July/August 2021

How to Build an In-House Coding Department
By Lisa A. Eramo, MA
For The Record
Vol. 33 No. 4 P. 20

HIM experts share insights and lessons learned.

When patient volumes decreased temporarily during the COVID-19 pandemic, coders at Georgia Cancer Specialists in Atlanta forged ahead with whatever noncoding tasks could be done. They ran reports, pulled data, and educated providers as needed. Leonta Williams, MBA, RHIA, CCDS, CCS, CPC, CHONC, CEMC, CPCO, CRC, director of medical coding operations, attributes her team’s flexibility to two factors: an in-house coding team that’s in place and Williams’ willingness to hire and train credentialed coders with minimal coding experience.

“Everyone wants experienced coders, but there are so many benefits to developing your own coders,” Williams says. “When crisis hits, the person who is less experienced but willing to do other things is incredibly beneficial.”

Waiving a minimum number of years of coding experience also enables Williams to focus less on technical skills that can be groomed over time and more on softer or other transferrable skills. “I’ve found that people who have worked in retail are very good with numbers,” she says. “If you want to include reporting tasks in their job responsibilities, it’s easier to do that with someone who has these skills.”

Having an in-house coding department also opens the lines of communication between physicians and coders, Williams says. “It’s about relationship building,” she notes. “Our providers trust the coding team to give them good, sound advice—and the coders have the benefit of learning from the clinicians about certain conditions.”

The in-house department has been particularly helpful during the transition to the new evaluation and management (E/M) guidelines that took effect January 1. “With the change in E/M guidelines, I think a homegrown coding program is even more important,” Williams says. “Providers didn’t have time to read and fully understand these guidelines with everything else going on. Having that internal support system and the ability to provide feedback in near real time is critical.”

Forming an All-Star Team
Julie Cowher, MA, RHIA, CHC, senior director of CDI, coding, and revenue integrity at The Ohio State University Wexner Medical Center (OSUWMC), says having a homegrown coding team allows her to avoid long-term coding vacancies. She builds relationships with coders from the start of their careers and continually invests in their education.

The organization originally implemented a coder apprenticeship program in 2013 to prepare for ICD-10. As part of the program, coding managers designed educational presentations and assessments for student interns who committed to in-person classroom training at the medical center for 20 hours a week.

When ICD-10 was initially delayed, the coding apprenticeship program was paused. The positive outcome? All of the coding interns were hired either at OSUWMC or at other hospitals. Many interns hired from this cohort remain in OSUWMC’s department today and have even advanced their coding career.

“[The internship program] affords us the opportunity to continuously interview them and assess how they would perform as employees,” Cowher says. “Did they show up on time? Did they ask good questions and retain knowledge? It’s these behaviors that you really can’t get out of an interview or from a résumé of a new grad.” 

Over the last eight years, the coding apprenticeship program has continued to exist in various formats. Recent partnership with a coding education vendor affords Cowher the ability to further develop existing educational content and provide a full-time instructor—a development she says was particularly helpful when the organization needed to recruit more coders to support the impact of ICD-10 and a growing academic medical center.

“I think it’s hard to find some out-of-the-box, off-the-shelf kind of training that gets to the level of training you need. One option can be to partner with a qualified vendor—‘Here are the types of cases we intend to see. Can you help us craft educational content around that?’”

Today, Cowher’s team is leveraging their homegrown model to provide targeted training to her in-house coding team as the organization prepares to open its first freestanding ambulatory surgery center in August.

Working with a vendor can help organizations get these programs off the ground and running, says Kelli Fosick, director of facility auditing services at CorroHealth. “The goal is to take the teaching beyond what coders learn in their academic programs and coach them up on what they need to know to work within a live case environment,” she says.

This includes how to navigate flags and edits within a specific EMR, complex cases, and more. “The instruction is very targeted and specific to the needs of the coders,” Fosick says. “We may target very specific PCS scenarios, for example.”

Fosick says many in-house coding programs developed out of the need to recruit and retain coders during ICD-10, a scenario that could also play out with ICD-11. “I know that hospitals are getting creative—teaching coders internally and then having them stay with an organization contractually through that learning process and beyond,” she says.

Mitigating Risk, Promoting Compliance
At Parkland Health and Hospital Systems in Dallas, an in-house coding program helps Lakeysha Moore, MBA, RHIA, director of coding operations, maintain coding quality and mitigate denial risk. “When there are issues, I can quickly resolve them,” she says. “I can pull everyone together and get things fixed pretty easily. I have at my fingertips all of the data I need for quick assessments so I can do on-the-spot training.”

Moore’s entire 92-coder team has gone through an initial coding course to train them on the health system’s specific coding guidelines. The coders also receive one hour of education each month. “Coding for Parkland is different than coding for a lot of other organizations,” Moore says. “Our [obstetrics] population is extremely challenging in addition to our trauma and ED visits. We see a lot of critically ill patients.”

Moore particularly likes the fact that with an in-housing coding program, she can personally select the coders who work for the organization. “I have more control over the hiring and selecting of the people who code our cases,” she says. “I can dig into their background and know their education.”

While fluctuations in volume are often one reason why organizations partner with coding outsource companies, Moore says volume management hasn’t been a challenge. For example, even during COVID-19, Parkland didn’t furlough any coders. “We used a lot of that time to provide education and training to improve our quality,” she says. “We’ve done a lot of cross-training. That’s the main thing that has helped us with volume management.”

Giving New Talent a Chance
“I’m a firm believer that we all need to start somewhere,” says June Bronnert, senior director of health informatics at Intelligent Medical Objects.

A former coding manager and supervisor who oversaw coding education, Bronnert used to familiarize herself with local coding programs so she knew the sort of education candidates were bringing to the table. “I knew when I was talking with each person what level of foundation they were exposed to. Then, through the interview process, I could determine whether that person was going to be a good fit for the organization,” she says.

Critical Components
Experts say successful in-house coding programs have the following eight components in common.

Executive buy-in. It’s all about having a plan for achieving a return on investment, Moore says. “You can’t just talk about it,” she says. “You need to show the data. How will you decrease denials? By what percentage? How much revenue will you gain? How much revenue leakage will you prevent? Then you actually need to follow through with what you say you’re going to do.”

For Williams, obtaining buy-in was all about showing return on investment. She originally asked for eight coders but received funding for only five positions. It wasn’t until three years later when her department had repeatedly demonstrated its return on investment that she gained two more coders. Two years after that, she finally gained the eighth coder.

“You need to provide the C-suite with that data,” Williams says. “What is your increase in relative value units based on coder review? Have you had better compliance in terms of avoiding overcoding? These are the questions managers need to be able to answer using data.”

Cowher’s strategy for obtaining executive buy-in for her in-house program prior to ICD-10 involved focusing on the cost of turnover during a time when remote coding had opened up a field of possibilities for coders. “You could live in Ohio and make more working for a hospital in Florida,” she says. “We had some vacancies because of this, and we used it in our argument to leadership. I could articulate the cost of turnover, and if we had more than one vacancy, it had a huge impact.”

Fosick says executive buy-in also includes buy-in for financial resources as well as a commitment to the timeline. “You can’t do this in 30 days. You need to give the time to the effort,” she says.

Sophisticated analytics, dashboards. If organizations plan to hire and train coders internally—especially new coders with no experience—they need to monitor productivity and quality closely, says Teresa Gulino, MBA, RN, managing director of business development at Pivot Point Consulting. This includes key performance indicators such as the rates for first-pass resolution, net collections, and discharge not final billed.

Cybersecurity. Just because an organization has an in-house coding program doesn’t mean coders are actually onsite. In many cases, they’re not—but that also means strong cybersecurity measures must be in place to ensure the protection of patient information, Gulino says.

Mission and vision. Having a mission helps coders understand how they fit into the big picture. As a bonus, it also helps get executives on board, Moore says. “Our coding department mission is to improve population health by providing accurate and quality data for the health and vitality of our community,” she says. “We want to be nationally recognized in coding by delivering quality data with accuracy, integrity, and accountability.”

Optimal workflows. At Parkland, coders use computer-assisted coding (CAC) technology that Moore says has boosted productivity and quality after she partnered with the vendor to optimize workflows. For example, if coders add certain codes a majority of the time, Moore requests that the vendor tweak the technology to suggest those codes. Similarly, if coders delete a code the majority of the time, the CAC is reconfigured to stop making the suggestion.

“It takes a lot of work, but it’s worth it in the end,” Moore says, adding that the boost in efficiency allowed her to leave various positions vacant when they became open.

External audits. Georgia Cancer Specialists hires an external auditor to perform an unbiased annual compliance evaluation. “You need to have these audits in place to make sure coders are coding correctly and applying internal and payer policies correctly,” Williams says.

Gulino agrees: “Conducting in-house audits can be costly and time-consuming, and they can take away from key business functions,” she says. “However, engaging with an external partner not only validates compliance but it also helps program leaders have crucial conversations from an objective perspective. This helps the in-house team foster growth and development with their current talent.”

Formal training program. “I believe in good education to get the best outcomes,” Williams says. “If people don’t learn the way they should or feel like they’re not getting all of the information they need, you’re not going to have a successful program.”

The 60-day coder training program at Georgia Cancer Specialists, which focuses on the organization’s internal coding policies and procedures, took Williams approximately six months to develop. Coders begin by coding previously coded cases. Then, senior coders audit their work. Once the coders reach a 95% accuracy rate, they move into a full production environment.

“With our coder handbook, coders know exactly what they’re going to be covering, what the expectations are, and how they’ll be graded in order to move from one section to the next,” Williams says.

Bronnert agrees that having an internal curriculum is important. “You are the master of that curriculum,” she says. “You can tailor it to areas of specific need at your organization.”

Ongoing education. Large coding outsource companies can easily provide ongoing coder education, but it takes more proactive planning with a homegrown program, Williams notes. “How can you effectively train and educate your staff? Leaving it up to the coders themselves isn’t going to work. You need to budget for in-house training or partner with an association or consultant,” she says.

As with the case at OSUWMC, it may make sense to partner with a coding education vendor, though this will still require a lot of effort on the part of the organization. “It has to be a joint collaboration,” Cowher says. “No two academic medical centers necessarily code the same way or have the same case mix. We have to be very engaged in bringing information to the table to build the coding content. Both sides need to be in constant contact. I’ve always looked at our vendor as an extension of my team.”

Looking Ahead
Bronnert says in-house coding programs will undoubtedly help organizations shape future coding positions. “The opportunities to work with coded data are expanding tremendously across the industry,” she says. “As we think about future roles for coders, how do we grow those roles when there might not be credentials or official programs from colleges yet? We need to ensure that coders will be ready.”

— Lisa A. Eramo, MA, is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.