Health Information Management

How to grow coders: 10 stages to a successful program

JustCoding News: Outpatient, June 16, 2010

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

by Elise Belanger, RHIA

For years the demand for coders has exceeded supply, and for many possible reasons. This may be because coders do not think that salaries are commensurate with the knowledge, expectations, and stress. And coders often move on to other positions and do not make a career of coding.

But whatever the cause, at the end of the day, HIM directors are faced with the challenge of meeting the volume of coding needs.

Filling the gaps

Many HIM directors turn to outsourcing to fill gaps in staffing, ensure coverage during vacations and leaves of absence, and fill vacancies. But finding a good company with well-trained temporary staff can be a challenge.

The good news is that outsourcing remains only one possible way to fill the gaps and meet coding needs. Another approach is to look toward technology to help improve the productivity of coders on staff.

Using a chargemaster is a common approach, but also the most limited in scope. In addition, encoders are popular and assist coders in coding accurately.

Another possible way to meet coding needs is for HIM directors to grow their own coders. This certainly requires considerable manager time and senior management support, but it can be worth the investment.

Growing coders in-house

Many facilities consistently face the need to increase productivity and do more with less. As a result, they have dropped many of the apprenticeship types of training that were the standard until the 1980s. But many departments lacking external resources may have no other recourse but to train their own coders. The following are the 10 stages of a successful coding apprenticeship or mentoring program, along with details regarding each level:

1. Recruitment. This involves looking for talent when interviewing for other positions or when working with existing staff members. It may also be accomplished through advertising for beginner or per diem coders.

2. Individualized programs. Design a program for each individual, based on his or her experience, test results, and interests. This may also include:

  • Offering formalized training if the coder has not had any formal instruction. (If he or she has, consider skipping the clinical practice and certification stages.)
  • Starting a certified coder with limited experience and knowledge as a per diem coder trainee or permanent coder trainee.
  • Testing candidates with a three-hour exam covering what they should be able to code for the position as well as some harder cases to see what they may be capable of.
  • Providing time frames, activities, and expectations for the program.
  • Limiting indirect coding functions.

3. Formal training. In this step, directors should assist the potential coder in finding the best training program for his or her situation (e.g., boot camps, college programs, online programs).

Describe what each option consists of in clear terms to help the candidate make a choice in terms of commitment of time, effort, and money, as well as what it may translate to in terms of career advancement. Answer any questions he or she may have and provide any readily available resources.

4. Clinical practice. During this phase, HIM directors and managers should:

  • Audit 100% of practice coding.
  • Notify departments that are downstream of the coder trainee to alert them that they may see an increase in errors.
  • Provide peer review. Most directors cannot perform the level of review required, but other coders can perform the verification and formalization. This reduces the senior coder’s productivity, but he or she would have had to code the record anyway, so having it prepared does help a little. Formalize the method for documenting the senior coder’s comments about specific errors and overall suggestions and recommendations. This saves time in the discussion between coders and provides good reference documentation for the coder trainee as well as for the HIM director.

5. Coding trainee, per diem. This step allows coder trainees to perform per diem coding to gain additional practice and solidify their coding knowledge after the clinical practice in an area is complete. It also allows the trainee to gain some confidence before learning the next area.

Typically, a trainee receives modest pay, because he or she is still learning. Directors should audit cases on a modified basis, selecting 10%–25% at random.

6. Certification. Certify coders (e.g., CCS or CPC) after they have completed appropriate training.

7. Permanent coder trainee. This training should focus on cases of advancing complexity.
Start with basic coding (e.g., office visits, labs, and simple x-rays).

8. Permanent coder on promotion ladder. Challenge the coder to learn more difficult or other types of coding to both increase retention and provide cross-training.

Start all coders at the bottom unless they are advanced coders not in the program. Consider beginning with simple outpatient cases (e.g., labs, simple x-rays). Move on to moderately complex x-rays, simple procedures, and ED and medical day hospital cases.

Further down the line, coders can tackle complex outpatient procedures and simple inpatient cases before finally moving to complex x-rays and moderate to complex inpatient cases.

9. Coding roundtables. Roundtables and other on-site group training exercises need to occur. Many find them helpful to do every other Friday afternoon, when productivity is low.

Consider providing a 20–30-minute educational component. Use AHIMA distance learning on specific specialties or discuss upcoming code changes, such as new codes that arrive in October and January of each year.

Also allow 20–30 minutes for discussion on coding—not operational—issues. Some training will also help coders meet their continuing education needs for their credentials.

10. Maintain reference information. For example, maintain updated procedure manuals, which will save time when training coders. In addition, maintain a “Controversial Code” book—a three-ring binder containing all codes disputed between various coders or between coding and billing staff members. In this way, the same discussions and controversies do not continue needlessly. Each code should have an example, the opposing rationales for coding it a certain way, and the final decision on how to code the case. Remember to demonstrate how to use all reference tools.

The program may sound daunting (and time-consuming), but experiencing backlogs and chasing coding companies takes just as much, if not more time.

Depending on the size of the department, the usual ratio of trainees to experienced coders is 1:4. Coders have expressed enthusiasm in moving up the complexity ladder because it is stimulating and they feel more connected to the group.

Editor’s note: Elise Belanger, RHIA, has been credentialed since 1975 and has worked in a variety of HIM capacities, including administration, teaching, and consulting, and is currently program chair for the Health Information Technology Program and Medical Coding and Billing Program at Gibbs College in Boston. E-mail questions to her at

This story was originally published in the June issue of Medical Records Briefing.

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular