Health Information Management

Cross-train coders to prepare for ICD-10 implementation

JustCoding News: Outpatient, July 25, 2012

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Cross-training coders has definitive short-term advantages, such as enhancing staff coverage during holidays and vacations and increasing the department's ability to handle periods of fluctuation in certain bill types.

Some coding managers might not realize that these benefits can also help hospitals with long-term preparation for ICD-10, experts say.

Productivity will suffer when ICD-10 takes effect so cross-training beforehand can help alleviate it, says Angie Comfort, RHIT, CCS, manager of professional practice resources at AHIMA in Chicago.

Some hospitals plan to exclude outpatient coders from ICD-10-PCS training, but employing staff members who understand both ICD-10-CM and ICD-10-PCS can help sustain productivity and ensure a smooth transition, says Comfort. Outpatient coders who typically use CPT® codes but are cross-trained in ICD-9-CM are likely to make the transition to ICD-10-CM much more easily because they are already familiar with inpatient rules, regulations, and guidelines, she says.

It may seem daunting, but focusing on coder cross-training in the midst of ICD-10 planning could be extremely advantageous, says Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer of First Class Solutions, Inc., in St. Louis. "The need for coders and coder training is high on the awareness list of the C-suite," she says. "An effective cross-training program throughout 2012 and 2013 should be on every HIM and coding manager's list."

Comfort agrees. "ICD-10 would be a perfect time to take advantage of it. We're all on the same learning curve," she says.

The timing is right in other ways. Hospitals should be well on their way toward EHR implementation during 2013, says Dunn. Clinicians should be documenting directly into the electronic record, and facilities should be taking advantage of natural language processing and electronic medical vocabularies, such as SNOMED. If an organization is approaching level six of the Healthcare Information and Management Systems Society EMR Adoption ModelSM, coders should be using computer-assisted coding (CAC) to enhance performance, says Dunn. These tools can be used in the short term to offset some of the time necessary to provide cross-training, she says.

Dunn encourages clients to consider the following strategies:

  • Cross-train ancillary coders so they can code ambulatory surgery cases
  • Cross-train ambulatory surgery coders so they can code inpatient cases
  • Delegate ancillary coding to CAC tools with coder oversight to maintain compliance

Pros and cons of cross-training
Despite the benefits of cross-training, many hospitals continue to separate inpatient and outpatient coders because of the two different code sets currently used in the United States (i.e., ICD-9-CM and CPT®), says Dunn. "As one becomes more of an expert in one or the other, accuracy and productivity improves," she says.

Coders specializing in either inpatient or outpatient coding also tend to fall into a rhythm, thereby increasing their productivity, says Dunn. "When a coder is in the rhythm of coding inpatients and then has to switch to outpatient—or vice versa—their thought process needs to change, and of course this impacts productivity," she says.

As hospitals implement ICD-10, some coders might decide to become more specialized-particularly those working in the interventional cardiology and radiology specialties, says Dunn.

Specialization may occur more frequently in larger, teaching facilities—rather than smaller hospitals, says Comfort. However, this specialization for some shouldn't deter hospitals from considering cross-training as a viable option, she says.

Hospitals also shouldn't eliminate the possibility of cross-training simply because of the time and resources necessary to do so, says Dunn. Productivity loss occurs for coders receiving and providing cross-training while it is under way. However, hospitals can reduce the learning curve by requiring cross-trained coders to code one record type for an entire day before changing to a different type the next day, rather than alternating throughout the same day, she says. After cross-training occurs, productivity usually resumes and even increases, she says.

Dunn anticipates that payers will find ICD-10 so "data-rich and predictive of resource utilization" that the industry may eventually transition to a single coding classification system. "Wouldn't that be a productivity enhancer," she says.

Plan an efficient, effective process
Dunn and Comfort agree that the pros of cross-training far outweigh any cons associated with the time necessary for cross-training. Consider the following strategies to ensure an efficient cross-training process:

  • Initiate cross-training with external education, such as an inpatient coding boot camp (for an outpatient coder), says Dunn.
  • Plan your timetable beforehand. The time necessary to cross-train a coder depends on various factors, including a coder's own knowledge and skill level and whether training is inpatient-to-outpatient or the reverse, says Comfort. Cross-training to the inpatient setting may be more difficult because of the volume of coding guidelines. Coders may be able to cross-train in as few as two months or as many as six months, she says. This includes the time necessary to cross-train a coder and any review period after cross-training occurs.

During this time frame, cross-training should be intensive. Coders receiving the training should code the new record type for approximately four hours daily, says Comfort. "If you don't have repetition, it takes a little bit longer to learn. If you're doing 10 to 15 charts per day versus one chart a day, it really does show," she says.

Dunn agrees. "The cross-training should be intensive—an hour a day doesn't cut it," she says.

  • Consider hiring extra staff. Coding managers should consider hiring contract coders while in-house coders receive cross-training, says Dunn. Doing so before ICD-10 implementation will be less expensive; demand for contractors will be high after implementation.
  • Audit cross-trained coders to ensure accuracy. Cross-trained coders should undergo ongoing reviews until they reach an agreed-upon accuracy rate and be subject to monthly or quarterly audits thereafter, says Comfort.

Editor’s note: This article originally appeared in Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at


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