The coding conundrum: a workplace perspective.
Abstract: Over the last few decades clinical coding has grown in complexity and importance in the eyes of bureaucrats, administrators and clinicians, as new uses for this valuable resource are constantly being identified. Anecdotal evidence suggests that many Australian hospitals are currently experiencing difficulty in both recruiting and retaining clinical coders. The current shortage of clinical coders is a national problem, rather than being peculiar to any one state, and has a multitude of causes. This paper discusses a wide range of issues that have been identified as being relevant to this situation, and they are elaborated from a number of viewpoints, including that of health information management. In this article suggestions for changes that could help rectify this situation are made.

Keywords (MeSH): Personnel Administration; Personnel Management; Mentors; Clinical Coding; Medical Record Systems, Computerised; Australia.
Article Type: Report
Subject: Medical informatics (Management)
Work environment (Management)
Practice guidelines (Medicine)
Authors: Postle, Barbara
Koeldnik, Nadia
Miocevich, Tanya
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 Computer Subject: Company business management
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 216488654
Full Text: For many managers, attracting and retaining clinical coders can be a real headache. We are an ageing society, which means that healthcare is now a growth industry with hospital beds providing an apparently never-ending 'turnstile' service. Most hospital Health Information Managers (HIMs) immediately link the word 'inpatients' with the clinical coding they indirectly generate, and groan at the thought of managing the associated increase in workloads, backlogs and deadlines which result from burgeoning inpatient turnover.

The sources of some of the headaches are easily identified; shorter lengths of hospital stays mean admission of growing numbers of inpatients, that is, greater patient throughput; while increasing longevity means that the modern western lifestyle many of us have enjoyed now has the opportunity to come back and bite us in the form of so-called lifestyle diseases. To those involved in clinical coding, these factors, together with a greater incidence of comorbidities, means an ever increasing workload. In addition, coders are confronted with coding books that resemble a maze, mountains of rules and standards to remember and an increase in coding complexity that reflects the significant advances in clinical care that has occurred in recent times.

The outcome of all this is that coding work is time consuming and requires the employment of highly skilled professionals in most workplaces, and, in common with many health professions, there is a national worker shortage. This is both a blessing and a curse, depending on where you stand. It is in the interests of everyone concerned in this area to look at the issues which have brought about this situation, and how it might be improved. In addition, many clinical coders realise that there is a level of ignorance in the workplace outside of the health information environment concerning just what clinical coding is about. Generally, there is little understanding amongst medical, nursing and allied health staff of the level of clinical knowledge and specialist skills that are required for accurate coding. When clinicians become involved in research and want to abstract information from medical records, however, the clinical coder's knowledge and ability to assist sometimes comes as a shock and pleasant surprise to them. To the HIM responsible for avoiding coding backlogs and submitting casemix data on time, this is often where the headaches start.

Clearly, it is time to think 'outside the square' in order to maintain and improve clinical coding services. As a starting point, we need to ask the following questions: Are there enough new coders entering the profession? Is the work environment supportive? What can be done to retain coders? Is the pay fair for the level of skill required? What staff development opportunities are available for clinical coders? Can we 'value-add' to clinical coding positions? Some of these questions are general and pertain to the 'big picture'; others can be addressed at a more parochial level.

We feel that all HIMs must engage in and contribute to this debate either from the perspective of clinical coders who can articulate what is needed, or from the perspective of line managers who have the capacity to improve systems and the work environment. Heads of departments have the responsibility to advocate outside of health information services for change. Yes, many workplaces have limited flexibility about what the HIM can or cannot do with regard to pay and physical working conditions, but this should not be used as an excuse for not attempting a great deal of reform.

At the outset, the extent of change that may be needed can seem daunting. The old adage, 'one bite at a time', holds firm here. If we look at what can be changed fairly easily and what is a more difficult or long-term project, we can prioritise and make an action list. By taking on the more easily achieved tasks first, we can build on success and work through the total list over time. The importance of the physical work environment is commonly acknowledged, but in reality many departments do not even have access to windows and natural light. Perhaps something as simple as a well chosen improvement in the general appearance and aesthetic appeal of the workplace is a good start. It is obvious that workstations should be ergonomically designed and the work environment should be one that supports workflow and coding related activities.

More questions can now be asked: Is there IT support and Internet access available? Is the clinical coder's computer capable of running all the desired applications? Are updates and releases installed as soon as possible? Is there clerical support available to clinical coders? Are discharge summaries completed within their timeframes? Is documentation within the medical record of sufficient depth to support clinical coding? Are investigations and results available?

Much of what happens within health information environments involves teamwork, regardless of the size of the service. Teamwork thrives on well thought out staff structures, communication, clear standards and guidelines, up-to-date job descriptions, staff training and development and systems that function well. We were all taught this in our training years, but we need to check that the theory translates into practice in the workplace. We also know that health information systems are far from simple and that one change can sometimes have unintended consequences. Timely intervention before problems grow out of proportion, communication, input from all staff, and feedback to staff can help avoid pitfalls and limit disharmony, all of which contribute to a work environment where staff are valued and respected.

Training and mentor support for beginner clinical coders can help the transition of new coders to the workplace and provide a solid basis for professional development. Different mentoring models exist, depending on, for example, the background of the new coder and the size and location of the hospital. In larger hospitals, support for the 'new kid on the block' is often provided in-house, whilst in small urban hospitals and those in rural, and particularly remote areas, mentoring may be external to the hospital or even the region, supplied by a government health department. Regardless of the model, the key to the successful attraction and retention of staff is an understanding of the needs of clinical coders and being able to support them in the performance of their duties without undue stress or frustration.

Australia has in effect a national clinical coding workforce. This is due to the roles played by the National Centre for Classification in Health and the Health Information Management Association of Australia, which offer coder education programs and accreditation of health information management courses. Coding issues such as salary entitlements therefore should be viewed from a national as well as local perspective.

In the area of recruitment and retention, remuneration rates cannot be ignored, particularly in the present employment market where it seems we have more vacancies than people to fill them. This means that across the country, we are 'robbing Peter to pay Paul', with staff moving between hospitals, public and private sectors and even different states to better their working conditions or salaries. It is not reasonable to expect people to remain in a position which offers a low pay rate with no likelihood of an increase; nor is it reasonable for the skills of clinical coders who have added responsibilities such as coordinating roles and responsibilities for statistics, edits, Performance Indicators for Coding Quality (PICQ), or for the development of reports, to be unrewarded.

This raises another question: What we can do as individuals? This question can be answered from a number of perspectives. Certainly with the increase in complexity of clinical coding and the increase in the level of skills coders need, in some states a case could be mounted for better and greater equity in pay between the different sectors and states. This may apply in particular to coders working in casemix environments where accurate coding and the understanding of casemix systems can contribute to significant increases in hospital revenue.

From a number of perspectives it is important that organizations that employ coders appreciate the tasks they perform and of course strive to retain them in their professional roles. The loss of clinical coders has financial repercussions for a hospital (apart from their role in attracting optimum funding, mentioned above); the departure of experienced staff will inevitably result in the loss of corporate knowledge, while recruitment of new staff can be difficult and stressful. In some workplaces, there can be a work overload, leaving no other option but the employment of contract coders at high contract prices. Surely it is better to look at the big picture, diagnose any problems and do your best to attract and retain staff before this situation can arise?

A high salary is not necessarily an overriding incentive for a person to remain in a particular position of employment. As Abraham Maslow (1943) theorised in his famous 'hierarchy of needs', once the fundamental physiological requirements for existence have been met, a person might seek social and psychological fulfilment. Inexpensive incentives can sometimes contribute to job satisfaction. Such factors as the flexibility of working hours, the ability to jobshare or work part time, organization of the work environment to meet a person's social needs, or strategies to structure work so that it provides mental challenge and variety can be crucial to work satisfaction. There is nothing like asking staff for their opinions in order to get feedback and to help us in understanding the issues and concerns of workers in this key area of health information management.

Some of these issues and concerns are within the HIM's sphere of influence, others are not. The ideal work environment is one where positive energy flows, where staff enjoy what they do and enjoy coming to work. How difficult can that be to achieve?


Maslow, A. (1943). A theory of human motivation. Psychological Review 50: 370-396.

Barbara Postle BAppSc, PGradDipPubHlth

Program Leader

School of Public Health

Curtin University of Technology

GPO Box U1987

Perth WA 6845



Nadia Koeldnik

Clinical Coder

Armadale Health Service

Albany Highway

Armadale WA 6112


Tanya Miocevich BAppSc

Manager, Patient Information and Clerical Services

Armadale Health Service

Albany Highway

Armadale WA 6112


Tel: +61 8 9391-2112

Fax: +61 8 9391 2149

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