Numbers game

It's all about numbers as hospitals, physician practices and health plans move forward with preparations to meet next year's federally mandated switch from the current 36-year-old system of coding for diseases, diagnoses and clinical procedures to a new, more comprehensive standard. It's not just the right code sets, but the right skill sets.

While hospitals and other healthcare providers might differ on the steps already taken toward transitioning to the new version of the International Classification of Diseases, known as ICD-10, they have until October 2014 to achieve compliance. Readiness begins by determining whether organizations have the necessary staff. Observers agree that finding qualified coders could be challenging. With 16 months until the implementation deadline, few coders have the needed ICD-10 skill sets. And it's still difficult to determine how many coders will be needed.

The U.S. Labor Department projects nearly 38,000 more health information technician jobs will be created from 2010 to 2020, a 21% increase. Health information technicians include coders, as well as transcriptionists and clinical documentation improvement practitioners. But even with the projected increase in jobs, officials worry that there won't be enough coders. In some cases, providers are already outsourcing work to coding professionals in other countries.

The stakes are high. If the transition doesn't go smoothly, hospitals could suffer deep losses of revenue, since proper coding is essential in all clinical and billing data.

What's driving the conversion? The current system, ICD-9, is outdated and often has severe limitations. The increased detail in the new system could lead to improved patient outcomes because the information, stored in electronic health-record systems, gets passed along to other clinicians. The data are also useful for monitoring quality measures and in other statistical analyses.

The U.S. has used ICD-9 since 1977. The World Health Organization modified the standard in 1990, and U.S. officials updated it once more in 1998. While ICD-9 has about 13,000 three- to five-character codes, ICD-10 allows for more detailed descriptions with about 69,000 codes between three and seven characters. The new standard also allows the use of more letters, increasing the uniqueness of the codes and leading to more precision.

Coding professionals are still studying the requirements of the new system, figuring out how to handle new clinical situations, says Nelly Leon-Chisen, director of coding and classification for the American Hospital Association. But with the launch still more than a year away, many hospitals are holding off on extensive training. “Hospitals are just developing their educational programs,” Leon-Chisen says. “If you think about it, if you had to learn something and then wait a year to apply it, could you trust that you would remember how to do it?”

While medical coding might not be considered a glamorous job, it's vital. Staffers translate physician descriptions of patient injuries or diseases into codes and enter the information into the patient's EHR. Providers then use the coding to file for payer reimbursement and to generate patient billing.

The most experienced coders are being charged with training newer staff members. But many veteran coders appear unwilling to relearn their jobs; instead they are choosing to retire, says Deborah Neville, director of revenue cycle, coding and compliance at consulting firm Elsevier. That leaves coding in the hands of a younger workforce, and many hospitals aren't comfortable with that situation.

The advent of computer-assisted coding also could be inhibiting the supply of experienced coders, Neville says. Some job-seekers might consider paying for training to achieve coding credentials—a risky investment if there's an increasing likelihood of being outsourced to a machine.

Some computer systems already assist coders by providing guidance, but Neville says it will be a long time before automation replaces human coders.

Computer systems “might aid in increasing productivity and being faster in terms of bringing forth the information,” Neville says. “But I think it's got to be a combination.”

U.S. health officials predict growing pains once the conversion is complete, including a drop in productivity among medical coders as they climb the learning curve with the new system. According to research from the Canadian Council of Human Resources Associations, coders at Canadian hospitals took three months to return to productivity levels seen before their transition to ICD-10, which occurred in July 2002. But given the differences in size and other aspects of the Canadian and American healthcare systems, the length of the transition is another unknown.

“I wish I had a crystal ball. What keeps me up at night is that exact question,” says Lynne Thomas Gordon, CEO of the American Health Information Management Association. How long will it take for coders to become comfortable with ICD-10, she says.

There's no shortage of candidates interested in coding jobs, Gordon says, again stressing the need for hospital experience. Many certified coding specialist job listings require candidates to have medical terminology knowledge.

One way AHIMA is attempting to help coders achieve the prerequisite experience is through an upcoming paid apprenticeship program, which will provide job candidates with a clearer career path and give them in-hospital experience.

This type of job shadowing will produce more-qualified coders, Gordon says. AHIMA and other organizations offer certifications, which make the job candidate more attractive to an employer. Coders with certifications also typically earn higher salaries.

Students can also take specialty code-set training. That could help with medical terminologies, but isn't needed. Credentials also aren't mandatory for ICD-10 work.

“It's not necessary, but it's certainly something that somebody would want to look for to show a certain level of competency,” says Stanley Nachimson, principal of IT consultancy Nachimson Advisors, based in Reisterstown, Md.

There's a substantial industry cost for the switch over to the new version of ICD. HHS projects that the changes, including the purchases of new IT systems and staff training, could cost $2.3 billion to $2.7 billion industrywide over 15 years. The cost of ICD-10 coder training alone could cost an organization from $2,405 to $46,280—depending on its size—according to Nachimson research.

Some concerns remain over the workload of veteran coders during the transition, because many will not only be responsible for their everyday work, but also for training less-experienced colleagues. While some hospitals and health systems may be well into their implementation plans, others are just getting started with training, Nachimson says.

One problem with training too ambitiously early on is the risk of staff losing key skills in the 16 months before ICD-10 is implemented. Systems such as Norfolk, Va.-based Sentara Healthcare and the Cleveland Clinic are solving that issue through dual coding. The health systems are using both ICD-10 and ICD-9 at the same time. Despite the time and budgetary constraints in hiring extra coders, hospitals can use dual coding to identify ICD-10 revenue losses and claim denials. It also lets staff members practice their ICD-10 skills before the implementation date and gives the systems a chance and to iron out any problems with less pressure.

Meanwhile, some providers, including Children's Healthcare of Atlanta, have used contract management firms to find coders. Dr. Jeffrey Linzer, associate medical director of compliance for the hospital's emergency pediatric group, says the ICD-10 transition is a major issue for physicians because most practices don't employ coders. The ICD-10 transition will cost a three-physician practice $83,290, according to research from Nachimson Advisors. That cost covers training, new staff and technology. The cost is $285,195 for a 10-physician practice and $2.7 million for a 100-physician practice, according to the research.

Changes are also necessary at the nation's medical schools, which Linzer says are not properly training physicians in ICD coding. “They have to make sure their medical documentation is appropriate and gives a clear picture of why they are seeing their patients,” Linzer says. “If we could improve physician documentation, it would make the coder's life much easier.”

Follow Ashok Selvam on Twitter: @MH_aselvam