February 11, 2013

Cherry-Picking Is the Pits
By Judy Sturgeon, CCS, CCDS
For The Record
Vol. 23 No. 3 P. 8

When dealing with inpatient coders, one of the more interesting workflow management challenges is developing an effective way to prevent “cherry-picking.” With ordeals such as ICD-10, recovery audit contractors, and insufficient staffing dominating the profession, why should coding managers devote time to something as petty as stopping staff from pulling the easiest charts?

Not all coders are dedicated professionals, which means there’s a chance someone in the office is pulling “easy” charts, leaving the more difficult ones for the rest of the staff. While some will argue that a chart is a chart, that’s simply not the case. Ignoring this fact can result in a serious morale problem and hamper the development of effective teamwork in the coding department.

Most coders follow the rules and take charts in the approved order. Still, there are some who take advantage of the situation to improve their productivity and quality reports.

Modus Operandi
My first experience with “baby snatchers” (the term used to describe coders who snagged the easiest charts) came as a fledgling coder. My office started an incentive program in which anyone who maintained a 97% coding accuracy (yes, it really was 97%) and coded more than five charts per hour for three months received a bonus for the next three months. Assignments were distributed based on the last two numbers of the medical record, otherwise known as the terminal digit order. It was thought that over the course of a month, each coder would have to deal with approximately the same number of complex charts. Everyone would get a mix of baby charts, huge Medicare behemoths, and plenty of others in between.

My coworkers and I soon figured out that the noble coder who had offered to stay behind and man the office while the rest of us went to lunch was removing newborn charts from the rest of the coders’ stacks, coding them, and returning them to the file to hide the evidence. This individual was the only one who qualified for incentive pay, while the rest of the staff found themselves facing corrective action for not reaching productivity goals. Morale suffered along with the work records of several good coders who were getting stuck with difficult charts, which lowered their productivity and accuracy rates.

In theory, sooner or later the baby snatcher would have to catch up with her hardest charts, but at the end of the month when charts were nearing filing deadline, the manager would make everyone share the at-risk charts, most of which belonged to you-know-who. Without support from our manager, the staff decided to squash cherry-picking on its own. As it turned out, threats of physical violence against the offending coder were ineffective (she knew we weren’t serious) and also illegal (a little chat from the human resources department ended that approach to chart control).

Can Technology Help?
Twenty-five years later, the problem of cherry-picking has not disappeared from coding departments. However, solutions to the underhanded practice are more high tech and effective. With the advent of EMRs and detailed data reporting, it is possible to parse out charts to coders one at a time based on any criteria a manager prefers: date of discharge, dollar amount of total charges, financial class, department—the options are seemingly endless. The EPIC chart, for instance, can create numerous work queues for the coding staff. However, if everyone can still access all the work queues, guess which ones are likely to get coded first? If one coder is grabbing easy charts and getting away with it, soon there can be a free-for-all whenever a coder is out or even working a later shift.

Some workflow management software tools, including several offered by computer-assisted coding vendors, can issue charts one at a time without allowing coders access to other worklists. But what if there is no option to place digital restrictions on workflow? What if a manager needs to employ flexible work assignments?

Working With Variables
Coding managers may look only at raw numbers to determine staff productivity and accuracy rates. However, others take into account the complexity of the case, awarding extra “points” for length of stay. For example, longer stays may count for 1.5 or two charts while one-day stays garner only 0.5 charts toward productivity totals. This sort of policy could be a great option at facilities where longer stays typically result in a more complicated medical picture. Keep in mind, however, that if it’s a long psychiatry stay or an extended rehabilitation stay, more days does not necessarily reflect more complicated care.

In departments that report total charges for each chart, cost of care may more accurately reflect complexity. In these cases, it may be wise to vary the coding time allowed for a chart based on its total charges. In essence, coders assigned an expensive stay are allowed more time to code while those who snag a $500 newborn chart have a tighter deadline. For example, given equal deadlines, completing 2.5 charts with an average of $40,000 in total charges would be equivalent to producing three charts with an average of $30,000 in total charges or 3.5 charts with an average of $20,000 in total charges. Of course, these figures vary based on facility type and the composition of patient cases.

Such a strategy keeps easier charts moving quickly while allotting more time to coders willing to tackle tougher cases. The more generous deadline helps ensure important data are captured, sending a message that quality won’t be sacrificed for faster turnaround times.

Not every short stay is an easy chart to code. Conversely, a long stay doesn’t necessarily translate to difficult coding. The same is true of expensive cases: A head injury might rack up huge charges but end up with only three or four codes on the chart, while a straightforward fever case may require medical research and two physician queries to ascertain what caused the admission. However, total charges or length of stay can be excellent barometers for establishing fair productivity expectations.

Nip It in the Bud
Coding departments that are having problems with cherry-picking should not dismiss them as inconsequential. Find a way to control workflow or adjust productivity expectations to allow for variances in coding complexity and speed.

Coders are in short supply, and these days good ones can get a job anywhere. Managers who establish fair workloads and reasonable job standards will increase their chances of keeping the best of the bunch on staff.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 22 years.