Saturday, July 11, 2009

Coding Mgr Handbook: Ch 3: Staff Training

Chapter 3: Staff training

* Hiring of Staff
* Generic Sample Interview Questions
* Cross training of Staff and Teamwork Concepts - Team building
* Disciplinary Action (disciplining your employees)
* Communication issues with your staff
* Training & Continuing Education - Tools for the job!
* Goal setting for coders and managers
* Coder Productivity
* Incentivize your coders
* Benchmarking
* Remote Coding - Outsource Coding: Do I? Don't I?

Hiring of staff is always a challenging endeavor for any manager, much less a coding manager. Coding staff come in many shapes, sizes and skill sets. You want to find the most qualified, skilled, talented, and dedicated person you can find. But, you have to balance budgetary "cost" that is allocated for new employee salary(ies). Then you have to find someone who will "fit in" with the other employees, buy in to the company "culture", and be productive quickly.

Certified staff such as RHIT's, CCS, CCS-P's, CPC's, CPC-A's all have their place within the coding departments. Most large facilities request that all their staff have some sort of coding "credential". Those credentials may not necessarily provide "proof" that the person is a "good coder", but at least it provides proof, that they were able to take the test and pass. You would be remiss in your hiring practice, if you did not provide an independent coding test, or even a medical records filing test etc.. prior to hiring an employee that will be working in the coding department. (regardless of what area they are going to work in).

If you do not have success in finding coding staff that is already certified, you may have to “grow your own”. What I mean by that, is that many times if you do not have the opportunity or ability to hire someone who is already a certified coder (CCS, CCS-P, CPC etcc) You may have to spend the time getting them the training within the organization, (by teaching yourself) or by sending them to class or training outside of the workplace. (i.e. community college, adult learning center etcc) Either way, it is always a good investment of time and money to have certified staff. Certification simply ensures that the employee has been educated in the minimum of coding criteria, and guidelines, HIPAA, Privacy, Security, and basic coding.

If you elect to hire a coding position, looking at the resume is the easy part. The hard part is the interview process. You always want to hire the best, so having a good set of interview tools is essential to the coding manager’s toolbox. The resume, gives you a blind look at the coding skill sets that the applicant has elected to disclose. If you choose to interview that applicant, it’s a tricky process to ask the applicant the set of questions, that will give you the information you need to make an informed decision about them and how they function as an employee. It’s this information that you have to rely on. You need to know if this person can perform the minimum job functions, work well with your team and “fit into” your coding department culture, then ultimately be a successful employee for your department, facility or practice.

Most offices or facilities have strict interview guidelines. Many times, the Human Resources department will do the first round of “screening” interviews and send to you only those they deem to be a “possible fit” for your department. If you have to do the interview process yourself, a little extra time and attention to detail can save you the “poor employee” or “poor fit” for the applicant down the road. This means you should be diligent about checking references, and consider doing a formal background check if needed. Don’t be afraid to have the employee sign a release of information from their previous employer(s), or school transcripts or records to disclose items of interest for you.(see figure 3_1) There have been instances of coders being involved in medical billing fraud or convicted of criminal activity that was not disclosed in the resume, or interview process. Unfortunately checking references, and background is very time consuming, but is extremely important you you as a manager, to learn behaviors about the applicant, and their the work “personality”.

If you are hiring an applicant right out of school, consider making a call to the educational provider, and inquire about that student’s attendance, work ethic regarding study habits, homework, if they met deadlines appropriately, and even their grades if it applies to the coding position. (i.e. such as anatomy, terminology, coding, transcription, HIPAA, privacy, security, filing etc..)

In the nuts and bolts of the interview process be sure that your questions are appropriate and applicable to the position that you are hiring for. Your human resources departments can help guide you in the legalities of what are/are not appropriate questions to ask during the interview process.

Prior to interviewing, the job description, and job functions should be readily accessible for prospective job applicants to review and have a copy of. When the applicant arrives for the interview, be sure to had the applicant another copy of the job description and job functions. You want the applicant to know what the expectations are of the job, the job “functions” and the standards of the department that they will be held to.

During the interview, ask applicants behavior based questions such as how they’ve handled previous work scenarios, and ask for situations that had a positive outcome, and also those situations that had a negative outcome and what (if anything) the applicant learned through the process. It is through those scenario’s that you will get and idea of how the applicant functions in specific situations, and how their thought processes and decision making skills measure up to what you are looking for in an employee. You will want to look for the applicant who handles both positive and negative situations in a professional manner.

Some companies prefer to have applicants take personality tests and find them useful in the hiring process. However, a personality test is no guarantee that the applicant will “fit” into your department’s culture.
In the interview, be sure to as the same questions to each of the applicants. You will also want to administer a coding or skills-type test to each applicant. I have found that some skills that you take for granted (i.e. typing, 10-key) your applicant may not be proficient in. If you are asking your applicant to type 45 wpm, then be sure to test them to ensure they meet the criteria.

As a manager be on the lookout for employees that come in with a pre-determined or “scripted” answers to questions you may ask. Another area of concern are applicants who give one-word answers, or will not elaborate. Some simply give “too much” personal information, or include negative comments about previous employers. Nerves will play a part for some applicants, however a bad attitude may not show itself on the first interview, so be prepared to interview candidates 2 or 3 times, looking for different ideals. A negative or bad attitude may also come out in the form of bragging, acting as a “know it all”, or being offended by the fact that they have to take skills testing, or personality testing. Then there is the opposite of the bad attitude, is the applicant who appears lifeless, or dis-interested, or possibly even bored. Do not ask personal or confidential questions. (i.e. how old are you? Are you planning to get pregnant? Are you married? Divorced?) Do not ask the applicant to reveal any type of confidential or proprietary information about their previous employer(s)

If you’re hiring a coding/billing type position give a skills test that appropriately tests the overall skills of the applicant. You will want this test to include basics about CPT, ICD-9 and HCPCS, coding conventions and guidelines (1997 and 1995) , auditing, HIPAA, privacy and security, modifiers, claims, appeals and coding from documentation.

Here’s a listing of some generic interview questions you may want to ask during the interview process. You don’t have to ask them all, but this list is a broad scope of many generic interview questions to help you find the right employee for your coding job opening.

Generic Sample Interview Questions
 Tell me about yourself?
 Can you give me 3 words to describe yourself?
 How would your friends/co-workers describe you?
 Why should I hire you?
 What can you do for us that someone else cannot?
 What are your short term and long-term goals?
 What have been your achievements to date?
 Are you a team player? Please give me an example?
 What is the most difficult job situation you’ve faced and how did you tackle it?
 Describe for me a situation involving a conflict with a (your) supervisor?
 How was it resolved?
 What is your greatest weakness? And how can that benefit you in this position?
 What is your greatest strength… and why is it applicable for this job?
 What do you like best/least about your present job
 What qualities do you think make a successful manager?
 Describe your ideal boss/manager/supervisor
 How does your job fit in to your department and company?
 What do you enjoy about this industry?
 Give an example of when you have worked under pressure.
 What kinds of people do you like working with?
 What kind of people do you find it difficult to work with?
 Give me an example of when your work was criticized.
 Give me an example of when you have felt anger at work?.
 How did you cope and did you still perform a good job?
 Give me an example of when you have had to face a conflict of interest at work.
 Do you prefer to work alone or in a group? Why?
 This organization is very different from your current employer - how do you think you are going to fit in?
 What are you looking for in a company?
 How do you measure your own performance?
 What kind of pressures have you encountered at work?
 Are you a self-starter? Give me examples to demonstrate this?
 What changes in the workplace have caused you difficulty and why?
 Give me an example of a time you did not meet a deadline, how did you correct the situation?
 Think of a time when you worked in a group, and one of the group was not doing their part. How was the situation rectified? What was your role in that?
 With multiple tasks, deadlines, and priorities, how do you determine the priority of which should come first, second etc…
Then add in the CPT coding specific interview questions such as:

Basic Sample Coding Interview Questions

 Describe for me the differences between ICD9 coding for Outpatient and Inpatient coding?
 What are the differences between the CMS 1995 auditing guidelines and the 1997 auditing guidelines?
 What is Terminal Digit filing?
 What is color wheel filing?
 What is a CMS 1500 used for?
 Describe the major reimbursement methods in healthcare: OPPS, RBRVS, APC, DRG’s?
 Describe the purpose of coding and linking in the billing process
 What is the difference between a UB92 and CMS 1500 form?
 What is the role of a third party payor?
 What encompassesMedicare Part A services? Medicare Part B services? Medicare Part D services?
 What is HIPAA
 What are some typical Fraud/Abuse and compliance issues within coding and billing departments?
 What is the use of “E” codes?
Lastly, give a 25 question“mini” coding based test to assess minimum coding skills in regard to:
 Basic Anatomy & Terminology
 Coding Conventions & Guidelines
 ICD9 diagnosis coding
 CPT E&M Coding, procedure/surgical/medicine coding, modifier application
 HCPCS coding
 Billing and claims submission
 3rd party payor guidelines
 HIPAA, Privacy and Security
 Release of information (medical and billing records)
 Claim submission, forms and appeals.

Begin and end your interview(s) on time. Be conscientious of the applicants’ time, in addition to your own. It is a common practice to do an initial interview, then call back the top 5 candidates for a 2nd or 3rd interview prior to hire. Give a timeframe of when the applicant can expect information regarding where they are in the the interviewing/hiring process. Let the applicant know that you will get back to them within “x” amount of time and do it!.

Make the phone call, or write the letters to those applicants letting them know they have made it to a second interview, or that they were not chosen for a second interview, but thank them for their time and interest in the position. I use a very generic “thank you” template for those applicants that I have eliminated from the hiring process.

Once you get the applicant hired, you should assign that employee an inter-department trainer/mentor. The trainer/mentor will help ease the transition for the new employee. The mentor will have the responsibility of training and educating the new employee (mentee) into a productive member of your team. Peer mentoring and training also provides a low cost way to train new employees. The new employee will also develop more intimate work relationships with these mentors as a peer to peer relationship. It can be rather intimidating to the new employee to have a trainer/mentor who is the department supervisor or manager, and this can potentially lead to uncertain outcomes. With the peer to peer trainer/mentor concept, the trainer/mentor gets the added benefit of building leadership, communication and teaching skills for themselves.

Investing time and effort into quality education and training (and cross-training) of new and existing employees will reward you and your company with more productive, and happier employees. This will also reduce staff turmoil and turn-over, during high stress workloads or situations.

Cross training of staff and Teamwork concepts
As a coding manager you should embrace the opportunity to develop a good department employee cross training program. Cross training programs allow employees to learn and function in different capacities within the coding department. This also encourages understanding of how the different jobs function and affect other areas within the department and the company. This also provides the opportunity for employees to gain additional skills, abilities and knowledge which can improve their outlook and job satisfaction within the department.

Cross training your employees will have some additional budgetary costs, but overall will have a positive impact upon the department. The most tangible benefit is that during times of high workload, or unforeseen employee absences cross-trained employees can step in/step up and provide the manpower to fulfill those critical functions. Or, you may have times when the workload is not equitable, and one area may need more help than another. With cross-trained employees you’ll be better prepared as a manager to meet those unforeseen demands successfully.

Another added bonus to having cross-trained employees is that you eliminate the pressure upon employees if they are absent. Employees can become resentful, that if they are absent (i.e. for vacations, illness, unforeseen situations) , that their work will just pile up, until they return. If staff is cross-trained, the work can continue to flow. This is extremely important in a coding department, as you do not want to interrupt the revenue stream due to employee absence or high work volume.
As a manager, be the first to step forward to be cross trained. Learn to perform the job functions of each employee in your department. You may not be able to perform the job as expertly as your employee, but you will gain the insight as to what it takes to perform that job, and how to manage the workload if you have an intimate knowledge of the job. In addition, your employees will have the opportunity to “train” you in how best to perform that function in their absence. Be the first to step forward during the times of high volume workload, or employee absence to keep the work flowing. This will not only provide you the satisfaction of keeping the department running smoothly, but will show your employees your commitment to them and their job during those situations. It is critical to the success of cross training that the employees who are performing these functions be the ones to cross-train their peers.

Be realistic in your expectations of those who are “filling in” for the absent employee, or during high-volume workload situations. Cross trained employees have the skill sets and education to perform the job, but will probably not have the speed and/or accuracy that the primary employee brings to the job. In some situations, you may need to replace the single absent employee with multiple employees just to keep the department flow from grinding to a halt.

In addition to cross-training, have each employee create a “how to” for their day to day activities within their job functions kept in a readily accessible file or notebook. This “how to” guideline helps the fill in staff perform the basic functions of that position and lessen the perceived pressure of missing an important work piece critical to the job function.

To implement a cross training program, you need to identify the areas and job functions upon which will need to be learned by the trainees. It is wise to have a simple, but formalized plan for implementation. If this is a broad type of cross training, a project manager and a project management system may need to be implemented. But for most cases keeping it simple, will provide the quickest rewards.

 Develop a checklist to outline the conditions of the cross training
 Create a progress report and evaluation form to be completed at specific timeframes.
 Create a skills test checklist (i.e. pass/fail type) and administer at the completion of the training.
 Update, review and re-test those skills at specified intervals after completion of the training (i.e. every quarter, every 6 months, once per year etc…)

(see sample cross training documentation examples 3-6. 3-7, 3-8, 3-9 )


What is the definition of Teamwork/Teambuilding? This is nothing more and nothing less than bringing employees together for a common goal or purpose. As a coding manager, you have to be the “teamleader” for your coding team, but you will be a team-member of the management team, or other corporate team affiliations. You have to know both sides of the team-work/team-building priciples, ideas and practicum. To run a successful coding department you need to make time to build team relationships within your department. It can be difficult as a manager, when your workload is large, and you have little time to “work” at building your team. However, the small amount of time it takes to continually build and enhance the relationships you have with your staff, the more devoted and committed they will feel to you, the department and to the company.

When building your team, you need to develop a strategy to create, and maintain the team for a long-term relationship. As teams grow together, the become stronger than 1 single individual. However, you still want your employees to “excel” at their jobs individually, but bring together their strengths, in addition to the strengths of the others in your department, therefore you have a strong diverse skill set within your coding department.

When working with a team-based approach, make sure that all employees are “bought in” to the concept of team cooperation. All members need to feel that if one member of the team is struggling, the other team members will step up or step forward to help accomplish the goal without seeking personal praise or attention. Team members all need to utilize effective communication skills within the department or team. Are there certain members of the department that function as the “mouth-piece” of the team. If so, that team needs to have some skill building and team-based exercizes to emphasize that each member of the team should have the opportunity to communicate what is going on within their team. In addition, the skill of “listening” is also critical. Many good ideas get lost in the shuffle, if only 1 or two members of the team are always at the forefront. Those in the “silent” majority need to have the opportunity to have their ideas heard and or acted upon.

As the manager, you need to show the department and teams that you recognize their efforts and care about what is going on within the team. In addition, you need to ensure that the department members feel as if their job and mission within the corporate structure is important, and they are a vital link to making it successful. Respect is a powerful force within a team. Respect must be earned and not demanded. Each team-member needs to value and respect the others on the team, and within the department. No one likes to be made to feel that their ideas or values are not worthy of note, or consideration. Respect should be at the top of the code of conduct of what goes on within the department. Embody respectfulness by saying “please”, “thank you”, “pardon me”, as part of your regular conversations with the department. Set the expectation, and others will rise to meet it.

In addition to respect, trust is also a critical value within the department. Employees need to feel that they can place trust in you to perform your job effectively as a manager, in addition to knowing they can trust their peers to also perform their tasks. All job functions are interdependent upon each other within a coding department. No one person can do it all!!! Don’t talk down to your staff or demean anyone on the team. If it does happen – admit your mistake, and take responsibility for your actions. Show your staff you aren’t perfect, but are conscientious to your mistakes and want to rectify them. Learn from your errors, and move forward. I have always adhered to the notion that you learn more from your errors, than you ever do from your successes.

Don’t be afraid to roll up your sleeves and help get things done. Managers who know how to work within their departments as well as “with” their department make their employees look and feel good. This translates into more trust and cohesiveness between all. Come prepared to work everyday with a good, positive, can-do attitude. As a manager, set the bar high for yourself, and try to meet your goals every day. If your employees see you reaching for the top each and every day, this will become an integral part of your departmental culture. In turn, your employees will also take on those traits and encourage their peers to do the same. Be dedicated to observing deadlines and project completion dates and timeframes. Manage your resources and employees, by empowering them to take ownership of the project(s) so that all will be responsible to seeing it through to completion. (and success!) Again, if unforeseen circumstances do happen, and you miss a deadline, or a project has failed, re-group and re-assess what needs to be done, then move forward with the revised plans. Communicate with those above you in regard to the set-back, and communicate to them what your plans are to rectify the situation. Then, coordinate with those on your team, ask for their ideas and options, to see the revised plan into action and completion. You will find as a manager, that each day will bring its own small successes and failures. It’s how you deal with those successes and failures on a day to day basis, that your staff will see and hopefully embody the best model and standard of work.

Below are some tips as to how you can effectively embody the team-work and department cohesiveness needed to succeed as a coding department manager.

 Set the standard!, Dress the part! – Live up to the expectation, and continually improve yourself

 Lead by example! – if you “talk the talk” then “walk the walk”
 Be consistent in your practice of teamwork – set clear expectations
 Respect each member – and be polite (ie – please, thank-you)
 Maintain integrity and ethical standards, be committed to the process.
 Recognize and value your biggest asset – Your employees!!
 State your objectives or goals - get it in writing - refer to it often!
 Create a good, positive work atmosphere, SMILE!!! And take a genuine interest in your employees and their dedication to their jobs.

 Acknowledge and recognize the efforts of all on the team. Especially those who may bring a specialized skill set to the department, or have special talents that are untapped.

 Learn to listen – take the time to hear what your employees are saying to you.
 Confront the fear of change and move ahead in spite of “what may happen”

 Be willing to look at new ways to solve old problems. Challenge yourself and your staff to find new and more efficient ways of delivering services and/or products

 Hold each other accountable for doing their best, even though it may be a new task or learning opportunity.

Disciplinary action (Disciplining your employees)

In spite of your best efforts, there are sometimes, when you end up with an employee who is exhibiting poor performance. You, as the coding department manager, need to put together a disciplinary action plan, or you may have to terminate the employee altogether. No matter which out come you have, it is never easy, nor is it pleasant.

The first step to always remember is to DOCUMENT, DOCUMENT, DOCUMENT! This is same theory that we practice with the physicians that we work for and with. It is a very common saying within coding departments “If it wasn’t documented, it wasn’t done”. I always advise communicating with your upper management and with human resources in regard to any employee disciplinary action or termination. In some cases human resources may have to put legal counsel on retainer. Each state has different laws regarding employee rights and termination.

Most often, companies employee some form of progressive discipline for poor performance. A disciplinary action plan should not come as a surprise to most employees who receive them. Do not wait until the yearly employee evaluation to “spring” this on the employee. By the time you meet with the employee for their yearly evaluation, there should be no suprises one way or the other as to what will be on the evaluation. You should be providing feedback for your employees on a routine and scheduled basis (both positive and corrective) throughout the year.

If you are unaware what “progressive disciplinary action” is, it is defined as a system of discipline where the penalty(ies) increase on repeat occurrences, with the ultimate penalty being termination of employment. The typical stages of progressive discipline are

1. Documented Counseling and/or a documented verbal warning
2. A formal documented written warning
3. A formal Suspension and/or a permanent or temporary demotion
4. Termination.

Depending upon the severity of the employee act or action, , may determine if a progressive disciplinary action plan would be effective. In some cases immediate termination is warranted (i.e. for a breach of confidentiality, embezelment, or criminal act). In other cases such as poor performance, multiple absences, insubordination, unwillingness to participate in team activities, or inability to get along with other members of the department, a progressive disciplinary action plan may be just the incentive to help the employee get back on the road to productivity.

When you have an employee who has previously been very competent, but is now becoming what I consider a “toxic” employee, you need to take immediate action and hopefully avoid the potential poisoning of the office or department. Some examples of toxic employees are ones w ho
 Are rude or threatening to patients and co-workers
 Routinely show up late/leave early with a myriad of excuses
 Push off their work onto others within the department/team (i.e. as in refusing to answer phones)
 Permeate the environment with a negative attitude.
 Gossip about other employees or patients
 Refuse to follow advice, instructions, or direction from peers, team leaders or managers.
 Refuse to follow established office procedures or policies such as dress codes, etc.

The worst part with these employees, is that their behavior sneaks up on you as a manager. Most often, these employees are able to perform the basics of their job, but in the day to day workflow, may go un-noticed by you. This is why it is so important that you are involved with all staff and team-members so that these issues can be averted before it permeates the entire department.
Given the financial realities of a coding department, good coders are few and far between. Hiring and training neww staff is extremely time consuming and expensive. With a “toxic” employee, you have to determine whether to try and salvage the employee and turn around the behavior, or to terminate and begin again.
If you have elected to pursue progressive discipline, begin with

Step 1 – Documented counseling and/or a documented verbal warning.
 As a manager you need to swiftly confront the employee.

 Be prepared to discuss the issue or problem in depth,.

 Outline the problem in detail and present concrete evidence or present specific examples of the issue at hand. .

 Do not use phrasing such as “poor attitude” that may have a different interpretation to you than it does for the employee

 Prepare your notes in advance and schedule enough time to thoroughly work through the issue with the employee.

 Ask the employee how he/she believes that the problem could be solved

 Set the consequences, and a timeline., spelling out in detail what will happen if things do not change.

 Respect the privacy of the matter and of the employee, but include a 3rd party in the room with you to avoid the “he said/she said issues” (such as another department manager or human resources officer)

 Remind the employee, that this is not about them as a “person”, but it is about our business and the success of the department and how they function within the department.

 Have the employee sign the documentation record noting that this is a documented counseling/verbal warning, stating what you discussed and determined to be the plan of action, the consequences if the action plan is not followed through.

 If things don’t improve or the employee does not follow through with their commitment to the action plan, you may need to move to

Step 2 A formal documented written warning
 Follow the basics of what is encompassed in step 1
 Review the failure of the employee to comply with the formalized plan (as outlined in Step 1)
 Remind the employee of the consequences of their actions, and implement those consequences at this time.
 Set a new timeline upon which the employees actions must change.
 Again, have the employee sign the “formal written warning” with the consequences clearly outlined to be either suspension, demotion or termination within the department if they do not comply.

Step 3/Step 4 A formal Suspension and/or a permanent or temporary demotion, or Terrmination.
 With Step 3/Step 4 again document all conversation,
 Outline what steps were taken prior to this one
 Document the failure(s) on the part of the employee to adhere to the corrective actions
 Have the 3rd party available,
 Have the employee again sign the documentation,
 Have HR there, if termination is the elected outcome.

In some companies employees are considered “hired at-will” Employment at will means that employees can be terminated or let go at any time with or without reason. It also means that an employee can quit or abandon the job without reason. Employers are not required to provide any type of notice if they are terminating an at-will employee. However, even if an employee has been hired “at will” some states have employement laws in place that protect the worker in those instances. So, prior to terminating an employee, even if they were hired “at will”, you should have the human resources office, or your legal counsel provide you with guidance in those situations.

If you do have to carry out a termination, most manager agree that this is the part of the job they hate the most. Sometimes, termination is in the best interest of the employee, the organization and even your department employees. Depending upon the circumstances, you may want to consider a couple of types of termination. 1) Immediate termination for just cause, or 2) Termination for non performance.

The firing of an employee does not have to be the worst experience of your management career, but at times it certainly feels like it is. As a manager, you always question yourself about what you could have done differently, or changed to have a better outcome. Sometimes, you just have to do the termination, and live with the consequences to the department. However, take the time to reflect on the relationship you have had with the employee and examine what went wrong, and learn from the experience.

Below outlines some of the steps you may want to consider if you do have to terminate an employee for just cause. Just cause terminations usually happen because and employee threatens violence toward another employee, or commits a violent act, brings weapons to work, views or downloads pornographic or prohibited information to company computers and on(or off) work-time, steals or vandalizes company property, or is caught embezzling funds or commits any other type of criminal activity. In light of the actions above you will want to perform an immediate termination for just cause. These steps will help minimize the “impact” to your department, and hopefully keep all safe.

 Ensure that the employee is not a danger to themselves or other employess (if so, call law enforcement, or security.

 If the employee does not appear to be a danger to themselves or others, notify law enforcement if an illegal or criminal act has taken place

 Remain polite and respectful

 State the offence to the offender calmly and with a witness in the room

 Tell the employee that their employment is terminated

 Collect all company property from the employee

 Allow the employee to pack personal items from their work are if circumstances allow it, if not, have the employees personal items packed and ready to go at the time the termination is taking place.

 Enable the employee to ask any questions about the end of the employment

 Escort the former employee from the building, or utilize security to escort the employee from the premises.

 DOCUMENT, DOCUMENT, DOCUMENT the entire termination proceedings.

The steps to take if the termination needs to be done for non-performance, or non adherence to a disciplinary action plan are spelled out below.
 Ensure via your documentation that the employee was clearly informed about the job expectations and failed to live up to them.

 Ensure that you have the written and signed documents showing that you and the employee attempted in good faith to adhere to the action plan outlined prior to the termination.

 Review with human resources that you have applied the performance standards, and job requirements fairly to this employee, and you have documented the failure of the employee to perform up to those standards.

 Ensure that your progressive discipline action plans were escalated so that you have the documented verbal warning, documented written warning, suspension and/or demotion.

 If the above is in place, the termination consequence should not come as a surprise to the employee.

 Schedule a meeting with the employee and human resources, and inform the employee that they have been terminated from the position and from employment with the company.

 Inform the employee of the reason for the termination.

 Be compassionate and respectful. Maintain the employee’s dignity and allow them to speak or ask questions of you or of the human resources witness
 Collect all of the company property, and allow the employee to pack up their personal belongings, or give them the option that you will pack their belongings up and they can retrieve them after hours.

 Walk the employee calmly out of the building.

 Last but not least DOCUMENT, DOCUMENT, DOCUMENT the entire termination process.

I have included some sample copies for you to use or review for implementation in your progressive disciplinary action plan for your management “toolbox”.

Communication issues w/your staff

Sometimes, no matter how good and how effective you may be as a coding manager, there will be times when you and your staff have communication issues that can be difficult to resolve. Communication is, of course, the bottom line to a successful department, or success of the manager/employee teamwork relationships. As the manager, you will always be looked up to, and expected to uphold the company policies and directives. There will be times when your staff will become angry or put pressure on you during times of high workload, or departmental stress.

When under employee scrutiny, how you react to it is important. You have the opportunity to “connect” with the staff and embody the professionalism that they expect of you. Are you prepared to handle such situations as employee criticism?. You need to have your emotional tools at the ready to maintain your “grace under fire. As a manager at one time or another you will be humiliated or criticized for decisions that you’ve had to make. Many times those decisions are made in the best interest of your department or company, but the employee’s may not see it that way, or not understand the full “big picture” of why you made the decision that you did.
When being pressured or criticized keep these tools at the ready:

 Don’t make excuses for your actions. Take ownership and responsibility for them (right or wrong)”
 Keep your cool, and be strong (i.e. never let them see you sweat!)
 Don’t break down and cry, and avoid recrimination
 Don’t think up ways to “get even” and don’t counter attack the criticism.
 Be honest and forthright,
 f needed, apologize for your shortcomings, but be confident and professional
 Lastly, learn from past mistakes, and try not to repeat them.

Then you may have the opportunity to manage a situation that includes angry patients, staff, or physician employees that are lashing out, but the issue may not necessarily be directed at you personally. Many times you can diffuse the situation with calmness and clarity, but other times, it may take a bit more to keep things under control.
 Keep your cool, as the anger is usually not about you personally, so don’t internalize it as such.

 Check your safety – do you need to have a witness?, do you need to call for security?

 Move the issue out of any “public” areas, or “patient sensitive areas”. See if you can accompany the angry person to your office, or an area out of the “limelight”.

 Acknowledge the anger, but try and steer the conversation toward resolution, not just allowing the person to “vent” without a solution to their issue.

 Try and elicit the real source of the complaint or the issue. It may be that what happened today was just the “final straw” in a long laundry list of minor problems, that the person just couldn’t handle any more.

 It may be that the complaint or anger is 100% valid, but it could be 100% not so, but more often it is somewhere in the middle.

 Listen and be empathetic to their complaint or issue. Don’t trivialize it, and don’t “talk down” to the person. Respect their view, even though you may not agree with them.

 Ask what the person would like you to do to rectify this situation, then negotiate if unreasonable.

 Offer an alternative if necessary (i.e if I can’t help you, who do you feel can?)

 Don’t take the anger or the issue personally. Realize that this is just another day, and tomorrow will bring a new set of opportunities.

Training & Continuing education –Tools for the job!

As a coding manager, you staff will always be need to have access to training and continuing education. Coding is an ever evolving job. ICD-9 Diagnosis and Procedure codes are updated on October 1st of every year. CPT procedure codes are updated on January 1st of every year, HCPCS codes are updated quarterly, and the field of medicine itself is ever evolving with new procedures and technologies moving to the forefront of the news on a regular basis. In addition to just the basics of ICD-9, CPT and HCPCS, your staff have to keep abreast of changes by 3rd party payors such as Medicaid, Medicare and high-profile insurance carriers. Your inpatient coders have to worry about DRG’s, APC’s, OPPS, chargemaster edits and errors, and ancillary facility charges.

Your employees need (at the very least) the current year’s coding books that encompass all the coding changes. Encourage your staff to become involved with their coding societies and state and national coding conferences, and allow them to pursue personal continuing education to further their career and employment objectives. Some companies allow each employee a certain amount of educational dollars to be spent at the manager’s discretion.

Be pro-active in coding training and continuing education. Meet with your staff on a scheduled basis to update them, and encourage them to bring items of interest to the “coding roundtable” type meetings. Share the “burden” of who will monitor and mediate these sessions. Encourage and empower ;your coders to share their knowledge with their peers and co-workers. This works hand in hand with cross-training.

Be open to new and ever-changing technologies. Encoders and chargemasters enable coders to work more quickly and efficiently. Look at emerging electronic medical record systems, automated transcription systems, PC’s and the internet for research and oursource coding and billing. Internet and Intra-net usage of prescription management and the personal health record.

Take advantage of continuing education presented by vendors and 3rd party insurance payors. Webinar’s, Audio seminars and data download options can open up many educational opportunities for coders to take advantage of. Ask your staff to attend some of these sessions, then bring back the information to your coding roundtable to be shared amongst your department.

Encourage all your staff to become “credentialed” or “certified”. This empowers the employee to pursue their own personal development, and adds to more job satisfaction, and happiness within the department. Encourage ancillary staff such as medical secretaries, data entry staff, and personal assistants, medical assistants, and clinical staff to join you at your coding roundtable and encourage cross education for those staff members too. You never know when one of your clerical staff may turn out to have a real interest in coding or billing. If they are allowed to be included in these educational activities, you may be able to “find” your next coder or biller just waiting in the wings for their opportunity.

Goal setting for coders & managers
So… What’s your goal? What is a goal?Are they important? Can I really achieve them? What’s in it for me? As I discussed in Chapter 1 goal setting is very relevant to all aspects of the coding department. Medical coding requires many different skill sets, and as I covered in chapter 1, goal setting for managers, we also need to help and enable our coding department employees set appropriate goals, and help them achieve them.

Again, the SMART system of goal setting is very applicable and easy to follow. It’s one of those “tried and true” applications that you can easily adapt to fit into the day to day workplace for your coding employees.
The SMART system criteria is as follows:
S = Specify,
M = Measurable
A = Attainable
R = Realistic
T = Timely

As the coding department manager, you may need to be the one to specify what goal you would like your employee to achieve. This can certainly be discussed during any of the 1-1 meetings you have with your employees as an on-going departmental basis.

It gives focus to where you would like the direction of your coding department to go. There will be times when you have to move your staff out of their “comfort zone” and really focus on “ramping up” the productivity, or focusing on a specific activity that is “outside” their coding realm, or perceived “coding job”.
When you specify the goal, it may be something like “I would like you to be able to code XXX amount of emergency department charts per day. You have now specified “what you want them to do, and now have made it measurable – by adding the caveat of XXX amount of charts per day. Now, as the manager, you have to make sure this is truly an attainable goal for your coder. To evaluate if this is truly attainable, research or inquire at some of the other facilities what their criteria is for that specific function. The goal you set forth should “push the envelope” for attainability, but should not make it out of reach. That is why you need to keep perspective of the goal and make it realistic. Of course, setting a realistic goal, does not infer that it will be “easy”. You want to make sure that the learning curve to attain the goal, is in proportion to the goal. The final piece of the goal setting project is making it timely… Be sure to outline a timeline for when you want the coder to be able to code xxx amount of emergency department charts per day. When you set this goal for your coder it should go something like:

Within 3 months, I would like you to be able to code XXX amount of emergency department charts per day. Currently you are coding XXY amount of emergency department charts per day. At facility ABC, their coders code XXX amount of emergency department charts per day, so we should be shooting for the same goal. Let’s look at ways that we can realistically achieve this goal. (i.e. by streamlining workflows, utilizing encoders, providing additional education etc) Let’s work on this goal together, and we will meet weekly to track our progress, assess our successes and failures.

Now that you’ve set the goal, WRITE IT DOWN, MAKE IT PUBLIC! Have each of the employees who are working on this fill out a formal “goal setting worksheet” to have at their workspace, to remind them of the goal and to keep them motivated toward success

Wow! You’ve really got something going on now!!! But as the manager, you will now need to become a “feedback fanatic”. You know that your employees have the ability to do the job, and really “get it in gear” and meet the goal put to them, but how do ou keep them focused on the goal??? You need to maintain and follow through on the scheduled meetings to assess successes or failures of the goal.. Make sure that the feedback includes both positive and negative aspects, but always start and end with the “positives” and couch the “negatives” in the middle. Make sure you use specific examples of the successes and the failures. You may want to meet 1-1 with the coders involved in this, and show them their “own numbers” to attaining the goal, then meet with the entire group and show a “group based” performance number. By diligently providing feedback, you will enable your staff to continue being engaged toward the goal.

Some managers look at only the “successes” they’ve had, but I truly feel that you learn more from your failures, than you ever do from your successes. Failure is the opposite of success, but failure provides you with a unique opportunity to learn from your error(s), and look for new ways to pursue becoming successful or succeeding at your goal. i.e. If you want to achieve more, do more! Don’t limit yourself – explore all options, and think outside of the norm. Sometimes it’s those “light-bulb” moments that really inspire, and spur your staff on to meet goals, or really contribute something of value to the organization.

Coder productivity is always a tricky issue to tackle. Each coding department will have it’s own specifics as to what makes it productive. Some departments have on-site full time staff, others utilize both full and part time on-site staff, while others use flex time, remote coders, and even outsource some coding functions. Not all productivity can be directly related to employees only. Utilization of encoders, charge-masters, electronic billing and medical record formats, automated transcription services, all play a part in productivity of the coding department. Then, couched with all of that, documentation requirements need to be met by the providers, and coders have to be the ones to analze and audit if that is appropriate. So you can see why this is such a difficult thing to wrap up in a nice tidy package.

When looking at your coder productivity, you need to make sure that you are comparing “apples to apples”, and not “apples to ice cream” One way to determine a baseline for coder productivity, is to have all your coders take the same coding test within the same timeframe. I would then take all the scores, and times and develop a “norm” or “baseline” for testing. Then develop a productivity protocol within those standards. You will have some coders who are going to function “above” the norm, but you should also have coders who “meet” the norm, and you will invariably have those that are “below” the norm. It is only then that you can determine what is the “correct” productivity standard.

When developing a productivity standard, you should also elicit productivity information from other coding departments who are similar to yours. (ie other practices within your market, state, etc) Don’t be afraid to contact specialty coding societies such as AHIMA, AAPC, MGMA, AMA, or even medical specialty societies for their input as to what they feel is a good productivity standard, and how they implement into their practices or facilities.

It is very hard to quantify a specific “number” but with the variables within coding, you will have to be flexible, when stating “you need to code 20 surgeries per day”. Those 20 surgeries, could be 20 easy, quickly coded operative reports, or they could be 20 “very difficult” surgeries. So again, you may have to do your productivity research over a period of time, just to get a “baseline” idea of what the productivity standard should be.

Another area of productivity that you should consider, is the area of “errors”. Each area needs to develop a standard percentage of error (i.e. 1% error rate, 2% error rate etc) and determine what factors will be considered “errors” (i.e. missed diagnosis codes, non-specific diagnosis codes, missed procedures, etc)

Once you have developed a specific set of norms for your productivity standards, then you have to put into place ongoing review and observation that these standards are being met. You should always meet with your coders 1-1 to evaluate their own progress within the productivity process, but you should also quantify the productivity goals for the entire department. Each coder should see how they stack up against the “department” as a whole.

Evaluation of productivity should be done on a “regular” basis, but probably not daily. You really need to allow for off-days, high volume days, low-volume days, and even personal or professional inefficiencies that may come up. Again, be sure you are comparing “apples to apples” and get a good mix of charts/records to ensure that your data is standardized to a certain degree. Assign the coding of records in as “random” a basis as possible, to eliminate some coders getting all the “easy” charts, and other get left with the “hard” charts. Don’t forget to factor in the non-coding duties that crop up during the day. These non-coding responsibilities such as filing, sorting charts, abstracting, telephone calls, locating documentation, you may want to rotate these between your staff so no one person is “stuck” with these functions more often than another.

Coder productivity has a direct correlation between revenue that comes back into the practice. You will want to manage the “error rate” percentages of your coding department (based upon the same set of error’s identified in your productivity matrix). If you have a 5% error rate as a norm, you may want to consider a goal of reducing that error rate. Even in the simplest of mathematical terms a 5% error rate, means that you are potentially losing 5 cents on every dollar. In a small practice 5% may not look like much, but if you regularly have $20,000 in gross charges per month, that is $1,000 potential dollars that you’ve let go untapped. If you’re a big practice that has 2 million in gross charges per month, that’s $100,000 dollars that have slipped through, so by shear numbers a 5% error rate in your productivity analysis is probably too high. A 0.5% error rate may not be attainable, but I think it should always be something to shoot for!

Other issues to address for optimal coder productivity, is to create as stress-free an environment as possible for your coders. Utilize standard “break times” and “lunch times”, be sure to allow your coders to have “voice mail” to eliminate telephone interruptions. Rotate the “non-coding” duties. You want to have as many coders “coding” productively with few being interrupted with ancillary duties. Move coding staff away from high-traffic areas and provide good lighting, tools to perform their jobs (i.e. encoders, books, PC’s, printers, )
Incentivizing your coders:

Now that your department is tops in productivity, and your error rates are down, now you have to keep the momentum going. Is it time to consider incentives for your coders? Do you need an incentive program to retain good staff, or attract new employees? There are pro’s and con’s to every incentive plan. The pro’s to having a good incentive plan in place is the potential to improve morale, coding timeliness, reduce coding errors, reduce “non-productive” time wasted on talking, breaks, and consistency of coder production. However, the “cons’ to an incentive plan, is that they are never “long-lasting” and usually have to be re-worked quite frequently. The other con to incentive plans, is that all staff may not respond to the incentives the same way. It is often thought that monetary incentive is the best way to motivate staff. However, with some employees, money is not what “motivates” them. For others it may be gaining more responsibility, or stature within the department, others it may be a pat on the back and recognition by peers or ancillary departments. So with incentives you really have to know how to motivate each individual employee to really bring out the best in each one of them.

I have never been a really big fan of incentive programs over the long-term. I think if you have a short-term project, an incentive based motivator works really well. Incentives for the short-term projects can be things such as a paid day off, or a $50.00 dollar gift certificate to a favorite restaurant or store, or maybe even Lunch with executive staff.

I know that for some of the more experienced long-term employees, the company has dangled the “coding at home” carrot in front of the coding staff as a type of incentive. Of course, coding from home brings another set of issues to the forefront. Yet, I still feel that for most staff, incentives should be a short-term and “fun” activity. In the long run, department staff should know what the productivity mark is set for, as the benchmarks have been set as an integral part of their job description and job function, and they will have a formal evaluation regarding these goals throughout the year. If your employee is meeting these goals yearly, they would be rewarded with an annual merit raise rather than just a cost of living type salary increase.

Now that you’ve decided to implement an incentive based program for your coding department, here’s a list of information for you to think about as you design your incentive based plan(s).

1. The fundamental make up of the program should be fairly simple and straightforward
2. It should recognize and compensate the employee for superior performance fairly across the board.
3. It should direct the individual employee’s behavior toward achieving the common goal(s)
4. It should be designed to effect change (positive and permanent) within the department or organization
5. It should allow a substantial portion of compensation to be a variable cost.(i.e. the plan should reward results rather than actions!)

6. The program should have some built in flexibility to meet the needs of the employee and the department.

Quality Monitoring tools for Inpatient and Outpatient Use

The term Quality monitoring “tools” may be misleading. Inpatient quality monitoring tools usually consists of a Data Quality Manager, who functions in concert with the Information Technology team. These individuals are charged with mining data and overseeing data quality that is consistently input into the system from the medical record. In addition to quality, the Data Quality Manager ensures that the data analysis of that information upholds the integrity of the record, and the processes surrounding the gathering of such data for reporting and analysis measures.

Data mining software has really come into its own on the medical market. Many types of data mining applications function with Electronic Medical Records, Patient Management and medical billing systems. For inpatient hospital facilities and stand alone ambulatory care centers and surgical care suites, they also utilize data mining for many different types of applications. he ongoing goal in regard to data management, is to
 Improve the accuracy, integrity and quality of patient data.
 Improve the quality of physician documentation within the medical record to support code assignment
 Utilize only standardized coding data sets in the such as ICD-9-CM, CPT, HCPCS,and DSM-IV,
ICD-9-CM, UHDDS, and DSM-IV are the norms used for inpatient reporting of procedures
CPT4, and HCPCS are the norms used for outpatient reporting of procedures

To achieve consistency of inpatient and outpatient coding of diagnoses and procedures coders should always
1. Thoroughly review the entire medical record as part of the coding process in order to report the most appropriates codes

2. Adhere to all standard coding conventions outlined in ICD-9-CM, CPT HCPCS, and DSM IV

3. Assign and report diagnosis codes, without physician consultation/query, for diagnoses and procedures that are not listed in the physician’s final diagnostic statement only if those diagnoses and procedures are specifically documented in the body of the medical record by a physician directly participating in the care of the patient, and this documentation is clear and consistent

4. Assign and report diagnosis codes within areas of the medical record which contain acceptable physician documentation to support code assignment include the discharge summary, history and physical, emergency room record, physician progress notes, physician orders, physician consultations, operative reports, anesthesia notes, and physician notations of intra-operative occurrences

5. Assign and report diagnosis codes if they are stated in other medical record documentation such as nurses’ notes, pathology report, radiology reports, laboratory reports, EKGs, nutritional evaluation and other ancillary reports. If these diagnoses are not documented by the physician directly participating in the care of the patient, the attending physician must be queried for confirmation of the condition or diagnosis.

6. Utilize medical record documentation to provide specificity in coding physicians’ diagnoses and procedures,within the radiology report to confirm the fracture site or referring to the EKG to identify the location of a Myocardial Infarction etc..

7. All POA (Present on Admission) indicators are subject to reporting and collection of information involving inpatient admissions as per federal law, and the POA indicators are assigned to principal and/or secondary diagnoses as defined as “present” at the time of the inpatient admission.

8. Coders must use a formalized query process when a diagnosis or procedure meets reporting guidelines, but is not clearly stated within the medical record, or conflicting documentation is contained within the medical record.

9. All inpatient records much have a coding summary attached and also must note the ICD-9-CM diagnosis and procedure codes in addition to the narrative description, the POA indicators, patient identification/demographics and admit and discharges dates.

10. The coding summary may also contain the discharge disposition (i.e. patient to home, to skilled nursing facility etcc) This summary may also contain the DRG assignments and descriptors. Once approved, the coding summary will become a permanent part of the medical record (and data information systems)

11. In addition to the coding summary, a physician attestation should also be included. It validates the physician agreement to what is contained within the coding summary. Verbiage for attestations need to state that the physician aggress and approves of the diagnosis and procedure codes listed and that the accurately reflect the episode of care.

12. Coders should not add any diagnosis based solely upon test results.

13. Coders should not misprepresent the patients episode of care by adding or deliberately omitting diagnoses.

14. Each record and episode of care should reflect the medical necessity of such.

15. Coders should comply with all standard coding conventions and guidelines. They should have a firm commitment to the ethics and morals of quality data integrity and perform their job functions as such.


What is benchmarking? Why does it matter? How do I start? In the medical industry, benchmarking is known as a process of measuring internal processes, then identifying, understanding and adapting the optimal processes and functions from other peers, companies or organizations that are considered to be best in class. You are basically seeing how you measure up against those considered to be the best of the best. Depending upon what you want to compare yourself against, you could benchmark your requirements for hiring a marketing director in healthcare against the processes for hiring a marketing director in the banking sector. Even though the industries are different, chances are the hiring processes are similar.

When benchmarking for coders, and coding departments, you will want to decide upon a standardized set of criteria, that is universal within your peer group. The first area that comes to mind is benchmarking coder productivity and coder salaries. The experts to look to within the coding industry would be American Health Information Management Association (AHIMA) and the American Academy of Professional Coders. These two businesses routinely compile data and statistics from their members in regard to coding salaries. Of course, both businesses have different outcomes with the salary surveys, but it certainly gives you the opportunity to see where your department or employer measures up in relation to others within your peer group. The surveys also present salary information based upon locality, state, region and national averages. In addition to the salary surveys, they also bench mark salaries for full time coders delineated by length of time (years) in the industry and part time coder’s by a set number of hours worked within the workweek delineated by length of time (years) in the industry. Another area that may be able to provide you with good benchmarking criteria is the MGMA (Medical Group Management association) and also your local or state employment offices and job data bank warehouses.

Most companies want to remain very competitive with salary, so they do try and keep abreast of what are the starting salaries for non-certified new and experienced coders, newly certified coders, and certified experienced coders. Comparisons to benchmark should be very similar to the comparisons and analysis that you do for data quality management. You want to make sure that you are comparing “apples to apples” not “apples to ice-cream”.

Areas of confusion for coder benchmarking is determining “who is the very best” and how do we position ourselves to meet or exceed these benchmarks? If you don’t know what the standard is, it makes it difficult to analyze where you or your organization fits in against the other organizations. Of course, it really helps if your peers contribute to the benchmarking standards, or if there is a designated independent pool or databank where this information could be stored then disseminated out anonymously. The AAPC and AHIMA do a very good job of these type of reports. One of the best things about benchmarking a specific set of criteria, is that it is a system that enables you to improve yourself, your department or organization from a very positive aspect.

There are 3 types of “benchmarking”
1. 1. Internal Benchmarking – most often used as the first place to start. Performing an internal benchmark of your coders productivity (against each other) can be very helpful. Especially if you have coders who perform the same or similar jobs but in different locations. You could benchmark productivity based upon the type of coding( E&M) , the experience level amongst the coders (long-term vs/newbies) , and even the location to location coded volume vs/dollars per day.

2. Competitor or Peer Benchmarking – with this type of benchmarking you are looking to set your business standard and practice next to how your competitor or peers are performing under the same standard and practice. With this type of benchmarking, it is helpful to know and work in conjunction with your competitors and peers to make the standard itself better. (i.e. in customer services)

3. Best in Class Benchmarking – it focuses outside your specific organization’s specific industry, and you compare yourself against national “norms” or “values”. This best in class benchmarking is usually only concerned with one specific function, and can cross many different industries. This type of benchmarking is oftentimes summed up in a report from an independent evaluator, crossing many different types of industries… i.e. Hospital XYZ wins the award for the best in customer service for 2009, but in 2008 Big Box Bank won the award for best in customer service.

So within these 3 separate types of benchmarking you can easily determine which type you want to pursue, and how it will best function for you as a coding manager. I personally liked being able to put the coder productivity to the test for the coders in the different locations. In looking at the data for these benchmarking activities. I determined that it was very useful for my staff to see how they stacked up against each other within the locations. Especially when they could see that the Internal Medicine office has xxx amount of coded encounters (E&M visit, procedure, injection) per month, and has generated xxx amount of dollars. The other area of benchmarking that really gets things lively is by benchmarking the amount of co-pay dollars that are brought in each month by each location. We disclosed this out to each location and let them see how they stacked up against each other, then we implemented an incentive for a 3 month period of time. The location with the most amount of co-pay dollars collected over the 3 month period won a “pizza party” catered luncheon, that included salad, drinks and dessert.

Interestingly enough, the location that won the “pizza party” was one of the “lowest” performers initially, but seized the opportunity and has consistently been one of our best performers since that initial benchmarking process. We still provide the feedback to each location every month as to where they stacked up against each other with the co-pay dollars. We haven’t done the “incentive” yet this year, but we will again within the next few months. This time…we’ve changed the criteria a bit. We will be having an incentive to see which location can collect the most amount of self-pay dollars within the 3 month timeframe. The incentive for the winners is a 15 minute chair massage for all the employees in that location. We have been fortunate to partner with the local technical college, and their massage therapy students will be performing the chair massages. This really is a win-win for both of us, as our employees get the massages free of charge, and the students get valuable experience during school hours.

Possible pitfalls to benchmarking is beginning the process before you are truly ready. You need to make sure that you have clearly outlined what it is you want to compare yourself to, and how you want to make this happen. The other consideration is the fallout (e.g. financial, employee turnover etc) if the data is skewed, or is not properly validated. Just doing 1-1 comparisons is not enough to truly elicit any type of change of process or focus. Poor preparation just leads to frustration and wasted time. To have a truly successful coding benchmarking program you as the manager need to be able to identify your internal departmental strengths and weaknesses, then recognize which of these processes need special attention. It is then you will be able to begin the critical processes for comparison and analysis. Again, communication is the crux of the process and when successful those changes become an accepted part of the routine, day to day processes.

Good coding benchmarks have the potential to increase your revenue stream, reduce your monetary days in AR, incentivize and increase productivity of your coding and billing staff, and reduce staff turn-over. Once you get started and see the successes, you will want to continue the process, finding many ways to utilize this often overlooked management tool.

Remote coding – Outsource coding: Do I? Don’t I?
As a new coding manager there may be times when you need to seriously consider whether or not you should take advantage of remote or off-site coding.. There are a number of ways that a remote coding situation can benefit both you and the department. There are also many different scenarios to consider when deciding to implement a remote coding situation, or utilizing your current staff in a coding from home employment option.

An inpatient coding manager, may want to consider utilizing outsource coding resources for monitoring and reviewing codes in the Charge Description Master (CDM) or utilizing them for clinical coding compliance audits and some facilities utilize outsource coders for help with department backlog and JCAHO preparation for the department. If you decide upon using an outsource coding firm, be sure to get references from previous clients as to how they performed for them. You will want to research the company to ensure that their employees are bonded, and also have them sign confidentiality and privacy agreements for your specific facility. You will want to determine the turn-around time on the coding of records that they are contracted to do, and oversee that these timeframes are being met. Perform due diligence, and have each of their coders take your own “coding test” that you’ve designed for your own employees. If possible, review these tests for accuracy before the outsource company begins working for you. Also determine if you will be charged separately for each type of record audited/coded/billed, or if all will be billed in one invoice as a combined fee.

From a departmental or facility standpoint, an outside coding/billing company can be a good use of your financial dollar. These outsource functions can help control budgetary costs by reducing your backlog of uncoded/unbilled charts, you don’t have to provide any sort of employee benefit package such as paid time off, medical insurance, overtime, holiday or vacation pay. Another perk that an outsource coding company brings to the table, is an increase of productivity in regard to your claims schedule and revenue stream, since you do not have to plan for unscheduled time off, or unplanned absences by your immediate staff.

Most coders will tell you that this is the "nirvana" that they are hoping for. If you talk to newly credentialed coders they want to know how they can start "coding from home". I hear this from coders in all aspects of the medical field. It bothers me to some degree that schools seem to be really emphasizing this "perk" for newly credentialed coders. I feel it is extremely important for a new coder to work side by side with a more experienced coder to develop the mentor/mentee relationship. My other feeling is that just because you've gotten your coding certification, it does not automatically make you a good coder. In my years of experience, I have seen many non-credentialed coders who were as good if not better coders than some of the credentialed coders.

However, remote coding, or coding from home is unique in the fact that you have to be very self disciplined to get the work completed accurately, and in a timely manner. I have seen many remote transcriptionists transition to the coding/billing from home workforce very successfully, as transcription deadlines are so very similar to the deadlines that coders face.

If you are a coder that is currently employed by a facility, and wishes to code from home, there are a number of issues to consider.

• The coding manager and the coder need to determine the amount of time that will be spent in remote coding. (i.e. part time, full time) and total hours per day.

• You will need to have a HIPAA compliant area for privacy and security within your home office

• You will need a PC with internet connectivity to your workplace, and possibly even a fax machine, scanner, and encryption software, OR the ability to dial into a VPN and access the facility or office's EMR directly.

• As the manager, you will need to have an accounting system or timekeeping system to oversee if the coder is truly "working" during the hours stated, or has completed the amount of work sent to them within the prescribed timeframes and is accurate. The coder must be able to work with little or no supervision, and have a great deal of self discipline to get the job(s) completed within timeframes.

• Human Resources will also need to be notified, as some states have laws governing employees that work from home and are considered telecommuters. This may affect how the employee's pay is determined and taxes are deducted or applied. This may also affect how the employee accrues vacation and sick pay.

• Also, the coder and the manager need to have regular communication regarding how things are going – I suggest weekly phone meetings or web-cam meetings. Then the usage of e-mail should be highly encouraged. Working from home is very isolating, so keeping in touch with peers and supervisors/managers is essential.

• Your remote coders should still be held accountable for keeping their licensure current, and maintaining their educational requirements for certification and per your coding department policies.

• The remote coder should also continue to participate (i.e. come into the office) for departmental meetings, educational updates, and for mentor/mentee participation.

• Usually the most rewarding of all, is that coder job satisfaction goes up, and you have less departmental turnover.

After evaluating the above, discuss with your upper management, human resources and financial officers and see if this is a good fit for enabling your facility or practice to create a “coding from home” program for your employees. This is probably not a good fit for all, but in some situations it can be a win-win.

Before committing to having “work from home” coders be a permanent part of your practice or facility, have each employee who wishes to pursue the “work from home” option, that you enact it on a “temporary” basis. the “work from home” program should undergo a 30,60,90 and 180 day evaluation of the success or failure of the program, and of each employee participating in it. Inform the employee (and have them sign a work from home agreement that states the same) that this program is temporary, and will be subject to being terminated at any time. If you elect to terminate the program itself, or terminate the employee’s work from home agreement, they will be required to work in-office from the practice or facility, as per the requirements and or needs of the facility or office. .

Coding Manager Handbook -- Chapter 2: The Medical Record

* Medical Record Docmentation (requirements)
* Standard Documentation Criteria
* Medical Record Audits and Audit review forms
* The Legal Medical Record (Legal Considerations)
* The Personal Health Record (PHR)

In this chapter I will discuss the documentation of what is necessary for the medical record. I will give you documentation guidelines for both outpatient and inpatient medical records, a long-term care record, and also filing systems for care of the records. I will also discuss the differences between the standard medical record, the legal medical record, and the personal health record. Last but not least I will try to give you the basics of the electronic health record system. I will try and cover the basics of choosing a system, implementation, necessary documentation criteria, storage and retrieval, and types of systems available.

Medical Record Documentation – The necessary basics.
Every healthcare facility has a medical record of some type. All documentation by any provider must be recorded timely and accurately, be complete legible and properly maintained. Medical record documentation is critical, for care of the patient for current, past, and future medical needs. Documentation is also critical for billing and payment of the provider, for legal protection of the provider and the patient. The medical record also helps paint the picture for the next provider of care that follows the patient. The information contained within that record should show all aspects of that patient’s heath care. That provider of care may be a dentist, chiropractor, physical therapist, social worker, health researcher or any of the ancillary health care providers, in addition to our “garden variety” of family practice, general medicine, pediatric and internal medicine practitionersAll of these need to have access to the patients previous medical record, in addition to their own documentation being added in. this record is truly vital to any health care practice as it helps provide a continuum of patient care, and also provide some financial and legal cushion to the practice.
The basics of any medical record include administrative data such as patient demographic information, insurance and billing information, release of information, assignment of benefits and consent to treat. Clinical documentation should have the patient’s relevant history, or a current History and physicial report, any referrals/consultation/correspondence documentation from outside providers, ancillary laboratory reports such as x-rays, pathology or blood work, and a current medication list.
Why maintain the record? The medical record is an invaluable source of information and record of the patient care. This includes a record of care for current and proposed treatment or procedures, this also provides a record to assess completeness, medical necessity and quality of patient care. Most outpatient records are not used for data mining, but inpatient records are abstracted for their data for research purposes, and legal justification of procedures if necessary.
Maintaining, or documenting in the record should be standardized for each practice, with an entry made for each time a patient is seen or evaluated. Be sure that you identify each entry with the date/time, and have a signature and title of the provider. All documentation should be legible. It doesn’t matter if the documentation is typewritten or handwritten, but if written, should be in black or blue ink. Do not “erase” or “white-out” any of the errors. If an error is noted, simply strike through the entry with a single line, and enter that this is an “error” initial and date with your initials above the error, then enter the correct information. Use abbreviations sparingly, and be sure to use only those that are approved well-known, or standardized for your healthcare specialty. If you do use unusual or “in-house” abbreviations, it is helpful to have an abbreviation key readily accessible to avoid any misinterpretation of the data contained within the record.
Records retention is always a concern, and there is not a “standard” timeframe for a medical record. State law determines how long those records are to be kept. However, you can transfer the data from hard copy, or electronic format to a storage facility (again hard copy or electronic) to save space. The ideal situation, is to have ready access to those records if the patient suddenly presents for care, or you need to release a copy of those records to an outside provider, or for a legal reason. It should be noted however, that the record itself is the physician or practice’s property, but the information contained within belongs to the patient. The patient is in control of the amount and type of information released, unless it is excepted by law. You cannot refuse patient access to their record, or the information contained within, but you can request that the patient be supervised if they would like to view their record, or you can choose to charge them for a copy of their record(s).
Documentation guidelines for dictation within the record normally follows a specific format. The most popular format amongst providers is the SOAP format or method. The other methodology for documentation is the POMR Method. This is the “problem oriented” medical recording method.

SOAP is the acronym that stands for :
S – Subjective findings
Patient’s Chief Complaint (CC)
History of present/presenting illness (HPI)
History’s, Patient’s Past Medical/Surgial, Family, Social, (PFMSS)
Review of Symptoms (ROS)
O – Objective Findings
Examination of the patient, and the results thereof
A – Assessment
The diagnosis, or impression of the compilation of complaint and findings together
P – Plan
This is the proposed or undertaken treatment for the above assessment
This includes prescribed medications, patient instructions, and or recommendations or referrals for other procedures or testing, or even admission for hospitalization

POMR is a bit different than the SOAP format, as POMR has essential components that are documented. These essential components are:
Complete patient history and information from complete examination and tests, also known as
t the clinical assessmsent
Initial Plan(s)
A complete detailed plan outlines the course of proposed treatment
Problem List(s)
A running list of the patient’s problems. current and historical
Documentation of completion of patient visit (SOAP notes)
Treatments or recommendations are documented within the record.

When putting together your basic medical record into a new office, standardization of the medical record should be put in place as a compliance policy of the office. In the table below, you will find a 25 point “checklist” of what should be included within your medical record(s) . Standardization of the medical record makes it very easy to train all staff in what does/does not belong in the record This checklist can also be used when performing routine internal compliance audits of your medical record. Some practices are subject to compliance audits for federal, state or legal reasons, which again, if you have a standardized medical record format being followed, it is much easier to retrieve and justify the medical documentation

25 Point Standard Documentation Criteria for use within an outpatient/office medical record.

Standard – Outpatient/Office Record
1. Elements in the Medical Record are organized in a consistent manner  The Medical Record is clearly and consistently organized

 Records are organized in chronological order

 Medical record does not contain information for other patients.
2. Medical Records are maintained and stored in a manner which protects the safety of the records and the confidentiality of the information  All medical records are to be stored out of reach and view of unauthorized persons

 All staff should be trained in record confidentiality and correct release of record information

 All electronic medical records will have access compatible hardware and software that will generate a legible copy of the record in order to comply with a patient, governmental, legal , or 3rd party payor request for record review, or ability to maintain a current electronic back-up of the electronic medical file.

 Ability to scan or insert hard-copy records into an electronic format into the electronic health record and be able to generate a copy and or backup as above.

 Record retention will be adhered to as per State, Federal or international or appropriate governing laws for Medical Record retention.

 Discarded or purged records shall be eliminated by the following methods:

1) Paper records: by incineration, shredding, pulping, redacting or other compatible process which renders the records permanently unreadable.

2) For electronic format such as computer disks, flash drives, tapes or microscan files, these must be completely purged and “wiped clean” or sanitized and re-formatted, not simply “erased or deleted”

3) For media such as film, photos or CD/DVD files, or any other type of recording media, the media should be destroyed with no possibility of recovery, to include crushing, incineration, and or “electronic purge” which can completely “wipe clean” or “sanitize and re-format” not simply erase or delete the information.

3. Patients name or identification number is on each page of the record  Each record should have either the patients name, or a unique identifier on every page of the record,to include both front and back pages of the record if documentation is on both sides of the page.

4. Entries are legible  Entries that are handwritten must be legible to a reader other than the author.

 Content of the record is presented in a standardized format that allows the reader to understand the content without the use of a separate legend and or key identifier

 Entries shall be made in Blue or Black ink.

 Errors shall be noted with one strike-through, with the notation of the word “error”, initialed and dated, corrected information to then be documented and initialed and dated.

5. Entries are dated  All entries must be dated at the time of entry documentation.

 Physician based visit documentation should be posted within the record within 72 hrs or three business days.

6. Entries are initialed and/or signed by the author  All entries need to be initial or signed by the author. However, this may be a handwritten signature or initial, a unique electronic identifier or initial, and this applies to all staff who document or contribute ANY information into the medical record.

 When initials are used, there should be a designated “key” on file within the office, as to who the initials belong to, and the same for each signature on file.

Standard – Base Line Data
7. Personal and biographical (demographic) data are included in the record  Demographic information is to be documented and include information necessary to identify the patient

 Patient’s current address and insurance billing information to include group number, policy number and current claim processing address/phone number

 Current Signature and Consent for treatment, in addition to consent for billing 3rd party payor insurance on file

 Copies of currently insurance cards – to be updated as necessary

 Demographic information may be maintained in a computer database as long as it is retrievable and can be printed as needed to transfer the hard copy record or to another practitioner or for monitoring and or clinical test/clinical trial purposes

8. An Initial H&P examination for new patients are recorded within 12 months of a patient first seeking care or within 3 visits whichever occurs first

Past Medical history is documented and includes serious accidents, operations or illnesses

Family history is documented

Birth history is documented for patients under the age of 6.  Within the initial visit (H&P) for new patients, there should be written evidence that the request for prior (or historical) medical records from the previous provider of care have been requested (if rec’d filed appropriately into the chart)

Documentation to be included:
 Initial H&P should be patient pertinent information such as age, height vital signs, past medical, mental heath, preventive health, screening health information, in addition to the currently chief complaint, Past Family, Medical, and Social history,

 Review of systems, patient questionnaires or data, Immunization history, prior surgical interventions, current and past medication lists.

 Pediatric history should contain birth history documentation and should be age appropriate
9. Allergies and adverse reactions are prominently listed or noted as “none” or NKA  All allergies (environmental, physical, and medication should be displayed in a prominent place on the record.

 A notation of when the allergy was first discovered should also be included if known.

10. Information regarding personal habits such as sexual behaviour, smoking, alcohol, use, substance use or abuse or lack thereof is recorded.
 Documentation of “social” history is to be treated with extreme confidentiality, especially in the cases of sexual behavior, drug use/abuse, alcohol use/abuse, tobacco use/abuse, sexual orientation, Gambling or addictive behaviors, exposure to sexually transmitted diseases or aberrant behavior of any type.
11. Updated problem list is maintained  A current and on-going “problem list” shall be maintained to summarize important patient medical information such as a patient’s major medical diagnosis, past medical/surgical history and recurrent complaints.

 Continuity of care between providers within the same practice should be demonstrated by each provider contributing to this documentation and by initialing, or signature if contributing or reviewing.

Standard: Visit Data

12. Chief Complaint or Purpose for visit is clearly documented  A chief complaint is the purpose for the visit as stated by the patient, and is recorded I the record.

 Documentation supports that the patient’s perceived need/expectation was/is addressed

 All telephone encounters (and or e-mail/internet encounters) relevant to medical issues are documented in the record and reflect the provider reviewed and/or acted upon the data.

13. Clinical assessment and/or physicial findings are recorded. Working diagnoses are consistent with the findings  Clinical assessments and physical examinations are documented and correspond to the patient’s chief complaint, purpose for seeking care and/or ongoing care for chronic or worsening illnesses.

 “working” diagnoses or medical impressions that logically follow the clinical assessment and physical examination(s) are recorded.

14. Plan of action and or treatment is consistent with diagnosis (es)  Treatment plans (proposed or enacted) therapies or other regimens are documented and logically follow previously documented diagnoses and medical impressions.

 Rationale for treatment decisions appear medically appropriate and substantiated by documentation in the record

 Laboratory tests are performed at appropriate intervals, and follow medically accepted guidelines for theordering of specific lab tests based upon “working diagnosis”, confirmed or chronic illness, or “rule out” dignosis confirmation.

15. There is no evidence the patient is at risk by a diagnostic or therapeutic procedure
 The medical record should always show clear justification for diagnostic, therapeutic and interventional procedures.
16. Unresolved problems from previous visits are addressed in subsequent visits
 Continuity of care from one visit to the next is demonstrated when follow-up of unresolved problem(s) from previous vists is/are documented in subsequent visit notes.
17. Follow up instructions and time frame for follow-up or the next visit(s) are recorded as appropriate  “Return to Clinic/Office/Provider” in a specified amount of time is recorded at the time of the visit, or as a follow-up to a consultation by a specialist, outside provider of service, such as laboratory, radiological or other diagnostic care provider.

 Follow-up is documented for patients who require specified periodic oversight for chronic, or episodic illnesses for reassessment, or medical clearance.

 Patient involvement in coordination of care is demonstrated through the use of patient education, follow up and return visits.

18. Current medications are documented in the record and notes reflect that long-term medication are reviewed at least annually by the provider and updated as needed  Current and past prescribed medications are easily found within the record.

 A current listing of over the counter medication that the patient is currently taking is also readily accessible.

 Changes to any medication regimen is noted when it occurs. If the regimen is to remain unchanged, the record needs to include documentation that the provider reviewed and decided to continue as initial prescribed, or denote that no changes will be made at this time.

 Medication review should be documented and initialed by the provider/prescriber.

 All medications (prescribed and OTC) should be reviewed on an annual or on-going basis.

 If the patient is being seen by numerous physicians, providers, specialists, document (if possible) those medications who’s oversight is being done by the initial prescriber.

Patient Education
19. Health care education provided to the patient/family members or caregiver(s) is documented in the record and updated as appropriate  Patient education may correspond directly to the reason for the visit, i.e. specific diagnosis-related issues such as dietary instructions, medication instruction/usage, DME care

 Non-compliance of said education/counseling is to be documented

 Patient education must be problem pertinent
Screening and preventive care

20. Screening and preventive care interventions are noted according to AMA guidelines  ,Counseling or education is given within the confines of a “wellness adult exam”, “well child check” or “preventive medicine/preventive illness” examination

 Preventive services from an outside provider should also be noted. (eg Pap test performed by OB/GYN)

21. Immunization records are completed and updated as given or due  Immunization from birth to present should be noted within the record.

 Current immunization given should also be noted even if provided by an outside provider of care.

Consultation/Specialty referrals
22. Requests for consultations are noted and filed within the record as appropriate  The provider of care should document clear decision rationale for a specialist referral or intervention(when needed) (eg when ortho requested for fracture, ENT requested for unresolved sinusitis etc..)

 Referrals or consultations are provided in a timely manner and the patient’s diagnostic severity is considered.
Ancillary, Diagnostic, Therapeutic services
23. Laboratory and diagnostic reports reflect that the provider has reviewed and provided interpretation as necessary
 A procedure or plan should be in place that as soon as the laboratory or radiology reports are received into the office, the medical record is retrieved and the reports are attached to the record.

 The ordering provider, or current provider of care should review, interpret and initial and date, or sign and date that they have reviewed the tests.

24. Patient notification of the laboratory and diagnostic test results and instructions, and follow up care are noted and documented when appropriate
 If any further testing or therapy is to be performed, that the request for this to be carried out is documented in the record

 The patient needs to be notified of their lab/radiology/pathology test outcomes, and any further testing or follow up noted.
 If notified via telephone call, documentation needs noted within the record

 If notified via hard copy, then a copy of that documentation needs filed within the record.

Continuity of Care
25. Continuity of care and coordination of care with other/outside providers such as primary and specialty providers is noted and documented within the record.  Communication and coordination of care regarding the patient care needs documented either via telephone call (with handwritten documentation in the record the call was made and the outcome)
 If notification and coordination of care is faxed or on hard-copy those documentations should also be filed within the record. (i.e. referrals to/from specialists etc)

Now that you’ve got your records documentation standardized, you will need to decide upon how you want to file these records within your office. There are numerous types of filing systems for office, but the most commonly used for hard-copy records within the office setting is the “color coding” alpha, year format. With this type of format, the color of the chart is chosen by the first letter of the patient’s first name, the charts are then filed by color, by patient last name (which is put on the colored file folder) , by current year (i.e. 08, 09) which is then also denoted on the chart. Some offices utilize a one color of chart or use a manilla chart, and file all charts alphabetically, by year. This is very common in long-term care facilities, or behavioral health facilities.
Inpatient records have basically the same standard format as an outpatient record, except these records are created and filed as 1 record “per admission” rather than each patient having 1 record with all the admissions contained within. The inpatient record closely resembles the outpatient record. Below, I’ve attached the table for the “standardized” format of the inpatient record. Inpatient records will vary depending on which area of the hospital and what is contained and required for each department.
Basic Inpatient Record Content
Content of the basic inpatient medical record  The medical record will contain sufficient information to identify the patient, and to support the diagnosis, justify treatment and document the course and results. These records must contain:
 Patient identification data to include the patients name, address, date of birth , next of kin, a unique identifying number and consent forms.
 History and Physical form to include Chief complaint, History of present illness, relevant Medical past/family/social history
 Review of body systems
 Physical Examination of patient
 Diagnostic and therapeutic orders
 Reports of procedures and interpretation and findings
 Any clinical observations related to patient care
 Discharge Summary
 Principal, and Secondary Diagnosis,
 Operative and/or diagnostic procedures performed
 Physician Signature/Attestation
Anesthesia Documentation
 Topical
 Local
 Regional  Preoperative Anesthesia Note
Must include an anesthesia history and risk of anesthesia by an anesthesiologist or CRNA
 Postoperative Anesthesia Note
Post Anesthesia recovery must document any allergic or abnormal reactions to anesthesia. Also document the patient’s medical condition prior to, during and afater the procedure. And Upon discharge must identify any significant problems, or need for follow up.

Operative Reports/Surgical Documentation
 Inpatient Operative Procedures
 Outpatient Operative Procedures
 Day Surgery/Ambulatory Proc.  Pre operative note including pre-op diagnosis
 Indications for surgery
 Contemplated procedures
 Reasons for proceeding in a high-risk case
 Post operative Findings and Diagnosis
 Submission of specimens to Laboratory or Pathology
 Name of the primary surgeon and assistant surgeon(s)
 Description of the procedures
 Description of the incision
 Technical procedures used
 Method of closure
 Drains or other medical devices utilized or implanted into patient
 Condition of the patient at conclusion of the operative procedure
 Any other pertinent data
Discharge Summary
 Should be completed with 30 days of discharge/death  Reason for admission
 Primary and Secondary diagnosis(es)
 Clinical course of admission or treatment
 Any significant findings
 Procedures performed
 Treatment rendered
 Discharge examination of patient
 Discharge planning notes reviewed and evaluated
 Patient condition at discharge
 Specific instructions for patient and family.
 If patient leaves AMA, it should be duly noted.
Progress Notes
 Progress notes must be written and signed within a 24 hour timeframe  Document any changes in patient’s condition
 Document any changes in treatment modality, or medication orders
 Progress from therapies (such as RT, OT, PT)
 Results from treatment
 Discharge planning and coordination of care with ancillary departments

Long Term Care (LTC) Facilites (acute care, skilled nursing facility) documentation is a combination of the Inpatient and Office type medical record. Documentation for these records needs to be “reasonable and necessary”, plus provide care appropriate to the patient who cannot be discharged to a home environment. Again, the basics of the record should be employed such as the basic inpatient record criteria and content for documenting within the record, and patient demographics, consents, and billing information criteria are the same.. The listing below outlines what documents are normally found within the LTC record.
 Pre-Admission screening and any additional appropriate updates
 Acute Care (Inpatient Hospital) H&P
 Acute Care (Inpatient Hospital) Discharge Summary
 Acute Care (Inpatient Hospital) transfer record (and orders0
 Current Physician Orders
 Current Physician Progress Notes
 Physician Consultation documentation
 LTC Discharge Summary
 Diagnostic Lab orders, indications and results
 Surgery or procedure intervention documentation
 Documentation to support and interrupted stay
 Documentation to support any and all procedures ordered and/or performed
 Nursing documentation is to include initial and daily assessments, treatment records, wound care documentation, medication administration records, fall risk assessments, and ADL’s (Activities of Daily Living)
 Respiratory care documentation of initial and daily assessments, ventilator management logs, respiratory plan of care, treatment goals, units of treatment provided
 PT, OT and Speech-Language Pathology documentation of initial and daily assessments, plan of care, treatment goals and units of treatment provided.
 Nutritional Therapy documentation of initial and daily assessments, plan of care, and patient goals.
 Case Management, Medical Social Work documentation to include admission screening tools, discharge planning, coordination of team goals and plan of care.
 Team conference documents for the entire LTC facility stay to include all discharge plans, coordinated plans of care, conference attendees and titles (to include physicians, NP’s or PA’s)
 Documentation to support the need for complex LTC i.e. “reasonable and necessary” for appropriate patient care based upon the patients current medical status.

Each facility, whether an office, outpatient, or inpatient can and will have different formats for how the documentation record is to be organized within the chart. All need to adhere to the basics of what should be entered into each and every chart.

Medical Record Audits and Audit Review Forms
Coding managers are normally charged with completing or having to have completed pre and post medical record and coding audits. These audits can serve many different purposes. Once you determine the focus of your audit, you will need to have specific audit tools to obtain the information you require from the medical record. Most audits that will be performed will be looking for data such as:
 Facility or Office policy regarding compliance
o All Signatures and initials are documented with specified timeframes
o Record is complete, and legible
o Patient identifiers are on every page
o Billing information such as CMS 1500 and UB82’s have been filed
o Patient demographic information is current, and consents are signed.

 ICD9 Diagnosis, ICD9 Procedures, CPT Procedures are validated by comparison to the operative/procedure notes, admitting and attending diagnosis(es) and discharge diagnosis(es)

 Complications and adverse events are properly recorded and documented

 All billing records that are filed with insurance carriers via the CMS 1500 or UB82 are validated by comparison to the operative/procedure notes, admitting and attending diagnosis(es) and discharge diagnosis(es), to include any modifiers

 RVU, DRG, APC, assigned values are validated against the billing that was filed with the 3rd party payors.

 Medical Record Audits much also clearly demonstrate that the care was medically “reasonable and necessary” (as defined by CMS) and appropriate for the diagnosis and condition of the patient during the visit, admission, or procedure.

The audit of the billing record(s) will ensure that the diagnosis and procedure codes billed and reported to the 3rd party payors match what has been documented in the H&P, Operative/Procedure records, Progress Notes and discharge summary

THE LEGAL MEDICAL RECORD – Legal Considerations

Currently, the term “legal medical record” is interchangeable with the term“medical record”, however there are some subtle differences. For legal purposes, most written (or handwritten) records are condidered “heresay” and not admissible in a court of law. However, medical records or “legal medical records” are considered a “business-type” record, similar to business records such as sales receipts, accounts payable, accounts receiveable records. If the basic medical record documentation is recorded accurately and timely as per policy (or law if applicable) and kept as a representation of your “medical business” and considered as an “official recording” of what happened between the patient and provider of care, then the record can be considered a “legal medical record” and is admissible with court systems.
It should be noted that no matter how “good” the documentation is, it may or may not represent good or bad medical care provided by the physician. A patient has the right under HIPAA law to dispute any and all recorded documentation by a provider in regard to the patient’s care, and documentation of service. A well documented record is also an asset in legal cases of malpractice. If your record is poorly written or has many areas that are “blank”, “disorganized”, incomplete, or missing large areas of documentation, this can appear to a court of law, that the practice, or provider of care, may have areas of incompetence, or be negligent in regard to patient care .
In some cases, the billing record is a separately identifiable record. The billing record stands alone, and the medical record stands alone based upon what is documented within each record. However, under HIPAA, both billing records and health (clinical) records are considered protected health information (PHI). There are cases in which the medical record needs to be kept in a “lock box” of such. Those are normally records that are being reviewed or needed in an on-going legal process. Some of these legal processes include treatment of a victim in a crime, the offender of the crime, or even the birth records of a baby being adopted out. These records require additional security. The protocol for releasing copies of these types of records have specific State and Federal laws that must be abided by. In the case of normal day-to-day medical records, it is protected from unauthorized disclosure by law, and use of consents to release records need to be utilized in all areas of medical practice. HIPAA law also covers confidentiality, and release of medical information. HIPAA law allows for disclosure of the medical without a signed patient consent for healthcare providers who are directly involved in the clinical care of the patient, for medical offices who need to access the record for the purpose of obtaining payment from a payor for care or treatment of the patient, and the record may be released for routine healthcare activities such as documentation review, quality management review, safety issues/risk management issues, and if requested by a government entity for legal or criminal proceedings.(i.e by court order, subpoena or other legal directive)
Within the legal medical record there should be some internal mechanisim for documentation/release of record accountability. This documentation needs to record and authenticate all releases of records. Within that documentation, it needs to show who performed the release, what records were released, and where the records were released to.
It is advisable for any coding manager to have a good grasp of the law regarding release of medical records within their organization, and state. If you are unsure whether or not to release a record, choose to delay the release until you can legally verify that those documents can be copied and released. Always err on the side of caution. If you are employed in a large facility, your Risk Management department can usually give you the most current information.

The verbage of “electronic medical record” and “electronic health record” are interchangeable. A good definition of what an electronic medical record is a medical record in a digital format. Deciding upon an EMR is a huge task. They come in many different types and variations for single provider offices with simple record keeping and documenting, to an “all inclusive” EMR with transcription capabilities, Medical billing interfaces, with all the “bells and whistles”. No EMR is “perfect” even though the software is getting better and better all the time, there are still flaws inherent in all systems.
HIPPA , privacy and security laws also play a part, as your EMR must be able to document who has accessed the records, recorded, authenticated, into the record. In addition, the electronic software must also have the capability to store and retrieve records when needed . `-There are many resources for practices to look at prior to implementing an EMR.. Some practices have implemented what is known as a “hybrid” record, which utilizes both a “paper chart” and an “electronic chart”. Some practices have even begun scanning old paper chart records into the digital record for convenience rather than using both a paper and digital format for their documentation purpose.
In addition to the electronic medical record, many practices want to bundle their patient management/billing systems with their EMR. Some of the benefits of an EMR/HER is a reduction of medical errors, increase physician efficiency, improve documentation, reduce costs, and have a standardized documentation methodology for all of your records, and the ability to fax physician orders and prescriptions directly to other providers. Some of the barriers to an EMR/EHR is physician reluctance to use a data system, poor project management and implementation strategies, technical challenges (i.e. not enough IT support, or hardware/software issues, clinic financial impact to the up-front expense of converting to an electronic record, and frustrations of slow or poor performance of the record systems. Once you have decided upon converting to an EMR, here are a few ideas to get the project started:
 Identify the staffing needed/required for the EMR/HER projct
 Define the project management requirements and goals
 Understand the EMR hardware, software and/or network configuration tasks
 Introduce the EMR “workflow” concept for all areas affected (office and clinical)
 Review training strategies for the physicians, clinical and office staff

Change will happen! Be sure to include the staff and keep them apprised of all the changes that can and will be happening with an EMR/HER conversion or implementation. These changes WILL affect how the provider and clinical staff interact with patients and the office staff. These changes can and will affect the coding processes, the billing processes, how patients transition through the office. New taks and assignments will be happening. Your staff will have to realize that their “job functions” will change. If those changes are going to be long term, you should change their “job descriptions” to match these changes.
Currently there are 2 forms of implementation process for an EMR/HER.
 “The Big Bang” which is a full-blown switch from paper charts/record documentation to a full fledge EMR/EHR system deployed all at one time on a prescribed date.
 “Modular – Phase-in” method. This method allows for secquential implementation of the EMR at timed intervals and assessing success/failures as they are implemented.

There are pro’s and con’s to each of these methodologies. The “big bang” is initially more work, and more “pain” so to speak, but with the rapid deployment, also comes quicker acceptance of the changes by staff, and hopefully a quicker return on your investment. With the “modular – phase in” approach, there is less disruption to your practice, but employee and physician acceptance may be also slower, and have more criticism to the “faults” or “failures” that may be real or perceived by the implementation. Also, with the phase in – it may be more long-term out of pocket expense for project management, hardware and software IT support, and most of all – physician support!
You will want your EMR to document some of these basics… I have outlined these basics in the table below:
Documented into the EMR/HER by: Who What/Where
Receptionist/Billing Front Office Staff  Patient Demographic Information
 Patient Insurance Information
 Release of Records
 Consent to Bill, Consent to Treat
Nurse  Vitals
 Chief Complaint
 Subjective Information
 Past, Family, Medical, Social, History’s

Physician/Provider  Review of Systems
 Examination
 Medical Decision Making
 Orders such as Lab/X-ray/Pathology Requests
 Referrals to outside providers
 Documentation of Prescriptions (faxed or handwritten)
 Electronic Signature or attestation of provider/physician
Coding/Check out staff  All procedures and diagnoses correctly assigned to correspond with the provider/physician documentation
 All modifiers correct appended
 CMS 1500 filled out
 Appropriate co-pays collected
 Billing of the claim to 3rd party payor(s)

Planning the implementation of the EMR will be critical to the success or failure of the EMR/EHR for your practice. I love the saying “fail to plan, plan to fail” as that really sums up what happens with an EMR. Other critical implementation factors are the ability to flexible with the timelines, and know that those timelines may need to be adjusted, expecially if you are doing a “phase in” type conversion. If you are doing a “big-bang” conversion, you may have to evaluate if there are any “showstoppers” or critical issues that are identified prior to the “go-live” date.
Careful planning and training of the staff will also aid to the success (or failure) of the EMR conversion. Communication with the staff is vital, but within that communication, involve your staff in the processes of planning and training. Get their input and ideas. Many times, those who are working directly with the systems are the ones with the best ideas of how to make is successful. In addition, if the staff has bought into these processes, they will be more productive and effective when the final go-live, or full implementation takes place. Don’t place unrealistic expectations upon the staff or physicians. The learning curve of EMR implementations is usually underestimated. Even if productivity is still “the same” in the front office, it may be taking the physician or providers more time for documentation, therefore the the amount of patients seen per day by the providers are less.
Training, Training, and more Training! A good tool for training is to designate “super-users” who can help all staff learn and become proficient in all areas of the EMR/HER. Be sure to perform lots of “mock scenarios” to simulate all types of situations that could possibly happen. Once the staff is comfortable with the processes, reinforce the knowledge with mini-test scenarios, using verbal, written, and real-time “tests”. Do the same thing for the physicians, providers, and clinical staff. In addition to their training, once you “go live” reduce your practice schedule for a “reasonable” amount of time. This amount of time, should be determined by how comfortable the front and back office feels about the implementation, and you as the manager see how things are progressing. As things begin running more smoothly after the implementation, gear up the schedules back to the “normal amount”. In summary, PLANNING, PLANNING, PLANNING, TRAINING, TRAINING, TRAINING, will lead to EMR implementation SUCCESS!!!

What is a personal health record? This is a record that is created and maintained by the individual upon which it pertains. The “ideal” is that the PHR contains a complete summary of the entire health and medical history of the patient. An electronic PHR would ideally be able to be contained in a computerized data format that could be accessed by medical personnel. The idea of a PHR is a relatively new concept, but is gaining momentum based upon the fact that more and more of the population has access to electronic data via personal computers, hand-held data tools such as cel phone’s, laptop and mini-laptops and PDA’s. At this time, there is not a “formal” or “mandated” information set to be held within a PHR. The most common data that is held within the PRH is
 Personal demographic information
 Emergency contact information
 Date of your last physicial
 Name of your current Medical and Dental Providers of care
 Your blood type
 Allergies and adverse allergic reactions (such as to specific drugs, or medicines)
 What current medications are being taken (both over the counter and prescribed)
 Chronic and Acute illnesses and hospitalizations
 Surgeries
 Vaccinations (such as flu, pneumonia, or tetanus)
 Current lab tests and results
 Personal and Family health history
 Living Will or End of Life plans
No matter which type of data storage you choose, Paper, Personal Computer, Portable Computer, or Internet based, be sure to update the information on a regular basis, and let your family and providers of medical care know that you have a personal health record, and how they can be part of the accessibility, or interchange of the data.