Be an Attractive Candidate for a Hospital Coding Position

By Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, RCC, RMC

Be ready if a hospital employment opportunity arises in a facility near you.

In our changing health care environment, there may come a time when you need to look beyond your physician practice and branch out in another direction. For example, based on the latest trend, your practice could be bought out by a hospital. If that happens, you’ll need to be able to prove you’re a viable candidate to hospital coding managers. However, many physician trained coders find hospital requirements very different and the transition difficult. You’ll have a much easier time if you are prepared, and a good place to start is by reviewing the hospital revenue cycle, which has significant differences from that of the physician office.

Review the Hospital Revenue Cycle

There will be differences between facilities in regards to the revenue cycle, depending on the size of the facility and whether they are for profit or not for profit. Typically, however, the chief financial officer looks at the hospital’s revenue producing departments and establishes certain monetary monthly goals for that department using service utilization, patient flow, and other data. The chief revenue officer typically determines a positive or negative outcome for each revenue-producing department using various reporting programs. If a department has an income deficit, this prompts a close look at why the deficit has occurred. There can be many reasons, but if the department does not produce expected revenue, particularly if the deficit occurs frequently, the department’s management must give an accounting of why and how he or she plans to improve the deficit.
The revenue cycle starts in Patient Access and moves to Benefits Verification. These are critical steps in obtaining correct demographic information, determining whether services will be covered, and calculating patient responsibility amounts. Errors in these steps usually have a ripple effect. If the patient is admitted as an inpatient or into observation, typically, case management is responsible for monitoring the stay and determining if the stay meets inpatient criteria and (if a Medicare patient) whether there is adequate inpatient days to cover the stay. If an observation patient is converted to inpatient status by the physician, this group will advise Benefits Verification that new authorization for inpatient services is necessary.

Understand Your Role in the Hospital Revenue Cycle

The next step in making yourself marketable in the hospital environment is to determine your role in the revenue cycle. The health information management (HIM) manager ensures that attending physicians complete the patient records in a timely manner and records are ready for the coders. Here is where a physician trained coder must be ready to shift gears. Regardless of what you are initially hired to do, you must realize that at some point, you will need to code inpatient records. This is where the money is for hospitals, so inpatient records take priority over outpatient encounters, even if outpatient coding is your normal assignment. To prepare for this new assignment and to stand out as a candidate for inpatient coding:

• Be proactive in showing an interest in learning inpatient coding.
• Take time to look at inpatient records coded by inpatient coders.
• Realize that inpatient and outpatient coding guidelines are somewhat different.
• Become very knowledgeable about coding conventions and guidelines in the front of your ICD-9-CM coding book. This is how hospital coders are expected to code the records. Encoders that are structured for hospital use will also assign codes based on these conventions. National Correct Coding Initiative (NCCI) edits are included in the encoder and generally flag the coder to look closely at two reported codes. Coding Clinic and CPT® Assistant are normally sources available within the encoder.
• Understand that CPT® is not reported on inpatient records. Procedures are coded using ICD-9-CM Volume 3, and there is not a direct crosswalk between CPT® and Volume 3. To assign codes from Volume 3, ask yourself: Is the procedure surgical in nature? Does it carry a surgical or anesthetic risk? Does it require specialized training to perform the service? If your answer is yes to any of these questions, a code is assigned. Using this information, take a look at some familiar CPT® codes and determine how the service might be reported using Volume 3. A reasonable rule of thumb is that if CPT® describes multiple steps, often more than one code from Volume 3 must be used to report the same service.
• Know that hospital coders report all conditions that the physician manages or affect the management of the patient. Inpatient records may require 10, 15, or even 20 diagnosis codes.
• Realize that sometimes there are different reporting protocols in CPT®, depending on whether you report for physician or facility services—infusions are a good example. Review the reporting hierarchy for facility infusions in your CPT® codebook to see how they differ from physician reporting.
• Be aware that facility evaluation and management (E/M) reporting is captured only in the emergency department and in facility clinics. History, exam, and medical decision making (MDM) are not factors in facility E/M; levels are determined based on use of resources and assigned based on a point system. Each facility typically determines their own point system; however, the service must be documented in the medical record, meet medical necessity, and be reasonable in the point assignments. Look at outpatient modifiers 73, 74, and 27, used by facilities, and know when these modifiers are applicable.

Understand How Charge Description Masters Are Used

In assessing your qualifications, hospitals may also look at your knowledge of charge description masters (CDM). Facilities establish services in the CDM that are charged to the patient’s financial record and are entered usually by the department performing the service. Hospital coders typically code for all diagnosis coding, surgical procedures, and infusions. They may code for other services, depending on if the service  is already embedded in the CDM. Your coding manager will advise of these services, but typically drugs, supplies, laboratory, radiology, and anesthesia are not coded by the hospital coder. Some clinics, such as pain management, may charge through the CDM or be coded by a coder, depending on how the hospital handles these functions.
Another important thing to remember: The physician is not available to clarify documentation; and you will not be able to use charge tickets, encounter forms, or super bills for coding assistance.

Meet Productivity and Accuracy Standards

Accuracy and meeting quota also may factor into whether you are a good candidate for hospital coding. When the coding department experiences a backlog of records for coding, the manager must take action to bring the records current. This is a good example of when an outpatient coder may be asked to code inpatient records, and why hospital coders are held to productivity and accuracy standards. You will be held to these same productivity standards.
Although there may be slight differences, depending on expectations of the coding manager, typical coding time is approximately:

• Inpatient records: 18-20 minutes. This includes all diagnosis codes, Volume 3 codes, assigning the present on admission (POA) indicator, and abstraction of the record.
• Ambulatory surgery records: 7-10 per hour
• Emergency department records: 20 per hour
• Referral encounters (example: patients coming for lab, X-ray): 30 per hour

These numbers translate to three minutes for emergency department records and two minutes for referral encounters.
If you are given a pre-employment coding test, the coding manager will not only look at accuracy, but whether there is reasonable expectation you can reach these production standards by the end of the normal 90-day probationary period. When records are not coded quickly, the entire revenue cycle is affected, in billing, insurance follow up, and other collection efforts. Accounts receivable days are closely monitored by hospitals, and are a primary measure used to determine their financial health. Slowdowns and backlogs of the revenue cycle directly affect the revenue stream. Time spent collaborating with other coders must be kept to a minimum if you intend to meet your productivity requirements.

Seek Training

When I speak with physician coders about transitioning to hospitals I am asked, “Where can I obtain this type of training?” Here are some ideas that may be helpful:

• Invite someone from your hospital to present at a chapter meeting. If a coding professional is not available, use someone from the billing or revenue cycle department.
• If there is a community college in your area that has a HIM program, invite someone from that program to speak at a chapter meeting.
• Use Quality Improvement Organizations (QIO) as a resource. They review disputes between Medicare and hospitals about correct Medicare Severity Diagnosis Related Groups (MS-DRG) assignments and necessity of inpatient admissions. They may send coding disputes to a contracted coder for supporting opinions, but they have already done an in-house review prior to that step.
• If you have a hospital-based member in your chapter, ask that person to help you get training underway.

Interested in implementing physician-to-hospital coder training in your chapter? Based on the three-day workshops I present, training might begin with an overview of hospital coding and billing on day one. On days two and three, activities might include hands-on coding of sample hospital records—reviewing accuracy and looking at how quickly coders can determine codes and POA indicators. Consider holding sessions on three consecutive days or on three separate Saturdays. Something else to consider: This is a good opportunity to collaborate with another chapter to arrange a group session.

Sell Yourself Using Knowledge and Adaptability

Through my experience when speaking with hospital managers about an ideal candidate, they often mention the need for coders to be able to code multiple types of records, meet productivity standards, and be familiar with hospital encoders. You may not have an opportunity to use encoders unless you are actually in a hospital, but you can focus on building efficiency in multiple encounters, being open minded, and knowing that you will need to meet productivity standards.
Take advantage of opportunities to learn the facility side of coding. Realize hospitals provide many more services than physician offices. If general surgery is your specialty, it’s likely you’ll need to code for many other types of services. Hospitals in smaller towns may be more lenient when using a physician coder, but you should still sell yourself in an interview by showing you are ready for the challenge. If you welcome the opportunity and are proactive in learning about the facility world, doors that are not easily opened will open for you.

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