A Report from AHIMA’s Coding Thought Leadership Council

By Anne Zender, MA

What does the future of coding look like? A panel of coding experts and health information management (HIM) professionals met in early June to answer this question and others.

This group convened as part of AHIMA’s transformation, a process that involves the creation of the “Coding Change Story,” a task force designed to envision the future of coding. This article is an edited summary of the panel’s discussion.

ICD-11: A Glimpse of the Future

Margaret Skurka, MS, RHIA, CCS, FAHIMA, attended an April 2019 meeting of the World Health Organization (WHO) Morbidity Reference Group and provided an update for the group on the development of the ICD-11 coding system. The World Health Assembly officially adopted ICD-11 in June 2019. The system will go into effect on January 1, 2022, which would be the earliest any country could implement it. Many countries will not be ready to transition to ICD-11 until later; for example, the US adopted ICD-10-CM/PCS in 2015 after many years of delays—25 years after it was endorsed by WHO.

Skurka said the US implementation timetable will depend on several factors, including whether or not there is a Clinical Modification and how quickly things move in Washington, DC. The system is designed to be fully electronic and comprehensive, Skurka said. While some countries such as Australia and Canada also have done clinical modifications in the past, WHO has strongly suggested that “it was built to be so comprehensive, we should not do a modification for a country … If we adopt the concept of electronic, we can move faster,” Skurka said.

Canada is already testing in a training environment, and Japan is likely to be the first to adopt, according to Skurka.

June Bronnert, MHI, RHIA, CCS, CCS-P, said she has participated in field trials for the United Kingdom as well. “ICD-11 is designed to be electronic, and I find it useful that way,” Bronnert said. “There is a lot of the same look and feel, but there are some big changes in how the system is designed. I liked the electronic piece of it and how you can move through the system. The international community is working and moving ahead.”

Has CAC Lived Up to Its Promise?

The panelists discussed a recent Journal of AHIMA article titled “Computer-Assisted Coding Reality Check” from the June 2019 issue that examined whether computer-assisted coding had lived up to its promises. In general, panelists felt that CAC has not been as successful as anticipated.

“The article really showed that CAC is not the panacea for coding staffing and productivity issues,” said Teri Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA. “That, to me, was one of the takeaways … we still need human interaction. CAC doesn’t do it all.”

Gail Smith, MA, RHIA, CCS-P, wondered, “A lot of the really easy stuff has already been taken away. Where does the rubber meet the road? What can’t the computer do?”

The panelists noted that “training” or properly calibrating the system can be problematic. Using CAC to support ICD-10-PCS coding can be “exceptionally difficult,” according to Lynn Kuehn, RHIA, CCS-P, FAHIMA.

“It is a complicated process to select the right root operation and then the right code” in ICD-10-PCS, said Kuehn. If users aren’t already trained in PCS, they can train their CAC systems incorrectly and it can be “almost impossible to redirect it to the correct type of coding.”

“PCS has been a game-changer in terms of how procedures are done,” Skurka said. And in hospitals, “you have to understand the medicine. That brings us to the educational programs and the kind of anatomy and physiology and pathology that is taught. Is that enough? We need to know more medicine.”

Educating Coders for the Future

On the topic of proper education and training for coders, there were a variety of opinions on how best to meet the needs of the future. “Wouldn’t it be great if we had RHIAs that were really truly trained in management, that had the knowledge of what coding is and does, and we had RHITs educated and ready to hit the ground running with an associate degree?” Kuehn said. “I know people were not trained that way, but it seems something like that would be the way to go. I know there was discussion of requiring a degree to have a credential except for the CCA. I can see where employers don’t know who is qualified to hire into which position.”

The panel discussed the need for more robust educational structures to support coding, as well as the need to distinguish between the many types of coding credentials. “Between the education and the various credentials, it can get muddy. How do we make it clear?” Bronnert asked. “When job ads list together requirements for one of the following: a four-year degree, a two-year degree, or the credentials tied to high school diplomas for the same position, it is a challenge to clearly distinguish the difference in skills associated between the various credentials.“

Jorwic said one of the biggest problems is hiring people with the experience sought after by employers. “How do you do that in an educational program beyond some sort of apprenticeship or what we can do in the classroom?” Jorwic asked. “That is what we hear: ‘We can’t get a job because they want experience.’”

“The market is a bit unrealistic,” observed Laurie Johnson, MS, RHIA, FAHIMA. “They don’t want to hire anyone fresh out of school without experience, but you can’t get experience unless somebody takes a chance and spends some time in educating them.”

Bronnert said it was important when hiring people to expect to do some education and training to build on existing skill sets. “You know you’re going to have to do some, you just want to know the starting skill set. If you create a program where the starting point is X, what skills do you want someone to have at the start and the end of the program?” Bronnert asked.

For employers, one panelist suggested, the best chance of success comes with substantial training or apprenticeship programs that provide training to employees in-house. This gives students the opportunity to code live information in a training environment, a chance they’re not likely to have in school.

Ideally, panelists felt that clinical education for coders would include a strong foundation in anatomy and physiology (A&P), as well as grounding in disease process and understanding of diseases and terminology. “I think we need to have really heavy-duty A&P,” said Rose Dunn, MBA, RHIA, CPA/CGMA, CHPS, FACHE, FHFMA, FAHIMA. “When I went to school, we had to do gross anatomy. I would love to see that coursework at the same level as nurses or med students. Obviously, you need medical terminology to define something. And some pharmacology would be beneficial.”

Smith pointed out that the way in which more-senior coding professionals were trained may not be transferable to today’s environment. “What do we need to know without our phones now? There’s some richness in education that could be built into this program,” Smith said. “We should not be tied into the way we were taught because I’m not sure its applicable anymore.”

Bronnert agreed. “I’ve read that the jobs we’re training for today may not even be jobs tomorrow, and the jobs of tomorrow, we don’t even know what they are today, because of how everything is evolving,” she said.

The Future of Coding

“With the electronic basis of ICD-11, and with SNOMED embedded in the foundation of electronic health records, what’s our take on the future of coding done by humans?” asked Dunn.

“I can’t think far enough into the future to think you won’t need a human to make decisions along the way,” Skurka answered. “Yes, there will be coding software, but I don’t know if the intelligence exists … It probably will happen as will everything else, but I can’t envision it happening soon.”

“Humans will be part of the process,” Bronnert said. “Exactly how will evolve and change, because technology is going to continue to change and to push us to think about coding workflows in new ways. As long as there is the element of subjectivity, clinical care, and context, I think we’ll be involved.”

Kuehn noted a common answer when people were asked about coding futures. “People said the most important attribute was a curious nature,” Kuehn said. “We’re trying to teach skills. Part of it is, we have to find a way to attract people to the field for the future who have this intellectually curious nature, because this is no longer ‘find a word in the dictionary.’ This is decision-making.”

Acknowledgements
June Bronnert, MHI, RHIA, CCS, CCS-P
Lisa Campbell, PhD, RHIA, CDIP, CCS, CCS-P
Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA
Rose Dunn, MBA, RHIA, CPA/CGMA, CHPS, FACHE, FHFMA, FAHIMA
Davin Foster, RHIT
Abby Hansen, MHA, RHIA, CCS, CCS-P
Kim Huey, MJ, CCS-P, PCS, CHC, CPC, CPCO, COC
Laurie Johnson, MS, RHIA, FAHIMA
Teri Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA
Lynn Kuehn, RHIA, CCS-P, FAHIMA
Mari Petrik, MBA, RHIA, CCS, CCS-P, FAHIMA
Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, CPC, FAHIMA
Margaret Skurka, MS, RHIA, CCS, FAHIMA
Gail Smith, MA, RHIA, CCS-P
Mary Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA

Anne Zender (anne.zender@ahima.org) is senior director, strategic communications at AHIMA.