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How Implementing a Career Ladder Improves Coder Accuracy

Analysis  |  By Alexandra Wilson Pecci  
   September 10, 2018

A career ladder for coders not only adds structure and rigor to training and advancement, it helps to improve coder accuracy

When Donella J. Lubelczyk, RN, BSN, ACM-RN, CRC, CRCR, entered her job as director of revenue cycle at Catholic Medical Center in Manchester, New Hampshire, she got a surprise when she visited the coders.

They were spending a lot of time on Google and YouTube researching procedures, turning to search engines to look up information such as the anatomy of the heart to properly code cardiac procedures.

"I felt that their training out of school didn't prepare them for the real world," she says. "Especially when ICD-10 came along [because] you had to code the approach to procedures, not just the procedures."

However, it's not only a lack of medical knowledge that impedes coders and other revenue cycle professionals from doing their jobs; it's the way they're often perceived in their own industry. Lubelczyk says that historically, revenue cycle jobs have been viewed as data-entry work that often doesn’t get the respect or understanding it deserves.

Lubelczyk has been on a mission to change that by providing education, mentoring, preceptorships, peer-audits, and other career-development resources and opportunities for the organization's coders.

"That whole group of people is responsible for multiple millions of dollars every day, so you get what you put into them," she says. "You need to support them and educate them and advance them. I felt that I needed to escalate their knowledge and also make them understand how important their work is," she says.

At Catholic Medical Center, the support, education, and advancement takes the shape of a coding career ladder that Lubelczyk established.

Structure and rigor

The career ladder adds structure and rigor to training and advancement for coders, while also providing clear requirements and in-depth job descriptions for each level of advancement. The ladder begins with an ancillary introductory data-entry position for those without certification, then advances to coder 1, coder 2, and coder 3, and team leader positions.

If coders want to advance, they need to do more than simply pass a test and work in the department for a long time. They need to apply for the new position by talking to Lubelczyk and the coding manager, Jenn Pelletier, CCS, CIC, CPC, as well as presenting a document outlining their accomplishments and why they want to advance.

Next comes a 90-day minimum mentorship program and preceptor training with supervisory audits throughout. Letters of recommendation and lots of advanced certifications (which are celebrated in the department) accompany coders on their journeys.

In addition, no coders advance in their first year. Instead, they have to meet work goals, such as accuracy and productivity standards, and they cannot have any performance or behavior issues.

With a career ladder in place, coding becomes more than simply a means to a paycheck.

"I'm looking for people who want to be on a career path," Lubelczyk says.

"I'm really looking for that all-around team player."

Lubelczyk says coders should be self-driven, value their education and achievements, and eventually become leaders and resource people within the department who can "code anything."

Clinical structure, solid results

Jenn Pelletier is among those who worked her way up the ladder, starting in the ancillary role and eventually becoming coding manager.

"When I first started there was barely any organization. You just showed up and here's what you did for the day," Pelletier says. Three different coders might have three different workflows.

"When Donella came on board it was eye-opening and so incredibly helpful," Pelletier says. "Now we knew what was expected of us. We had goals we had to meet, and we were recognized."

Lubelczyk credits her background as a nurse—which focuses on career advancement via continuing education, mentoring, and precepting—with the structure of the coding career ladder.

"I didn’t realize I was bringing my clinical structure [to the department] until one of my employees told me that a year ago," she says.

External audits with auditing vendors have showed impressive results, Lubelczyk said to HealthLeaders via email.

For instance, their department had a DRG audit of 100 inpatient records with a 99% accuracy in both 2016 and 2017, and emergency department charging and coding was 99% accurate in 2016 and 96% 2017.

"We also do internal audits of our coders at a minimum of twice a year, but [it] can be up to four times a year to ensure they are within the 95% standard," Lubelczyk said. "They may not be at the standard with the first audit, so we will audit them again after education to make sure they can reach the 95% standard."

Partnering with physicians

The department also now has physician champions who share the importance of coding with their colleagues, resulting in a more collaborative relationship between coders and physicians.

"It changed how most physicians would respond to our queries and our questions," Pelletier says.

She also adds that before those relationships were established, coders sometimes felt they were "bothering" physicians with their questions.

"I think most coders come out of school fearful of even speaking to a doctor," she says. "It's a different atmosphere now. It's more equal."

Lubelczyk has also arranged for physicians to do presentations for the coders about their work. A vascular surgeon shared information about veins and different approaches to procedures, and other surgeons have talked about dialysis, shunts, and obesity treatments.

Now that the career ladder is underway, Lubelczyk next wants to get coders in to watch live procedures to further deepen their understanding of what they're coding.

Lubelczyk stresses that the work coders do speaks to the overall quality of an organization, from quality scores, to risk scores, to mortality scores.

She also believes that "the industry itself needs to change in how they prepare coders" for their careers, and that in-depth coding degree programs should replace certificate programs. But until that happens she's making strides within in her own organization.

"I feel that it is very important for revenue cycle professionals to have a career ladder as it escalates their value and status while giving the employee something to strive for in the career that they are in," Lubelczyk said via email. "It motivates them to learn and grow further."

Alexandra Wilson Pecci is an editor for HealthLeaders.


Use a clinical structure to establish a career ladder for coders to provide consistency around training, advancement, and job expectations.

Mentoring, precepting, and auditing helps coders advance.

Establish partnerships between clinicians and coders to improve coding accuracy.

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