix
You just might be asked in an interview if you understand case mix. It's a good indication of whether someone really understands DRGs. And I have to admit, in my sometimes sadistic manner, I like seeing that look of glazed-over confusion on someone's face when I bring up case mix. But case mix is simple. It's the average relative weight for a hospital. So get out a big piece of paper for your hospital and start writing down the relative weights for every single case and then divide to get your average. Okay, so it's computerized now. But that's all case mix is - an average.

In the industry, we officially refer to case mix as the type of patients a hospital treats. Let's say at Happyville, we have a high volume of transplant cases plus a trauma center and a well-renowned cardiac program. These are all highly weighted types of cases and our overall case mix will be higher than say, Anytown Hospital down the street that has no trauma center, no transplant program, and basic cardiac services (they transfer all their serious cardiac cases to Happyville!). Happyville's case mix will be higher than Anytown's.

As a coder, you don't need to know what your specific hospital's case mix is at any given time. But knowing what impacts case mix is an indication that you know your stuff. First and foremost, case mix fluctuates. Most hospitals monitor case mix on a monthly basis because changes in case mix are a precursor to changes in reimbursement. Of course your CFO wants case mix to continue to rise, but that could be a red flag. And he certainly doesn't want case mix to fall. If case mix begins to decrease, the first place hospital administration usually looks is coding - after all, case mix is based on DRGs, which are based on codes. But there are lots of things that can impact case mix and many of them have nothing to do with coding, such as:

• The addition or removal of a heavy admitting physician - especially specialty surgeons
• Opening or closing a specialty unit
• Changes in a facility's trauma level designation
• Movement of cases from the inpatient setting to outpatient, and
• Anything else that impacts the type of services the hospital provides

Your Life as an Inpatient Coder
As an inpatient coder your job is to make sure you get all the codes on the claim in the correct order so that the accurate DRG is assigned and the hospital gets paid appropriately. When I put it that way, it sounds so easy! The reality is, with more and more patients being treated as outpatients, those who are admitted as inpatients are sicker than they've ever been. And sicker means harder to code. For instance, the patient comes in with shortness of breath and the final diagnosis is acute exacerbation of COPD, staphylococcal pneumonia, and respiratory failure. How you code and sequence the case will determine the appropriate DRG and reimbursement. The good news is, you'll have an encoder to help you model the DRGs and see what pays what. The bad news is, you have to paw through the medical record to determine the true underlying cause of that shortness of breath.

So are you ready for the challenge? Are you ready to apply DRGs?

How to Get Started in a Medical Coding Career

I'm trying something new and launching a video blog.  You may have noticed that I haven't written much lately and that's mostly because I can't write anything quickly without a million edits.  And with a full time job and small child, ain't no one got time for that!  Not that the videos aren't without outtakes and redos, but they do seem to be quicker (when I put all vanity aside and ignore the bad hair days).  The frequency of videos is yet to be determined, but you can bet it will be related to how often I decide to do hair and makeup while working from home!  It only took me just over a month to get the nerve to post this first video.

This episode was inspired by countless social medial posts where people are asking how to get started as a medical coder, so that is answered here.  Where do you find a program?  AHIMA or AAPC?  CCS or CPC?  Don't enroll in a medical coding program without watching this video first!  And share this video with anyone you know who wants to be a medical coder.

In the video, I mention two websites and here are direct links to the pages that will help you locate coding schools:

• AHIMA
• AAPC 

Both websites have information about coding schools with face to face instruction as well as web-based instruction.  Best of luck to you!

Slim Year for ICD-10 Coding Updates

Just like the past couple of years, we've been waiting rather impatiently over the last couple of months for the release of the fiscal year (FY) 2019 ICD-10-CM and ICD-10-PCS code updates.  While the PCS code sets have been out for a month or two, the CM updates were released just last week, sans coding guidelines, which we are still eagerly awaiting.  FY 2019 codes will be implemented on October 1, 2018 (the federal fiscal year runs from October 1 through September 30).  In case you're wondering how the code changes stack up to previous years, what the process is for updating the code sets, or why they aren't released at the same time, this post is for you!

In comparison to past years, it's a slim year for code updates.  When the code sets were unfrozen for FY 2017 after ICD-10 implementation, we saw a whopping 2,710 CM and 4,330 PCS code changes.  Last year, for the FY 2018 release, there were 731 CM and 6,029 PCS code changes.  FY 2019 has a pretty sharp drop for both code sets with 473 CM and 616 PCS code changes. 

If you've been playing along at home and waiting for the code releases, perhaps you've been wondering why the CM and PCS updates are not released at the same time.  Even though both code sets are presented to the Coordination and Maintenance Committee for review and discussion before the Cooperating Parties and general public, each code set is maintained by a separate government agency. 

ICD-10-CM is maintained by the National Center of Health Statistics (NCHS), a component of the Centers for Disease Control and Prevention (CDC).  ICD-10-PCS is maintained by the Centers for Medicare and Medicaid Services (CMS).  Twice a year (every March and April), both agencies present proposed code changes at the Coordination and Maintenance meetings in Baltimore and then each agency works to finalize the code sets. 

Over the past couple of years, we've noticed that PCS changes happen more quickly and are released earlier than their CM counterparts.  CMS presented code proposals for FY 2019 as late as the March 2018 meeting.  On the other hand, most of the code proposals that NCHS presented for CM in March were for consideration for FY 2020.

The other trend we've been noticing since converting to ICD-10 is the last thing to be released is generally the ICD-10-CM Official Guidelines for Coding and Reporting.  We are still waiting for the FY 2019 coding guidelines to be released.  It's been common for NCHS to release the code sets first and the guidelines at a different time, whereas CMS has been pretty consistent with releasing the PCS code sets along with the ICD-10-PCS Official Guidelines for Coding and Reporting.

If you read this post hoping I would give some spoiler alerts, you'll have to wait for the webinars I'm presenting in August for Haugen Consulting Group.  I hope you'll click the links to the marketplace and register for one or both (CM and PCS) updates webinars where I will outline the changes with some background information and a healthy dose of Haugen fun.  Well, fun is relative - we're still talking about coding, but who said that has to be boring!

Here are the links to help keep you updated for FY 2019!

• 2019 ICD-10-CM Updates: Diagnosing What You Need to Know
• 2019 ICD-10-PCS Updates #FirstToKnow

Spotlight on Certification: Certified Interventional Radiology Cardiovascular Coder (CIRCC®)

Lately I've heard a lot of buzz about the AAPC's credential, Certified Interventional Radiology Cardiovascular Coder (CIRCC).  Interventional radiology (IR) coders are in demand because of the complexity of the field and the notoriously high error rates seen on audits. It may sound like a great credential to get, but before you make any sudden movements, here's what you need to know about the CIRCC exam.

Why this credential exists
I've been coding now for 22 years and I've seen quite a bit.  I helped train the workforce in ICD-10-CM and ICD-10-PCS. I've audited ICD-9, ICD-10, CPT and HCPCS codes.  I've read the Federal Register on DRGs and APCs.  But the hardest thing I've ever had to learn to code is IR and cardiology.  The coding rules are complicated, ever changing, and often inconsistent for different parts of the body.  Learning how to code IR and cardiology procedures by just looking at the CPT book is tough enough, but not all the rules are written there.  There are other societies that develop suggested guidelines and then there are the payer's rules and interpretations.  In a hospital setting, an understanding of IR and cardiology coding also usually requires an understanding of hospital charging and how departments are credited revenue.  This credential exists to show that you've mastered these areas of coding.  In my mind, this is the most difficult area of coding there is.

This is not an entry-level credential
I took the CIRCC exam four years ago with about 10 years of experience under my belt.  It was a tough exam.  As a matter of fact, it was the hardest multiple choice exam I've ever taken and I would put it up there with the Certified Coding Specialist (CCS) test as one of the toughest.  If you are thinking you will get the CIRCC and then land a job as an IR coder without any experience, think again.  This is the test you take after you've been coding those types of cases for a long time and feel confident in your abilities.  AAPC recommends, but does not require, at least two years of coding experience before taking the CIRCC exam.

What's on the test
The CIRCC exam is spotlighted for its focus on IR coding, but it also includes cardiology procedures.  The procedures we're talking about are surgical-type procedures done in a radiology suite or cardiac cath lab using radiological (fluoroscopic) guidance.  For IR, this can be vascular studies (angiograms) and interventions (e.g., angioplasty, stenting, thrombectomy) or nonvascular procedures (e.g., placement of biliary stents, nephrostomies, and fluoroscopically-guided biopsies).  For cardiology, this can be diagnostic cardiac catheterization, angioplasty and stenting, and cardiac electrophysiology studies and arrhythmia ablations.   If you don't know what any of that means, I don't recommend taking the test until you learn more!

What it costs
At the time of this writing, the cost to sit for the CIRCC exam is $400.  But the cost of taking the CIRCC doesn't end when you register and pass the exam.  Like other credentials, you need continuing education units (CEUs) to maintain the certification.  But unlike most other AAPC credentials, there are limited vendors from which you can get those CEUs.  Before you decide to take the test, look at the CEU requirements and visit the vendor websites (the AAPC has links) to see how much your CEUs will cost you and be very realistic about what you can afford.  If your primary job is coding these types of cases, check with your employer to see if they will reimburse you for any of the costs.  This is an expensive credential to maintain, but if it's valued by your employer, they may cover the costs.

Read all about it
I could regurgitate the contents of the AAPC's website about the CIRCC exam, but instead of doing that, I will direct you to their website with this simple instruction: Do your homework!  There is a plethora of information on the AAPC's website for this exam and it will tell you everything you need to know from the breakdown of the exam questions, approved manuals and materials (yes, you can bring anatomy cards showing selective vascular ordering), certification requirements, history of the exam, and FAQs.  If you were going to spend $400 on a new smartphone, you would probably read up on the different models before making a final decision.  Why wouldn't you also do this for a credential?  Don't take this exam until you've read all the fine print.

Preparing for the exam
Once you decide that you're ready to pull the plug and take the test, it's time to prepare.  Even if you've coded these cases for a long time, there is still preparation to be done.  Here is my list of recommendations:

• Get the right CPT book.  The AAPC's website is very clear that they will only allow you to use the American Medical Association's (AMA) version of CPT.  If you have a CPT book from any other publisher, you cannot use it.  I recommend the AMA's Professional Edition of CPT for its color coding and pictures.  It's more expensive than the standard edition, but I think it's worth the money.
• Mark your CPT book.  Don't waste time writing in the things you already know, but I do recommend making cross-reference notes for any codes that have a one-to-one relationship.  For example, I wrote all of the C codes for drug-eluting stent placements next to their CPT counterparts so I didn't have to open another book during the test.  Sometimes CPT includes instructional notes in the Surgical section directing you to the Radiology component code.  And sometimes it doesn't, so I wrote those in too.  Especially if you are used to using an encoder, make sure you have your book set up so you can flip to different code sections fast.
• Get the exam prep book.  Yes, it costs more money and no, I am not being paid by the AAPC to push their products!  The exam prep book will go over what's on the test.  It will give you practice questions and show you the type of questions that will be on the exam.  The one thing I remember from the exam prep book is it said in several places that none of the questions are meant to be trick questions.  That might sound like a no-brainer, but when you really get into IR coding, you'll see why that's an important thing to remember.
• Spend your study time on your weak areas.  Don't waste your time studying things you already know.  If there is an area that is not your strongest, make notes on those CPT sections and find tricks to help you remember.  When I took the test, I was strong in vascular IR and cardiology, but not so much on nonvascular IR, so those sections of my book had the most notes.  Remember: you can write notes in your CPT book, you just can't put any loose pieces of paper in them.  
• Take a prep class.  If you can find a class that will cover part or all of the exam content, enroll now.  I am teaching a vascular interventional radiology class in October 2017 in Denver, which covers some of the trickiest IR coding.  I would love to see you there and chat about your CIRCC aspirations!

If you've ever considered taking the CIRCC exam, I hope you found this post useful.  Want to learn more about IR coding?  Stay tuned - more posts to come!

What You Need to Know About Coding Using EMRs and Encoding Software

I haven't been perusing as many coding sites and Facebook pages recently as I was a couple of years ago, but I did recently come across a post that captured my attention.  Someone was asking if there was a way to get trained in a popular electronic medical record (EMR) to help them meet the requirements of a job.  It seems many employers are looking for work experience with a certain EMR before considering a person for a position.  Is this fair?  Well, it may not seem fair if you've never worked as a coder, but if you have, chances are pretty good you've had exposure to some of the major EMR software vendors.  For those of you who don't have any practical EMR experience, here's what you need to know.

Is it reasonable to require EMR experience?
First of all, if you've never coded before and your coding school didn't have a relationship with an EMR vendor allowing you to learn the system, any reasonable hiring manager is not going to expect you to have experience.  And if they aren't reasonable, then you don't want to work for them anyway (problem solved!).  If I pick up your resume and see you have taken some coding classes and have never worked in the healthcare field but are "proficient" in EMR software, I am going to have more than a few questions for you.  How did you get your EMR experience?  Which systems did you use?  What did you like or not like about it?  In other words, I won't believe you have experience with it and I will try to weed that out of you.  Or even worse, I may be inundated with resumes and feel like you're lying about something on the resume and I may not have the time or energy to do any investigating.  Your resume may be relegated to the "no" pile.

Fact: your employer will train you
Here's a fun fact.  Even if you've worked as a coder for 2 years using a certain EMR software, you will have to have training at your new facility.  You may think you know everything there is to know about a certain EMR software, but they are all customizable.  As a consultant, I've used the same EMR software at several clients and they are all a little different.  You may find documents stored in different places.  Your favorite EMR feature at Hospital A may not have been "turned on" at Hospital B.  So expect to be trained on the same software you've already been using every time you change employers.

EMRs are from Mars, encoders are from Venus
EMRs aren't the same as encoders.  Of course the EMR is where you will find the medical record documentation, but it is also where you will find financial information and abstracted data.  Encoders and computer assisted coding (CAC) software are usually separate from the EMR.  As a matter of fact, there aren't a lot of EMR vendors who are also in the business of encoder software.  That makes two different kinds of systems you need to be aware of.  But have no fear: while it's a plus if you have been trained on an encoder, you can expect your employer to train you there too.

You need to understand interfaces
Rather than obsessing over how to get trained on a particular EMR or encoder, here's something more important for you to focus on: you need to understand software interfaces.  Because your EMR and encoder are coming from two different vendors and they have to talk to each other, they rely on interfaces.  How that's set up is not important to you (although it's very important to the information technology department), but how and why you enter data the way you do is based on interfaces.  I've coded for lots of hospitals with lots of different computer systems, but in general, here's how it works:

1. You pull up the patient in the EMR.
2. If you work with a CAC product, you launch the CAC by clicking a button in the EMR.  This opens the CAC using an interface, so that it automatically pulls up the patient you are working on in the EMR and displays medical record documentation for coding.
3. If you don't have a CAC, you review the medical record documentation in the EMR and then launch the encoder using a button in the EMR.
4. Once you are in the CAC/encoder, you code the record.  This software allows you to look up codes and save them to a list.  When you're done, you click a complete button, and then you find yourself back in the EMR in the abstracting screens.
5. If the interface is working properly, everything you entered in the CAC/encoder is shown on your abstracting screens.  This is also where you can assign surgeons and dates to procedures as well as any other abstracted data your facility chooses to collect.
6. You send the account to billing in the EMR by indicating the account is complete.

(Most) EMRs don't have grouper software

Groupers are the magic software that calculate DRGs and APCs based on assigned codes.  Grouper logic is something that is built into CAC/encoder software, but not into EMR software.  If you ever need to make a change to codes to rebill an account, you can't just change the code in most EMRs.  It's pretty standard practice to reopen the account, relaunch the CAC/encoder, make corrections, send them back to the EMR through the interface, and then send for rebill.  This concept is something that many coders don't understand and, I would argue, this concept is more important than knowing the ins and outs of any particular EMR product as a new hire.

Knowing how to code is more important than anything

After all this, the most important thing you need to know to get a coding job is how to code.  Your employer can teach you everything I've mentioned above specific to your facility.  And they can also work with you on enhancing your coding skills.  But it's more important for you to focus on coding, coding guidelines, and a cursory background in coding reimbursement than it is for you to know an EMR inside-out.  

The Reality of Coding from Home with Children

These days I have more going on than audits, updates, and continuing education for CPT and ICD-10 as I eagerly await the arrival of my first child.  The beauty of the internet means I can order all kinds of things for my pregnancy and the baby from the comfort of my recliner and have them delivered directly to my doorstep.  One recent package included a packet of "stuff"  - everything from a baby bottle, to gift cards for obscure things I'm pretty sure I'll never order, to coupons, to a flyer telling me I can work from home as a medical coder while I take care of my baby.

It was the last item that really jumped out at me and gave me pause.  I wasn't really surprised by the claims about making lots of money while working from home.  It wasn't the statement about the "prestige" of working for physicians.  What caught my eye were the pictures on the flyer of women sitting in front of computers with infants on their laps.  Because while I don't know what it's like to be in charge of a baby all day (yet), I do know what it's like to be a coder working from home and the job doesn't lend itself to simultaneous babysitting.

Most days I love working from home.  It's awesome on those days when you know you have to get work done but you don't really feel like taking a shower or being in public first thing in the morning. So yeah, it's great if you are not a morning person! On those days, there's nothing better than shuffling down to my office, coffee cup in hand (okay, so it's half-decaf these days), flipping the switch on my computer, and easing into my day.  Some days I am joined by my eternal lap cat, who could sit on my lap all day if I were a statue.  On some days she wants to sit on my lap while I work, which is generally only okay if I am on a conference call where I don't need to take notes.  Which is pretty much never.

Here's the big secret the flyer doesn't advertise: coding requires an immense amount of concentration and some days I can concentrate pretty well and block out the world.  Other days, I have to shut off all email, the ringer on my phone, and the radio just so I can focus on work.  On those days, I shoo the cat off my desk/lap and try to direct her to her bed in the corner.  If necessary, I can put her in the hallway and close the door.  You can't really shove your kid aside when you need to concentrate.  And you can't code effectively and efficiently with a kid on your lap.  And if you can, then your child isn't getting the attention he/she needs.

The point: coding from home is a nice perk, but it is not a substitute for child care.  Like most other new parents, I'm discovering the joys of budgeting for child care after maternity leave.  And I get it - it's expensive.  

Just in case this post hasn't quite convinced you, maybe this will.  Many remote coding contracts include a clause on child care.  You may be required to promise in writing that you will not engage in child care when you are on the clock.  So if your reason for wanting to code from home is so you can save on child care, coding isn't the job for you.

Top 10 Cringe-Worthy Things Wannabe Coders Say

My blog is over six years old!  Seriously, I just checked.  In the last six years as I've put myself out there as the Coder Coach, I've spoken either personally, over the phone, or via email to hundreds - okay, it's really probably dozens - of coders and tried to answer their questions about what it takes to be a coder.  I've been amazed at how those answers have changed since then, from the evolution of technology, which allows most coders to work remotely to finally seeing ICD-10 come to fruition. So I figure it's about time I published my top 10 list: the most cringe-worthy things people say when they tell me they want to be a coder.

Don't get me wrong.  My intent is not to put anyone off, but over the last six years, this coding thing has really caught on and I wouldn't want to steer anyone into a career that isn't right for them.  So take a moment to read through the list and decide if you're guilty of any of these. Since David Letterman's Late Show is no longer a thing, consider this my replacement Top Ten List.

And before you get upset, please read the sign: I'm not arguing, I'm just explaining why I'm right.  In other words, I'm being a coder (occupational hazard).

Number 10:Which type of coder pays the most?

Answer:  A really good one.  Focus your efforts on landing a job and then mastering it.  If you choose your work setting solely for making money, you may find yourself miserable and (maybe) sort of well off.  If you choose to follow your passion, the possibilities - and pay check - are pretty much endless.  Employers are willing to pay good money for really good coders who don't complain about how much they hate their jobs.  I don't actually do any hiring, but if I did, I would hire the hungry novice coder with a good attitude and a willingness to learn over the experienced grouchy coder who seems to hate her job.

Number 9: Should I be a hospital or physician coder?

Have you ever seen the movie City Slickers?  The answer is in that movie when Jack Palance says the meaning to life is "one thing."  Billy Crystal asks him, with great interest, what that one thing is.  The answer: that's what you've gotta figure out.  You and only you can decide which setting is right for you and there is no right or wrong answer.  I love getting an inpatient hospital chart and trying to figure out the latest surgical procedures and how to code them.  I would rather poke my eyes out with a dull pencil than assign an E/M level to a physician's chart.  I know other coders who love E/M coding.  It's like being a cat person or a dog person.  You will probably find that you like one more than the other and there is no wrong answer (unless you are not a cat person, and then we can't be friends anymore).

Number 8: No one will hire me with the coding credential I have; they all want something else

This is probably going to sting a bit, so brace yourself.  Why did you pay to get credential without first looking at local job postings and doing some research?  If you are reading this before going to school or getting certified, then do your homework before you pay any money to any educational institution.  All kinds of people will tell you anything to get your money.  Only local employers will be honest about what credentials they want.

Number 7: Where can I get free continuing education credits?

Free CEUs are out there, you just have to look for them.  Most AAPC local chapters offer free monthly educational sessions.  There are opportunities to summarize articles and get credit.  Coding Clinic offers a quarterly webinar that is free.  Other organizations offer free CEU credits.  Do an internet search and you may be surprised what you will find.  Did you do something, like attend grand rounds at a hospital, that you thought was very educational but you don't have a certificate?  Contact the certifying body and see if they will grant you CEUs for it.

Number 6: I can't afford to join AHIMA or AAPC

This one might sting too.  Find a way to make it happen.  As far as I'm concerned, when I hear this, it tells me you don't want it bad enough.  Granted, I started very young and was still living at home when I first joined AHIMA, but make no mistake, I worked hard to get where I am today. Find a way to afford that membership and show people you are serious about a coding career.  And if you have a credential through and let your membership lapse, you likely lose the credential.  You worked hard for that credential - don't let it go.

Number 5: This is my second (or third) career; I can't afford to start at the bottom

This is a great second or third career for people who discover they missed their passion until later in life.  But here's the reality: you still likely have to start at the bottom.  I've seen people find their way into coding by some very unusual means, but the ones who make it are the tenacious ones who won't take no for an answer.  Pretty much no one starts out in their dream coding job.  You will have to pay your dues.  And please don't think that means  I can't appreciate your experience in your previous profession.  There are definitely things you can bring to the table, but remember that in coding, you are a novice.  I'm a great coder, but I'm pretty sure if I decided to change careers tomorrow and become an aerospace engineer, there would be a bit of a learning curve. 

Number 4: Will you mentor me?

It's an innocent question and I'm flattered.  Really.  But I decided a long time ago that I would mentor from afar by penning this blog.  I don't have a consistent schedule to be able to spend a lot of quality one-on-one time mentoring.  But if you email me a specific question, I will do my best to answer it.  My advice is to find someone local to mentor you.  Ask them if they can meet you once a month for lunch and come prepared.  What are the questions you want answers to?  What challenges have they had in their career that they wish someone would have told them when they were getting started?  This is a great entry into your local coding network.

Number 3: I went to school for (fill in the blank) months/years and I'm certified; I'm qualified to be a coder anywhere

No.  You're really not.  I went to school too for two years and let me just tell you that even though I learned some good fundamentals, the real coding world is nothing like I thought it would be.  I learned everything I really needed to know about being a coder on the job, not in school.  I've now been coding for more than 20 years and I hold four different certifications and I have a news flash for you: I am not qualified to code anywhere.  I lack the practical experience of a physician office coder.  I find coding radiation oncology charts waaaaaayyyy outside my comfort zone.  And please don't ask me to fill out an IRF-PAI for inpatient rehabilitation.  In other words, after 20 years, I am not all that and a bag of chips, so please don't insult the world of experienced coders by thinking you have this all figured out.  I learn something new each. and. every. day.  Keep an open mind and be willing to learn - and admit when you're in over your head.  Natural curiosity and a willingness to learn is a good thing.  Acting too big for your britches is not.

Number 2: How can I get experience if no one will hire an inexperienced coder?

I would give anything if people would stop asking me this question.  Because honestly, I don't know the answer.  I don't know what your background is.  I don't know what your aptitude for coding is - and it is a skill that many people don't possess.  I don't know where you've applied or how hard you've tried to sell yourself.  And probably most importantly, I don't have a clue what it's like to try to get a job today because the atmosphere is so different from 20 years ago.  But this is what I do know.  Don't limit yourself to coding jobs.  Find a job - any job - that will require you to have coding knowledge.  When you do an online job search, search on the code sets (ICD-10 or CPT) and not the word coder.  There are so many jobs out there that revolve around coding that aren't traditional coding jobs.  Getting your foot in the door is one step closer to getting that traditional coding job - or something even better than you ever imagined.  And don't forget to network.  If you want to work with coders, surround yourself with coders.  Who you know may be your golden ticket.

And the Number 1 Cringe-Worthy Thing Wannabe Coders Say is: I want to be a coder because I want to work from home

AACK!!!!  Not a good lead in!  And if this is the first statement out of your mouth when you go into an interview, you probably won't get hired because here's a huge industry secret: hiring managers hate hearing that's why you're there.  It's like going on a first date with someone you just met and gushing about how badly you want to get married and have 6 kids. It's just not done.  If this is the real reason you want to be a coder, please re-evaluate.  Coding is a great career if you love it.  If you don't love it, you will be miserable for 8 hours every day.  And if you are miserable at home for 8 hours a day, that can be really depressing.  Also think about the child care aspect.  I often hear people say they want to work from home because they can't afford child care.  Many coding contracts require you to have child care in place.  Coding takes intense concentration and you can't babysit a kid at the same time.  Working from home is a great perk, I will admit, but it is not the reason I have the job I have.  I refer you back to Number 10 above: follow your passion.  If you're lucky, you can make some good money while you do what you love... from home... in your bathrobe.