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by ronick

Coder shortage goes straight to the Bottom Line

September 30, 2011 in Medical Billing/Coding


The prob­lems asso­ci­ated with nurse and phar­ma­cist short­ages are becom­ing an old and sad story. Now you can add a new chap­ter: The lack of med­ical coders has risen to crit­i­cal lev­els in some areas, and those who do noth­ing about it stand to lose mil­lions of dol­lars in unbilled charges.

Cod­ing is a key com­po­nent in the rev­enue cycle,” says Phil Incar­nati, president/CEO of McLaren Health Care Corp., Flint, Mich. “If you get bogged down in cod­ing, you stop the rev­enue. With the dif­fi­cul­ties health care sys­tems and indi­vid­ual hos­pi­tals are deal­ing with to make a mar­gin to sup­port their mis­sions, you cer­tainly don’t want to short­change your­self on the rev­enue side.”

McLaren board Chair­man Charles Weeks agrees: “Hos­pi­tals can’t afford to wait until the sit­u­a­tion becomes dire. They need to be dili­gent about keep­ing up with the sit­u­a­tion or they stand to lose a lot of cash flow.”

William Cronin, pres­i­dent of PHNS HIM Inc. (Provider Health­Net Ser­vices Health Infor­ma­tion Man­age­ment Inc.), Mon­u­ment, Colo., esti­mates the short­age to be as great as 30 per­cent nation­wide. A study by the Amer­i­can Health Infor­ma­tion Man­age­ment Asso­ci­a­tion, Chicago, finds that the short­age is most crit­i­cal in the north­east­ern and west­ern parts of the country.

The Bureau of Labor Sta­tis­tics esti­mates that U.S. hos­pi­tals will need 97,000 new med­ical record and med­ical health tech­ni­cians by the year 2010 to replace those who are leav­ing the field now.

The sit­u­a­tion is going to get worse before it gets bet­ter,” says Incar­nati, who has helped imple­ment a num­ber of mea­sures to min­i­mize the short­age among the health care system’s six hos­pi­tals. “Hos­pi­tal board mem­bers have a fidu­ciary respon­si­bil­ity to facil­i­tate the preser­va­tion of assets for a hos­pi­tal. Cod­ing is so crit­i­cal that it needs to be high on the radar screen for board mem­bers and hos­pi­tal admin­is­tra­tion. You don’t want to be in the posi­tion where you are mak­ing a lot of mis­takes in this area because the penal­ties are extreme.”

Fewer peo­ple are choos­ing cod­ing as a pro­fes­sion, in part because of the com­plex­ity and chang­ing nature of the job due to fre­quent revi­sions of gov­ern­ment reg­u­la­tions. Greater work­load result­ing from expanded prospec­tive pay­ment reg­u­la­tions are also to blame. These include out­pa­tient, skilled nurs­ing, reha­bil­i­ta­tion, home health and long-term acute care. Addi­tion­ally, because there are no degree pro­grams in cod­ing, hos­pi­tals have no direct source or pipeline from which they can recruit.

On top of that, learn­ing how to do clin­i­cal cod­ing is no easy task. The coder is respon­si­ble for review­ing all tests, diag­noses, results and med­ica­tions and giv­ing them a numeric value. This requires sub­stan­tial clin­i­cal under­stand­ing as well as med­ical record and com­puter tech­nol­ogy knowl­edge. Many coders come from the clin­i­cal field look­ing to begin a sec­ond career. Oth­ers pur­sue a degree in health infor­ma­tion man­age­ment to help pre­pare them for the job. To become cer­ti­fied, they must undergo an 18-month AHIMA pro­gram and pass an exam offered by that orga­ni­za­tion or take a cer­ti­fi­ca­tion pro­gram offered by the Amer­i­can Acad­emy of Pro­fes­sional Coders.

To really become com­pe­tent at the pro­fes­sion, on-the-job expe­ri­ence is a neces­sity, says Nelly Leon-Chisen, direc­tor of cod­ing and clas­si­fi­ca­tion with the Amer­i­can Hos­pi­tal Asso­ci­a­tion. While they are often hard to find, there are cer­tifi­cate pro­grams that spe­cial­ize in cod­ing, Leon-Chisen notes. Some asso­ciate degree pro­grams in health infor­ma­tion tech­nol­ogy teach cod­ing and there are sev­eral bachelor’s pro­grams in health infor­ma­tion man­age­ment that cover cod­ing as well. “The prob­lem is that there aren’t a lot of edu­ca­tional pro­grams that offer these degrees, and when they do, they are in larger cities,” she says.

Typ­i­cally, those enter­ing the pro­fes­sion have a med­ical records back­ground and are forced into on-the-job train­ing, accord­ing to Incarnati.

That leads to another part of the puz­zle. Because hos­pi­tals are so short-staffed with cod­ing per­son­nel, many lack the man­power to pro­vide essen­tial train­ing for new coders. Even those peo­ple with an edu­ca­tion in med­ical infor­ma­tion man­age­ment need direct over­sight and train­ing for six months to a year to get up to speed on the com­plex­i­ties of the job, Leon-Chisen says.

In the rush to fill med­ical cod­ing vacan­cies, hos­pi­tals need to be scrupu­lous about hir­ing qual­i­fied peo­ple. After all, a hospital’s rep­u­ta­tion is on the line, says Bill Robert­son, pres­i­dent and trustee of Adven­tist Health­Care Inc., Rockville, Md. “Hos­pi­tals have a lot to lose if they don’t use qual­i­fied peo­ple,” he says. “Cod­ing essen­tially cre­ates the win­dow [through] which oth­ers judge the com­plex­ity of care you’re pro­vid­ing. Out­comes are adjusted by sever­ity. If your cod­ing is not com­plete and up-to-date, it will affect how out­side com­pa­nies judge your level of care.”

Rita Sci­chilone, AHIMA’s direc­tor of cod­ing prod­ucts and ser­vices, agrees: “Coders are an inte­gral part of a health care sys­tem. Not only are they key in reim­burse­ment and pro­cess­ing claims but they are crit­i­cal in deci­sion sup­port, index­ing of dis­ease and over­all clin­i­cal man­age­ment. They are respon­si­ble for mak­ing sure the hos­pi­tal fol­lows the appro­pri­ate gov­ern­ment rules and reg­u­la­tions. Inac­cu­rate and inap­pro­pri­ate codes are what get a hos­pi­tal into com­pli­ance prob­lems with fraud and abuse.”

Con­tract cod­ing com­pa­nies pick up the slack for many hos­pi­tals, and have become a $5 bil­lion busi­ness, says Cronin.

It is not uncom­mon to see more than $1 mil­lion to $2 mil­lion worth of charts that have been untouched for weeks or months, accord­ing to Cronin. He’s even seen the num­ber rise above $20 mil­lion because of missed dead­lines. The result is a sig­nif­i­cant loss of revenues.

A tell­tale sign that your hos­pi­tal may be short of coders is an increase in accounts receiv­able or out­stand­ing days to col­lect pay­ment, Incar­nati says. Adven­tist strives for a three– to four-day turnover, Robert­son says.

For McLaren Health Care Corp., which has annual rev­enues of approx­i­mately $2 bil­lion, a day lost in accounts receiv­able trans­lates into approx­i­mately $5.5 mil­lion in lost reim­burse­ment, Incar­nati says.


Many hos­pi­tals, such as Adven­tist, are begin­ning to imple­ment inter­nal mea­sures to ease the short­age: upgraded pay scales, sign­ing bonuses, flex-time and over­time oppor­tu­ni­ties, schol­ar­ship pro­grams for cod­ing edu­ca­tion, online train­ing pro­grams, in-house train­ing for inter­nal employ­ees and increased use of free­lance coders.

Hos­pi­tals also should con­cen­trate on employee reten­tion. “Coders need to know that they are respected and rec­og­nized for the impor­tant con­tri­bu­tions they make,” Sci­chilone says. “Cur­rent coders need to be sup­ported by oppor­tu­ni­ties for con­tin­u­ing edu­ca­tion and pro­fes­sional development.”

Adds Incar­nati: “Our indus­try receives a lot of crit­i­cism that we are not proac­tive enough [with] rev­enue. There are some good lessons to learn from the pain of oth­ers. This is one issue that hos­pi­tals can’t afford to sit on.”

Writ­ten By: Susan Meyers

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