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The Evolution of a Profession
By Wendy Coplan Gould, RHIA

While attending the 83rd Annual AHIMA Convention & Exhibit in Salt Lake City in October, I began reminiscing about the HIM profession. Two things quickly came to mind: Wow, we have really come a long way in 83 years, and wow, I have been doing this for a long time.

Almost the entire convention was focused on ICD-10. Not to date myself (assume I was a child prodigy), but the chaos from the ICD-8 transition to ICD-9 was not as traumatic in 1979 as will be our move to ICD-10. Back then, reimbursement based on prospective payments and diagnosis-related groups were not in place nationally. Coding was conducted for statistical purposes and was not the foundation for revenue.

Despite this major difference, I believe the RHIAs of today can learn a few important lessons from the registered record administrators of yesterday. This article takes a look back and, in doing so, provides practical ideas to help coders take the leap forward.

The Maryland Experience, Circa 1978
In 1978, I was working as an associate director for the Maryland Resource Center (MRC) which, like New Jersey, had been awarded a grant from National Center for Health Statistics to work directly with the Health Care Financing Administration, now the Centers for Medicare & Medicaid Services, to begin developing a model for Medicare reimbursement based on the coding. The MRC was a consortium of Maryland hospitals that submitted their data to this central commission. We assigned DRGs and established reimbursement.

Hospital data came to us in those antique media called tape and floppy drives. While it was only inpatient information, it quickly became apparent that record format and data layout consistency were critical. Standards became a huge imperative. Coding now mattered. The designation of a primary diagnosis and the ordering of a secondary diagnosis were necessary for correct DRG assignment.

Prior to this time, the order of codes didn’t matter much. Codes in the 1970s and early 1980s were primarily for statistics. Then in 1983-84, DRGs entered the national scene, and coding and the medical records department went from the basement to the executive suite. Now that timely, accurate coding was critical to dropping the bill, hospital executives sat up and paid attention. I believe this was the catalyst that changed the HIM profession.

In the 1980s there was no credentialing for coders, and coding quality varied greatly. When DRGs entered the scene, the need for training and education became obvious and drove the process of coder professionalism. Coders started to become supervisors and directors in hospitals, creating a paradigm shift. Their importance continued to expand as prospective payment- and DRG-based reimbursement widened from acute care to outpatient, nursing homes, and more, now covering the entire continuum of care.

Opportunity Knocks Again
The transition to ICD-10 is now the point of no return for the HIM profession. This is where coders can raise the profession another level—from the executive suite to the boardroom. The increased granularity and complexity of implementing ICD-10 into every setting and modality of healthcare is providing endless opportunity for coders.

Besides the entire continuum of care, ICD-10 will impact many other aspects of healthcare, such as workers’ compensation, managed care, pay for performance, audits, and medical necessity. If coders make the effort, this should be our greatest moment.

The stakes are high, and the effort required is enormous. HIM professionals need to take responsibility for their professional transition to ICD-10. Just meeting minimum education requirements for ICD-10 is not enough.

Additional Learning Opens New Doors
It is essential to do some learning on your own and drive your knowledge base beyond the basics. You will not only be irreplaceable to your organization but also become the “go-to” person for ICD-10 issues. And beyond your current role, opportunities will be available throughout the entire healthcare industry.

For example, with ICD-10, the area of data analytics will be critical. Having the ability to compare ICD-9 to ICD-10 and use critical analysis skills to determine documentation gaps, reimbursement risks, and actionable variances will be important for every healthcare provider.

Secondly, any good coder knows it is all about the documentation. With a solid base of ICD-10 knowledge, you can be a detective and understand the impact and new documentation requirements of ICD-10. You’ll become the driver for clinical documentation and workflow changes. This visibility with physician leaders will also help drive HIM professionals to the boardroom. ICD-10 propels coding and clinical documentation improvement into one focused activity, and perhaps a single department moving forward.

Other opportunities lie in building institution-specific mappings from ICD-9 to ICD-10 and vice versa. General equivalence mappings are a starter kit but need a lot of work. Computerized physician order entry (CPOE) systems and EHRs also need to be reworked to accommodate ICD-10, and HIM professionals are well suited for this task. (I’ve learned that the term “crosswalks” is inaccurate, although we all use it.)

Generations Drive Evolution
Beyond education, your personal evolution within the HIM profession depends a lot on what generation you are from and where you life goals and ambitions lie. Baby boomers are less technologically adept but more likely to focus on personal growth and soul searching. They will question authority but will do well in a team effort, such as the one required by ICD-10.

Generation X (those born in the 1960s to early 1980s) will be more comfortable with technology but may be more intimidated by authority figures throughout the ICD-10 process. They are apt to change jobs more often and want more family/career balance than their predecessors. Beware of their tendency to “job hop” as you invest in training them.

Generation Y (those born in the 1980s and 1990s) can’t imagine a world without technology. They are the consummate multitaskers and will be extremely useful during these turbulent times.

Understanding the abilities, wants, and needs of each group will make the process of change smoother and more cohesive. And as the transition to ICD-10 gains national recognition, job seekers from all generations are expected to enter our profession.

Coding Hits the Headlines
Coding has started to receive national attention, including exposure on NPR and in The New York Times. The attention has helped widen the opportunities for coders and sparked interest in job seekers. Healthcare providers are scrambling for experienced coders, but HIT providers, payers, consultants, EHR vendors, and education/training companies are also trying to hire the best and the brightest.

Even if you do not want to continue coding in ICD-10, just learning it will present other opportunities, such as the ability to help improve clinical documentation, build institution-specific mappings, rework CPOE systems, and update templates for ICD-10. The demand for HIM professionals is going to spike, just like it did in the 1980s. Given that supply cannot meet demand today, the problem is going to be exacerbated for the foreseeable future.

We have definitely come a long way. Gone are the days of entering data on the face sheet and sending it via sneaker-net to the billing department. Now HIM has fast-paced electronic records and digital communications both internally and beyond the hospital walls. The new world is before you; just do the work and get ready to make the leap.

— Wendy Coplan Gould, RHIA, is president of Health Record Services.