Wendy Stanfield: Health Information Manager, Warringal Private Hospital, Melbourne: profile of a coder.
Subject: Medical librarians (Beliefs, opinions and attitudes)
Medical librarians (Practice)
Practice guidelines (Medicine) (Evaluation)
Medical protocols (Evaluation)
Pub Date: 02/01/2009
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Feb, 2009 Source Volume: 38 Source Issue: 1
Topic: Event Code: 200 Management dynamics
Persons: Named Person: Stanfield, Wendy; Stanfield, Wendy
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 216488660
Full Text: Background

As a school leaver in Melbourne in the year 1972, I had no particular career in mind. My work in the world of medical records had its beginnings when the Associate Diploma in Medical Record Librarianship caught my attention at a school careers night. However, as I finished my Higher School Certificate (Year 12) at the age of 17, I was ineligible to apply; at that time the requirements for entry were age 18, with passes in biology and typing (keyboard skills). These academic requirements were almost impossible to achieve in the prevailing secondary school structure. Nevertheless, I was able to find a clerical job at St. Vincent's Hospital in the Medical Record Department, where I spent 12 months working full time, and then as a weekend worker during my diploma course. I at least had the advantage of understanding the workings of a department by the time I started the course and also was reasonably confident that the course I had chosen would suit me. At the same time, I took a night course in typing as it was still a requirement for entry into the course.

When I began my Medical Record Librarian (MRL) course there were three separate types of coding systems to be learned: the International Classification of Diseases (ICD), the Hospital Adaptation of the International Classification of Diseases (H-ICDA) and the Standard Nomenclature of Diseases and Operations (SNDO), the most difficult system to master. Each classification had its own set of books (that also had to be carried!) and all systems had separate examinations that had to be passed. The operation and procedure codes for the ICD and the H-ICDA were obtained from yet another separate, Australian classification. Coding training included visits to hospitals to practise with 'live' records.

Work history

My first job after graduation in 1975 was at the Queen Victoria Hospital (QVH--later relocated and renamed as Monash Medical Centre), which used the SNDO coding system (in this I was considered unlucky by my fellow students!). Staff consisted of a Chief Medical Record Librarian (MRL), an Assistant MRL who did all the obstetric coding, a coder who was actually a qualified Italian doctor, and myself as the junior MRL. As such, I was a general coder and day-to-day supervisor of most of the clerical staff. The PMI (Patient Master Index), the equivalent of a very large mechanical Filofax, frequently broke down.

After two years at QVH, I moved to Prince Henry's Hospital. Prince Henry's (now no longer in existence) was a much more structured environment with a Chief, Deputy and usually three or four Assistant MRLs. As assistants, our duties were rostered on a rotating basis between supervising the outpatient clinics, training clerical and medical typing staff, clinical coding, and general duties. Computers were just becoming working tools at that time, and most procedures used manual paper-based systems, although I remember the deputy reviewing reams of computer printouts of bed-day statistics each day. Coding was done using H-ICDA and indexing was undertaken using a manual card system.

I was at Prince Henry's for a couple of years and then resigned and took some time off before being employed by the Agent Orange research project, reviewing Australian Army health records for relevant information. This also took me back to QVH for research into birth defects in the children of Vietnam War veterans.

In 1982, I was employed at Warringal Private Hospital (WPH) to set up the Medical Record Department. The second private hospital in the state to employ a Medical Record Administrator, WPH was about to undergo its first accreditation process review, for which a structured Medical Record Department was a requirement. The Department consisted of a room measuring approximately four by three metres, with a bench and shelves on two walls. Existing records were not colour coded and were filed in numerical order. A new coding system had to be set up and a cross-indexing system begun. There were no computer systems within the hospital. I was the only staff member in the Department and did all the departmental work, including typing the operation reports which were recorded on cassette tapes via a telephone dictation system. I remember asking some friends to come in and help get the coding up-to-date before the accreditation survey team arrived!

Following the achievement of successful accreditation, I left WPH to start a family and for the next couple of years worked part-time managing the records of a couple of nursing homes, typing clinical correspondence for consultants, from home, and coded back at Prince Henry's, where the coding system had moved on to ICD-9-CM.

I then obtained part-time professional employment at the Bundoora Extended Care Centre (BECC) where I undertook clinical coding. At a coding education session on one of the new editions I met other MRAs whose departments required additional professional coders, and during this period I did work for the Heidelberg Repatriation Hospital and at WPH. Casemix funding was introduced in 1993 initially for funding of public acute care hospitals, but as BECC was a public rehabilitation facility it was not in use there. At WPH I did my work using a dumb terminal and all coding was batch grouped at the end of the day.

During this period ICD-10-AM was introduced and, following pre-implementation education sessions held at the Northern Hospital, I recall despairing of ever being able to remember any of the new system codes in the way I was able to do with old coding systems, as ICD-10-AM was such a completely different style of coding from that which we had been using.

Current employment

WPH is an acute surgical/medical hospital with 143 beds and a 6-bed Intensive Care Unit (ICU). Specialities include major cardiac surgery, interventional cardiology, orthopaedics, general surgery, urology and oncology, with both day surgery and day oncology units. In 2001, WPH offered me a full-time coding position, which I hold today. The professional staff in 2001 consisted of a full-time Chief Health Information Manager and myself, with an additional 8 to 12 hours per week covered by contract or casual coding staff.

In 2006, I completed a short course in internal Clinical Coding Auditing at La Trobe University. Our Health Information Service regularly participates in professional practice placements for HIM students and we also have students occasionally for coding practice with hospital records. In 2007, a member of the administration staff undertook a fast-track terminology and coding course, which I helped to oversee; she now works as a clinical coder in our Health Information Service.

Health insurance, reimbursement, and clinical coding

WPH is currently part of the Ramsay Health group but has been owned by three or four other companies since I joined the hospital in 1995. Each health group owner has individual contracts with the major health insurance companies. While private health insurers HBA and MBF, for example, are wholly case-payment based, Medibank Private was partially case-payment based with partial per diem payment, but has now become wholly case payed, and the Department of Veterans' Affairs contract is all funded on a per diem basis. Therefore, when one is coding, it is necessary to be aware of each patient's health fund and the funding arrangement for individual DRGs. For example, a DRG of I03A, I03B or I03C attracts the same case payment under the HBA contract, but different payments for a patient insured with Medibank Private. Each health insurance fund contract may also have different outliers for the same DRG; for this reason, provisional DRGs are assigned on admission and a daily check made by HIS staff in close communication with billing staff and Nurse Unit Managers (NUMs), to keep an eye on days to 'step down' (1) or a change in the patient's condition that may require allocation of a different DRG.

Of further concern is the fact that the health insurance funds are only billing in version ARDRG 4.2 (and in some cases 4.1) of the grouper. This often leads to discrepancies when each new version of ICD-10-AM is produced, as new codes introduced do not always have correct mapping back to 4.2, which leads to grouping anomalies. Some new procedure codes, for example, are not recognised in 4.2 and cases can be allocated incorrectly to a medical DRG.

The hospital has regular (usually yearly) coding and billing audits carried out by an external company, and has recently undergone an audit by HBA which is a requirement under the contract arrangements if requested by the health insurance fund. As Ramsay Health is a national company, Victorian additions to the standards are not applicable.

While there is a continuing education program for nursing staff to ensure more accurate and complete documentation, this is more difficult with medical staff, most of whom are visiting consultants. However, we do get excellent documentation from the resident medical officers staffing our ICU. We are dependent on education provided in a nearby public hospital to educate the medical staff on rotation to Warringal. While on long-service leave recently, I was able to visit and speak with clinical coders at Ulster Hospital in Belfast, Ireland and found that this large public hospital, some 17,000 kms away, has the same problems with clinical documentation that we experience!

We are lucky at WPH to be located across the street from the Austin Hospital and are in contact with their HIMs, which allows us to share in their professional development and education sessions, where relevant. The HIMs within Ramsay Health in Victoria also conduct regular meetings which provide information, professional support and education.

In my experience, clinical coding over the last 30 years has been a non-stop progression of learning, from the original three systems through to our current ICD-10-AM 6th Edition. There were the e-Books to master, and which I now would not be without, and possibly next year the 3M Encoder will be employed. Clinical coding requires an excellent memory, the ability to decipher hieroglyphics and sometimes the detective skills of a Sherlock Holmes to put together the pieces that make up each patient's story. Real coding experience can only be learned in the hospital workplace and like the Never Ending Story, there is always something new cropping up.

Coding has certainly kept me busy and working whenever and wherever I have chosen over many years, and I am sure will do so for a few more years yet. I have a (not very) silent ambition to work in the United Kingdom or Ireland at some stage in the future and I hope my coding skills will make this possible.

Wendy Stanfield AssocDip(MRA)

Health Information Manager

Warringal Private Hospital

216 Burgundy Street

Heidelberg VIC 3084

AUSTRALIA

email: StanfieldW@ramsayhealth.com.au

(1) Case payment DRGs are paid within a specified number of days (e.g. 2 to 13 days). After the 13th day the patient is in 'step down' and a different (usually lesser) payment is in place.
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