Vol. 11 •Issue 16 • Page 27
Concurrent Coding
A New Tool in HIM
By Elba L. Rivera, RN
Health information management (HIM) departments in most hospitals have the coders in a separate quiet office, away from the commotion of the file room and record completion room. That is the way it used to be here, at the Veterans Affairs Medical Center in the Bronx, NY, up until a few years ago.
In the past, ward clerks would bring patient discharge charts to the HIM department for them to be analyzed and then coded. This would occur no later than three days after the patient was discharged and the resident wrote the discharge summary. Sometimes, charts wouldn’t make it to the HIM department in a timely fashion because discharge summaries were not finished, a resident took the record to another hospital to do research or records were transferred with patients to other institutions on an emergency basis. These types of instances contributed to the delinquency rate of incomplete records, and physicians were adamant about not spending more than a few minutes to complete their records because it pulled them away from patient care.
A Move to Concurrent Coding
Then one day, as part of the hospital restructuring effort to improve documentation and record completion, it was decided to move the coders onto the wards for concurrent coding. With coders on each ward, it would be easier to review the records, assist doctors with documentation issues and query them for clarification of a patient’s condition, operation or procedure.
First, we had to train coders on how to review the records upon admission and collaborate as a team member, not only with the physicians but also with the ward clerks, nurses and other personnel on the ward. The coders also needed to get acclimated to the ward environment so they would be accepted as part of the team. It was easy at first, due in part to the personalities of the coding group at the time. In their own words, they felt “more professional” being among other professionals and able to understand the terminology. Having their own unique coding skills that no one else had on the floor gave them an edge and a feeling of professional standing among the team members.
In retrospect, there are many issues that have been addressed and some that have not. There are negatives and there are positives. At the beginning, so the staff did not feel “abandoned” in a strange territory, I spent many hours making rounds on each ward, sitting down with each coder to talk about the day’s work and any problems he or she may have been experiencing. I always told my staff that if they needed me for anything, whether it was a coding problem or anything else that was on their mind, all they had to do was call or send me an e-mail and I would always make time to talk to them and give them support.
With this policy, my work began to pile up on my desk. I would plan and evaluate, organize and re-organize, make schedules and try to keep everyone focused. My advice is if you want to try concurrent coding, you need to be consistent and you need to persevere. You also need to be there for them to some degree, depending on the experience of the staff. I found out quickly that they had many questions, and that the person they depended on for help and guidance was not on the same floor any more. Now they would have to wait because when they called my office, I would inevitably be on rounds and there were many wards throughout the hospital and the nursing home (which is a separate facility) that I had to visit, because there were coders in all areas of the hospital and nursing home.
A Positive Outcome
Within five years, we went from paper records to a computerized patient record system. Abstracting information from the records and analyzing them became a lot easier because there were no more handwritten progress notes or signatures to decipher. We also launched computerized record tracking and incomplete record tracking systems. There were no more index files or “tickler” files to be handwritten and no incomplete record room. We brought the coders and the charts up to where the physicians and the patients were, and we made it easier for all.
We have made available rooms that could be utilized for other personnel without having to build new facilities for the expanding hospital, and we have saved many dollars for patient services. We can now get a working or temporary DRG that is used for decision-making and allocate resources on a daily or weekly basis rather than a yearly basis. The number of incomplete or delinquent records is at a minimum acceptable level in keeping or exceeding the Joint Commission requirements. We also were able to train the analysts to become coders, which eliminated problems of having no coders for emergency charts or during staff shortages, vacations and extended leaves. There is no more time consuming task of locating records for completion. Deadlines for closing-out the patient treatment files was consistently met along with census data that is now done quarterly rather than yearly.
In all, there has been an increase in workload over the years as there are new mandates, policies, monitoring, validation and stringent coding guidelines imposed by the Centers for Medicare and Medicaid Services (CMS) and other regulatory bodies. It’s refreshing to say that our coders have kept pace with and have not yet failed to meet a deadline, even with severe staffing shortages.
Handling the Negatives
On the down side, I would be less than honest if I didn’t include the negativity that was present at times. Sometimes, I was very close to throwing in the towel and saying “It doesn’t work.” Converting to a concurrent coding program required hard work, with many long hours. Some of the coders complained of how difficult it was to work on the wards with so much distraction. There were complaints of a constantly ringing telephone and many other interruptions. The coders were also concerned about the patient population, as they were exposed to infectious diseases and other conditions that they never were subjected to before. Sometimes there was a clash of personalities between the coder and the ward clerk, especially when one made errors that impacted the other’s work.
With the advent of the computerized record, some coders did not see a need to be on the wards any longer and wanted to return to the HIM department. In addition, a staffing shortage, vacation times and extended sick leaves were creating a hardship on the coders, thereby resulting in low morale. There was an increase in incomplete records and coding backlog for a time. The backlog under concurrent coding grew bigger at one point due to the staffing shortage because we were unable to have all the wards covered. Also, we found that some coders did not manage their time effectively and needed more supervision when on the wards.
In summary, concurrent coding was hard work, but it’s the future at this facility and its benefits have outweighed the negatives. It’s a known fact that some people resist change, and experience shows that change is good for us. As we learn about the negatives, we can work on them to turn them into positives. We may still have a long road to travel, but we have come a long way and we are on the right track. n
Elba L. Rivera is the coding supervisor in the HIM department at a Veterans Affairs Medical Center in the Bronx, NY. She is currently a student in the health information administration (HIA) program at Stephens College.
