Solving the ICD-10 Staffing Conundrum

Martin Luther King Jr. once said, “We must build up the dikes of courage to hold back the flood of fear.” In healthcare IT, ICD-10 is the rapidly-approaching flood of fear. And as the Oct. 1, 2014 deadline for implementation grows closer, healthcare provider organizations seek out “dikes of courage” in the form of consultants, educational partners and outsourced coding firms.

Fifty-three percent of HIM professionals plan to use outside firms for ICD-10 education,1 according to AHIMA’s comprehensive survey of ICD-10 readiness. Thirty-six percent of those anticipating increased coding needs will hire outsourced coding companies to fill the gaps. And 25 percent of health IT executives lined up specialty consultants for ICD-10, according to Stoltenberg Consulting.2 Industry studies are clear; extra hands will be needed for ICD-10, and outsourcing partnerships build solid dikes to thwart the ICD-10 flood.

For HIM professionals, this article recognizes two time-sensitive criteria related to ICD-10 outsourcing – staff turnover and ICD-10 onboarding. It also explores three strategies to counter ICD-10 staffing demands through outsourcing with tips for effective, long-term partnerships. Finally, every effort must be made to maximize new FTEs and consultants, with the goal of garnering long-term value for every dollar spent. A centralized ICD-10 staffing approach helps accomplish this goal while also maintaining positive indicators for financial reporting and organizational balance sheets.

Watching the Clock: Time for Turnover and Onboarding
HIM Directors planning to internally hire for ICD-10 have two time-sensitive criteria to consider – coder turnover and coder onboarding. Hospitals already struggling with staffing issues will experience additional coder churn and extended recruitment times. And once hired, time must be dedicated to carefully on-board new coders prior to the ICD-10 deadline.

The first step is to identify existing staff turnover rates and average time-to-recruit. Armed with this knowledge, HIM directors can prepare more accurate timelines and staffing plans for ICD-10. As ICD-10 approaches, staff turnover increases. Trained and skilled ICD-10 coders are already in high demand.

Furthermore, aggressive coding vendors are adept at dangling coder carrots and enticing hospital staff to join their ranks. More perks, higher salaries and the opportunity to travel are common incentives. However, coders should be informed of the downside. Outsourced coders often experience greater career volatility as they often work as independent contractors and can be let go at any time.

If your organization already struggles with 25 percent staff turnover every two years, now is the time to bolster retention programs and protect existing staff. Four tactics are listed in the Table below.

The time required for new coder onboarding is valuable and must be factored into the overall ICD-10 timeline. While every hospital varies, the onboarding of a new coder could take anywhere from 30 days to three months.
The following steps are part of effective coder onboarding for ICD-10:
• Learn the organization’s IT systems and how to effectively code within them.
• Read charts and get acclimated to the organization’s clinical documentation.
• Rely on train-the-trainer approaches, if available, to increase resource efficiency.
• Budget time for process and workflow changes among and between coders to support the new hire.
• Bolster quality assurance checks through mirroring, auditing and coder feedback.
• Give existing staff time to help train, support and answer questions.
• Align productivity goals with IT system realities. (Coders can only code as fast as the technology supports).

Despite everyone’s best efforts, directly hiring all of the staff needed for ICD-10 may not be feasible. In these cases, outsourcing is a requirement. The following three strategies are considered best practice.

Three Tips for Effective Outsourcing Partnerships
There are three methods to effectively secure outsourcing partnerships in advance of ICD-10 implementation: contract early, secure multiple firms and leverage resources.

Contract Early
Of all the CMS headaches facing healthcare providers, ICD-10 ranks third-just behind Medicare and the overall effects of healthcare reform.3 Contracting early for extra ICD-10 support relieves organizational pressure while securing premier resources far in advance of the 2014 deluge. Long-term contracts should be executed to ensure coverage throughout the ICD-10 transition phase and up to one year beyond.

Questions to ask outsourced coding vendors include:

  • What are the credentials of your current team?
  • How do you evaluate the skills of your coder candidates prior to and during employment?
  • How will you ensure adequate coding coverage through the entire ICD-10 transition and up to 12 months beyond?
  • What are your remedies for failing to produce trained coders?
  • What is your turnaround time?
  • Will you code directly in our information systems, or will you require an interface to export our accounts to your coding platform?
  • Do you require a minimum account volume commitment?
  • Describe your QA program. What are your quality commitments?
  • How is quality measured? By chart or by codes?
  • What training curriculum / methodology is being used for ICD-10?
  • What is your standard escalation procedure?

Secure Multiple Firms
The exact coding volume increase resulting from ICD-10 remains only an estimate. Reliance on a single coding firm increases organizational risk. If at all possible, avoid putting all efforts or money into one outsourced coding vendor or plan of action.

With so much ahead of them, HIM professionals need the collective intelligence and resources of multiple outsourcing partners. Best practice is to contract with multiple outsourced firms for ICD-10 support.

Leverage Resources
Outsourced coding firms typically provide several services and a variety of skilled resources. According to the AHIMA survey, HIM directors prefer outsourced partners offering multiple skill sets such as support for end-to-end testing, physician education, coding audits and revenue impact assessments.

Furthermore, by using outsourced resources both within and outside the HIM department, maximum return on investment is realized and ICD-10 implementation is expedited.
For example, one customer contracted with a firm for both coding and CDI assessments. Coupling efforts strengthened the partnership between CDI and coding teams while hastening documentation readiness and physician education for ICD-10. Coder assessments and education also combine effectively: assess first, then educate to needs. Using the same product or system streamlines the process.

One large urban hospital chose their coding services provider of 20 plus years, to also complete ICD-10 operational assessments, awareness workshops, communication campaigns, training plans and clinical documentation gap analyses. The facility also used the provider to fill a new coding support role for their physician network central business office-freeing up in-house staff to complete ICD-10 training. The outsourced firm’s resources are also being used to provide physician shadowing, one-to-one audit and education for physicians, as well as advanced, scenario-based ICD-10 training boot camps for hospital and physician network business office staff.
Finally, centralization of ICD-10 resources, outsourced or in-house, helps solve staffing challenges.

Will It Work for You?

A Hybrid Approach

How this method enhances EHR documentation.

Centralize ICD-10 Resources
An organization’s ability to leverage ICD-10 knowledge workers across a variety of areas helps balance workforce demands, staffing metrics and outsourcing contracts. With centralized ICD-10 staffing, new HIM hires and/or outsourced resources also serve as part-time or floating support for other ancillary departments. Workflows and processes are altered to “borrow” instead of “buy” additional personnel in non-HIM areas.

Centralization establishes a core team of ICD-10 expertise. Three possible areas to leverage ICD-10 knowledge include:

  • Medical Necessity Checking in Patient Access
  • Claims Suspensions in Patient Accounting
  • Physician Education and CDI

As an example, ICD-10 coders hired for dual-coding can assist CDI and physician education programs. These coders have spent months dual-coding live cases. They are well-versed in new documentation requirements and serve as validators of clinical documentation. Use their skills as far “up front” in the documentation cycle as possible for maximum effectiveness.

Virtually everyone in healthcare will feel the staffing impact of ICD-10. Any resource hired or contracted for ICD-10 should be leveraged throughout the organization.
Right Resources Mean Everything

HIM professionals can’t prevent the ICD-10 flood, but they can prepare for it. Outside contractors, partnerships and consultants should be seriously considered, strategically vetted and promptly secured. By partnering now, HIM professionals build a strong dike for their departments and organizations.

Elizabeth Stewart is corporate director of HIM at HRS.

Table: Four Tactics to Retain ICD-10 Coders

Coder retention becomes increasingly important as the October 1, 2014 deadline approaches. Here are four tactics to consider:

1. Secure employee contracts in exchange for complete ICD-10 training.

2. Promote from within, making several people team “leads” for the various components of the ICD-10 project.

3. Give a voice to employees. Ask them what they need to feel satisfied throughout the transition and post-transition to ICD-10.

4. Offer incentives for meeting milestones within the ICD-10 transition and post-implementation.


1. The Impact of ICD-10, CDI and CAC Initiatives within the Health Information Management Community”. Survey Conducted by: Barron Professional Consulting Services. Available online at:

2. “Meaningful Use Presents Health IT Execs with Opportunity for Significant Improvements”. HIMSS13 Survey Conducted by: Stoltenberg Consulting. Available online at:

3. “Regulatory Strategies from Medicare to Meaningful Use”. HealthLeaders Media Intelligence Report. December 2012. Available online at:

About The Author