swcoder
New
We are looking on input in regards to how hospitals and/or clinics split their coding department. Is it by specialty, payor, facility coding, professional coding, etc.? Thanks!
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Wiki Input on how coding departments are split
- Thread starter swcoder
- Start date
rdoerrer
New
By payer. Medicare, Medicaid, Work Comp and commercial is how we did it.
swcoder
New
Followup question- are you able to tell me how many specialties you have and is this for a clinic, multiple clinics, hospital, etc? Thank you!
amyjph
True Blue
This is a really broad question and I think you are going to find you may get answers that are all over the place. I have seen it split by subspecialty, payer, no split at all (you get what you get in a queue), by provider, alpha by patient last name, and other ways.
It really depends on the size and scope of what is being coded and what are the coding team members tasks or expectations as far as work? Are they coding "from scratch", cleaning up edits only, working huge IP cases, working surgeries, office, labs, imaging, procedures, are coders expected to work AR at all, appeals, ? etc. etc.
What type are you trying to figure out and how big of a team/group?
It really depends on the size and scope of what is being coded and what are the coding team members tasks or expectations as far as work? Are they coding "from scratch", cleaning up edits only, working huge IP cases, working surgeries, office, labs, imaging, procedures, are coders expected to work AR at all, appeals, ? etc. etc.
What type are you trying to figure out and how big of a team/group?
rdoerrer
New
Under each payer it included the hospital, clinics, offices didn’t matter place of service it was divided solely by payer. I worked at MU health
My department splits by provider. I work for an oncology physician practice.
13 physicians (10 med onc, 3 rad onc), 13 NP/AP
13 physicians (10 med onc, 3 rad onc), 13 NP/AP
swcoder
New
Currently, our coding team consists of 10 coders. They code most accounts from scratch and include inpatient, surgeries, skilled IP, ER/Observations, same-day surgeries, outpatient services, clinics/wound care, radiology, PBB clinics, RT/sleep studies, PT/OT/Speech, etc. They also have simple visit coding error WQs for the ancillary and ambulance encounters when something needs addressed. They all work their personal coding denial WQs, some work the charge router WQs, $0 WQs, DNB account WQs, pending charge WQs. and I'm pretty sure I am missing some. That group of 10 coders code accounts for 2 critical access hospitals, 6 rural health clinics, 8 non-rural health clinics, for 30 specialties and 140 providers (give or take a few).
amyjph
True Blue
How is that working out? Are you having issues keeping up and trying to figure out a better split? On the surface, that seems like a lot especially if all is from scratch.
I agree that sounds like a big workload for 10 coders who are coding from scratch!
My department has 5 coders. As I mentioned in my comment above, we code for 26 providers. 10 med onc, 3 rad onc, and 13 NP/PA
Technically it's 7 coders, I suppose. We have 2 additional coders who work the medical oncology edits and denials. (I do my own rad onc edits & denials.)
amyjph
True Blue
As an example: I managed a coding team in a very large orthopedic practice with greater than 100 providers (including NPPs), PT, OT, multiple outpatient offices, IP/OP elective surgery, multiple hospital locations and trauma including Level 1 trauma, IP rounding, ASCs, radiology, procedures, injection clinics, physiatry, EMG, NCS, walk in/urgent services, after-hours, etc. & all related services and procedures in ortho subspecialities.
2 coders dedicated to trauma and all related surgeries and services. This was all from scratch, very complicated. Lots of multi-trauma, complex cases, high modifier usage, understanding IP/OP/Obsv rules, etc. Other coders provided backup for surgeries as needed.
2-3 billers dedicated to all therapy billing. Work queue which went through billing edits and some claims did not require human review.
5-6 dedicated to office/outpatient and all elective surgery cases. (all surgery from scratch, E/M, procedures, etc. went through scrubber and edit queue worked by coder).
1 supervisor/manager who also stepped in to code as needed. Which made it where the manager/supervisor was always coding and could not manage other duties as well.
Coders also helped with prior-auth and pre-coding review of a queue of all elective surgery/injection orders.
Each of the office/outpatient was split by specialty with a minimum of two at any time able to confidently and correctly code that subspecialty. Split by provider and grouped by subspecialty. When I took over this team it was split by just "whoever got whatever they got". What I found was that this did not allow coders to get really good at certain subspecialities and did not work with the strengths of each person to succeed. Some folks may not be great at spine but they were really great at sports or scopes. You have to set people up for success. Or, maybe someone really loved doing E/M so why would I make them work physiatry if they were not great at it? You can't always give people exactly what they want because the work has to be done, but I felt that we were more successful this way with less errors.
Coders in this group also helped a separate A/R RCM team (about with complicated appeals, questions, and helped with clearinghouse rejections. Coders answered questions from providers, others in the group, and RCM teams such as medical records, customer service and managers.
There was still too much work for this amount of coders and billers to handle at the time I was there. I think most places do not have enough help to manage the workload. It is a very difficult balance to have enough help and still make your HR budget but also get all of the work done. It feels like most places are always "behind". For example, in this setup above, the amount of elective surgery and injection orders submitted on a daily basis for coders to review, code and send to the auth team was always greater than 100 or more per day that came in.
I am no longer at this place, and it has gotten even bigger with a larger team now. I am guessing it is still a struggle.
2 coders dedicated to trauma and all related surgeries and services. This was all from scratch, very complicated. Lots of multi-trauma, complex cases, high modifier usage, understanding IP/OP/Obsv rules, etc. Other coders provided backup for surgeries as needed.
2-3 billers dedicated to all therapy billing. Work queue which went through billing edits and some claims did not require human review.
5-6 dedicated to office/outpatient and all elective surgery cases. (all surgery from scratch, E/M, procedures, etc. went through scrubber and edit queue worked by coder).
1 supervisor/manager who also stepped in to code as needed. Which made it where the manager/supervisor was always coding and could not manage other duties as well.
Coders also helped with prior-auth and pre-coding review of a queue of all elective surgery/injection orders.
Each of the office/outpatient was split by specialty with a minimum of two at any time able to confidently and correctly code that subspecialty. Split by provider and grouped by subspecialty. When I took over this team it was split by just "whoever got whatever they got". What I found was that this did not allow coders to get really good at certain subspecialities and did not work with the strengths of each person to succeed. Some folks may not be great at spine but they were really great at sports or scopes. You have to set people up for success. Or, maybe someone really loved doing E/M so why would I make them work physiatry if they were not great at it? You can't always give people exactly what they want because the work has to be done, but I felt that we were more successful this way with less errors.
Coders in this group also helped a separate A/R RCM team (about with complicated appeals, questions, and helped with clearinghouse rejections. Coders answered questions from providers, others in the group, and RCM teams such as medical records, customer service and managers.
There was still too much work for this amount of coders and billers to handle at the time I was there. I think most places do not have enough help to manage the workload. It is a very difficult balance to have enough help and still make your HR budget but also get all of the work done. It feels like most places are always "behind". For example, in this setup above, the amount of elective surgery and injection orders submitted on a daily basis for coders to review, code and send to the auth team was always greater than 100 or more per day that came in.
I am no longer at this place, and it has gotten even bigger with a larger team now. I am guessing it is still a struggle.
swcoder
New
Thank you for this response! Your reply seems to mimic our situation in a lot of ways.
Our HIM department includes 1 HIM leader, 1 HIM supervisor, 10 coders, and 2 HIM clerks for records releases, scanning, phone calls, etc. Like you stated above, the HIM leader and HIM supervisor spend most of their days in coding, denial, or error WQs to help their coding team and have such little time to spend addressing their own job duties or issues. Coders are given the choice of the top 3 specialties that interest them and/or what they would like to learn and take on and we try hard to given them those; however, we feel more often than not that we are asking coders to help out in other specialties just to keep our head above water. Coders answer question from providers or reach out to providers/nurses regarding missing orders, documentation that is missing, MAR documentation issues, etc.
Due to the wide variety of specialties we have and the amount of growth we have had over the last 4-5 years, we really have tried to having coders follow the CPT and ICD-10 coding guidelines and if the billers need the "charge" billed a different way or with a different modifier at the request of the payor, we ask for them to put in some sort of claims logic to have that done in the back. The billers don't typically like that, but there is absolutely no way 10 coders are going to remember payor policies and guidelines for multiple specialties on top of the coding guidelines they are to already follow, especially when they are getting pulled to code visits they don't have much confidence with.
I also feel like since we are critical access with provider-based rural health clinics, PBB specialty clinics, and additional outlying non-rural health clinics, it causes a lot of manual processes for coders in our Epic system and would also be one of the reasons why a lot of our coding is from scratch. With that said, we have tried letting certain clinic E/M visits without procedures get simple visit coded if we felt the provider was doing well with leveling and diagnoses; unfortunately, most of those have been pulled back to be reviewed by coding for one reason or another.
We have a billing department that consists of 1 Leader and 16-17 billers, which is a completely separate department from our HIM department. They are split by payors and alpha; however, coders receive an abundance of emails from them with questions that are more related to billing or asking how their payor wants something billed........our coders don't even have login access to payor sites to access the policies.
A prior auth team, that is separate from the coding and/or billing departments, was recently started and that has been nice.
Again, thank you for your reply and if you have any other suggestions, please feel free to send them on!
amyjph
True Blue
I have complete empathy for you! It's a difficult position. One thing I found that helped was to have dedicated coders to specific place of service or specialty. Pulling back a lot of the interruptions to the coders can help. Coders need to be able to focus, concentrate and code. You can't do that if you are constantly interrupted by emails, calls, and internal pings. Having set "Q&A hours", a specific time per day to reply to internal emails and calls, or a specific person dedicated per day to answering questions can help. It takes a big load off if you know you can concentrate for a day and code without having to stop constantly. I think it also depends on the EMR/EHR the place uses. Some are better than others. Having a specific day/person assigned to a billing or rejection queue on a rotating basis can also help.Thank you for this response! Your reply seems to mimic our situation in a lot of ways.
Our HIM department includes 1 HIM leader, 1 HIM supervisor, 10 coders, and 2 HIM clerks for records releases, scanning, phone calls, etc. Like you stated above, the HIM leader and HIM supervisor spend most of their days in coding, denial, or error WQs to help their coding team and have such little time to spend addressing their own job duties or issues. Coders are given the choice of the top 3 specialties that interest them and/or what they would like to learn and take on and we try hard to given them those; however, we feel more often than not that we are asking coders to help out in other specialties just to keep our head above water. Coders answer question from providers or reach out to providers/nurses regarding missing orders, documentation that is missing, MAR documentation issues, etc.
Due to the wide variety of specialties we have and the amount of growth we have had over the last 4-5 years, we really have tried to having coders follow the CPT and ICD-10 coding guidelines and if the billers need the "charge" billed a different way or with a different modifier at the request of the payor, we ask for them to put in some sort of claims logic to have that done in the back. The billers don't typically like that, but there is absolutely no way 10 coders are going to remember payor policies and guidelines for multiple specialties on top of the coding guidelines they are to already follow, especially when they are getting pulled to code visits they don't have much confidence with.
I also feel like since we are critical access with provider-based rural health clinics, PBB specialty clinics, and additional outlying non-rural health clinics, it causes a lot of manual processes for coders in our Epic system and would also be one of the reasons why a lot of our coding is from scratch. With that said, we have tried letting certain clinic E/M visits without procedures get simple visit coded if we felt the provider was doing well with leveling and diagnoses; unfortunately, most of those have been pulled back to be reviewed by coding for one reason or another.
We have a billing department that consists of 1 Leader and 16-17 billers, which is a completely separate department from our HIM department. They are split by payors and alpha; however, coders receive an abundance of emails from them with questions that are more related to billing or asking how their payor wants something billed........our coders don't even have login access to payor sites to access the policies.
A prior auth team, that is separate from the coding and/or billing departments, was recently started and that has been nice.
Again, thank you for your reply and if you have any other suggestions, please feel free to send them on!
It's complicated and I am not sure the answer, it is unique to each facility/group I think. It is "nice" to give employees what they want to code, but it sounds like you may need to just establish work splits and stick to it. The volume will dictate what every must do. Unfortunately, we can't always just code what we like.
Growing pains are definitely a problem. I hear you there. I remember being told, oh by the way, you have to onboard a group of four (or more docs) in a couple months from a separate practice. Make sure they are all up to speed and coded, yet not necessarily get any new coders. LoL.
Having "lower level" office visits and procedures go through the scrubber and having billers handle very basic items without a coder touch is an idea. Let the internal scrubber and the clearinghouse work for you. I understand the problems that can arise from it though. All of that goes out and then is rejected or denied anyway so someone has to look at it on the backend. From what you said, it sounds like your practice management system may not be optimized to scrub and edit by payer rules. That has to come from your internal IT and upper managers to set it up to work for you. It must be setup to get updates from the vendor, and it must be setup by payer so it follows the rules but also you don't miss revenue by coding everything by CMS/NCCI for example, when it really is a WC case (just an example).
Unfortunately, sometimes it takes the upper managers and directors to stop and take notice and the entire process and setup may need revamping. How much overtime is everyone working? Would that amount of overtime pay make more sense to pay an additional staff member? Is everyone burnt out? I can remember working 50-70 hours a week sometimes just to keep afloat. Is revenue consistently being lost because of timely filing, what is the denial & rejection rate? What is the charge lag time? Some of those KPIs and slow cash flow can help make the case that you need more help. Is all the work done in house or is some of it contracted out/outsourced?