Coding Evolution AMN Revenue Cycle Solutions RCS

The Evolution of the Hospital-Based Coder

Even though coding was being done long before the 1980’s, my journey began then and that is where this article will begin.  Big hair and all, I witnessed first-hand how the “coding bar” was raised year after year which impacted the pool of available coders. I referred to this era as The Great Coder Shortage and it lasted for decades. 

Prior to 1983 coding was mostly done for data collection and mortality reporting.  Coding Professionals had been working with ICD-9-CM for four years by this time and little did they know the codes they assigned would soon permeate every business process in healthcare.  The coder’s first rise to fame came in October 1983 during the birth of DRG’s (Diagnostic Related Groups).  The Department of Health and Human Services mandated the development of a way to classify inpatient hospital discharges.  At the same time CPT codes were required for reporting physician services for Medicare Part B.  The coder’s job was now tied to healthcare payment and the coder became a valuable commodity. 

In July 1987, as part of the Omnibus Budget Reconciliation Act, The Centers for Medicare & Medicaid Services (CMS), formerly Health Care Financing Administration (HCFA), mandated the use of CPT for reporting hospital outpatient surgical procedures. It was time again for the coder to enhance their skill level.  This coding system was written for physicians to understand and was organized very differently than ICD-9.  The index wasn’t very easy to navigate and once a procedure was located it sometimes presented a range of codes rather than one. This range of codes would then need to be referenced for the most appropriate selection based on operative report documentation.

In 1988 we saw the American Academy of Professional Coders (AAPC) make their maiden voyage into the coding field as physician-based coders were also in short supply.  

In 1992 The American Health Information Management Association (AHIMA) launched a new certification for coders called the Certified Coding Specialist (CCS).  Exceptionally skilled coders could now be nationally recognized for their top-level coding expertise and knowledge.  A CCS made the coder highly marketable in a booming field. In 1997 AHIMA developed the Certified Coding Specialist for Physician’s (CCS-P).  Now the physician-based coder could be recognized nationally for their exceptional skill levels as well.  The job market was ripe for skilled coders and finding work was relatively easy. 

Flash forward a few more years where the information age was upon us and progress was moving very quickly towards automation of health information.  The electronic health record (EHR) allowed coders to work from home which was an enticing benefit for facilities looking to hire.  However, the EHR provided coders some significant hurdles to overcome. Outdated problem lists and redundant information meant scrolling through numerous pages of electronic data adding valuable time to the coding process.  Coding professionals still face these challenges today to varying degrees.    

In 2007 a new classification system called MS-DRG’s arrived on the scene. This new system – with its expanded number of DRG’s – offered a more detailed way of classifying patients according to severity. Coders had to become skilled at understanding the impact that CC and MCC diagnoses had on reimbursement.  CC (complication/comorbidity) diagnoses had been around a while but MCC (Major complication/comorbidity) diagnoses were new.  Diagnoses with MCC identified diagnoses that required a significant amount of hospital resources to manage.  MS-DRGs also required the assignment of POA (present on admission) status to each diagnosis code reported, yet another element the coder had to learn and apply.

After 30 years of working with ICD-9-CM, the shiny new ICD-10-CM was implemented on October1, 2015.  Along with this new system came formatting changes, five times the number of codes and a separate coding system for procedures.  The new Procedure Coding System (PCS) challenged the coder to learn new guidelines, procedure definitions, and an entirely new code format; since PCS codes are built one character at a time.  ICD-10-PCS procedural coding system is unique to the United States so the demand for skilled coders will remain for some time to come.   

In recent years we have seen technology advances such as computerized assisted coding (CAC) arrive on the scene.  These tools assist coders by combing through massive amounts of documentation within the EHR and presenting possible code options.  This has saved significant time and staffing hours. Could it be an end to The Great Coder Shortage?  I say not.  CAC still has its challenges and limitations such as its inability to contextualize the record.  Coding Professionals need to be careful to not just blindly accept the codes that CAC suggests.  For example:  a newborn record may have the mother’s history on it and codes for diagnoses such as depression may be auto-suggested.  Healthcare data occupies a massive space of untapped potential.  A coder with the historical knowledge of coding and the commitment to continuously enhance their skill level will always be in demand.   

What’s ahead? ICD-11 is looming in the distance and I am told is built for machine application resembling SNOMED.  The initial assignment of diagnoses may be completely done by machine; so well that the World Health Organization (WHO) has no plans to develop beyond ICD-11.   It is speculated that the coder’s role will take on more of an auditing role.  One thing is sure; PCS and CPT procedure coding will continue to be done by coders for years to come offering a high demand niche’ for the Coding professional of the future.


Dee Mandley, RHIT, CCS, CCS-P, CDIP