Kristi Pollard, RHIT, CCS, CPC, CIRCC

Coding Educator Gives High Marks to Knowledge-Based Encoders

I’m a second-generation HIM professional—after my mom—who went to HIM school right after high school. I fell in love with coding during an internship and never looked back. I’ve worked as a facility inpatient and outpatient coder, coding supervisor and consultant. In my current position, I am a lead developer on coding training materials. ICD-10 implementation was a dream come true for me and my coworkers as we toured the country presenting ICD-10 education. In 2009, I started a mentoring group and blog for novice coders to help them find reputable educational institutions and get a leg up during the hiring process.

When I first started out, we didn’t have an encoder and I coded from the books. The first encoder I used was logic-based, and I often used it as a crutch or a learning tool without verifying unusual coding pathways with the book. Unfortunately, I either learned some things wrong or didn’t take the time to research things I should have. That created obstacles with auditors, who would tell me that the encoder wasn’t an official resource. I’ve used encoders that are all logic-based, all knowledge-based or a combination of both. I find the knowledge-based encoders to be closer to my roots as a book coder and I feel comfortable knowing that TruCode is giving me the same information as the codebook—and in the same format.  I like that coding references are readily available without having to search for them, so I can code more efficiently.

As an educator, presenting students with realistic coding scenarios is a must. And during training, “How did you get there?” is always the first question I would ask when a student arrived at an incorrect code. Since my training sessions involve presenting answer keys that include index entries, a knowledge-based encoder is a must. I also love the functionality of the ICD-10-PCS portion, which allows me to build only valid codes. Another requirement is being able to quickly and easily access coding resources from both the integrated Research Pane and the standalone references.

Whether you’re using a logic- or knowledge-based encoder, you still need to know the underlying coding system. “The encoder took me there” is not a valid rebuttal during a coding audit, especially if you would arrive at a different code if you had used the codebook. But I do feel the learning curve with a knowledge-based encoder is more intuitive once you know the book. With some logic-based encoders, errors can be made due to lack of coder knowledge or by quickly clicking through unspecified options.

I first heard about TruCode several years ago at an AHIMA conference when my company’s booth was next to TruCode’s. I got a personal demo and remember thinking if I was ever in a position to choose an encoder, I would look into TruCode. That opportunity came in my current position when I was hired as the first coding professional in a startup company. As co-chair of our AHIMA state component association, I facilitate coding coffee chats and since not everyone has a code book, I project TruCode on the screen as we work through exercises and look up references. People often ask me how I like the TruCode Encoder and my response is always the same: I love it because it feels just like coding from a book.

As for the future of coding, there’s a lot of discussion about advances in computer-assisted coding and whether there will be a need for coding professionals, but I think we’re here to stay. It seems impossible to automate every possible clinical and documentation scenario that could occur. Add to that the increasingly complex reimbursement environment, and I definitely see an ongoing need for coding and reimbursement specialists.

Cathy Brownfield, MSHI, RHIA, CCS

Coding manager embraces change within an ever-evolving industry

I started coding in a hospital after receiving my undergraduate degree in Health Information Management. After some time had passed I started coding on the weekends with a contract coding company. It did not take long for me to realize that working for the vendor was a better fit for me, as well as my family. I really enjoyed going into different facilities and seeing their systems and processes for coding. 

My goal was always to use my degree and credentials in management. At TrustHCS, I worked my way up through the organization. I believe that by starting out coding helps me to see the bigger picture as a manager. My experience of working in many different coding departments helped me to provide more insight to my clients and be an overall better manager to my team members.   

For someone who’s considering a career in coding, it is important to be open to continuing your education. Coding is not something that you learn once and never look back on—it’s an ever-evolving and ever-changing industry. The change is what makes it new and exciting market and you should embrace the change and learn to adapt quickly.

I’ve been a TruCode customer since 2010. I love that the references are front, center, and easily accessible. I believe this cultivates the culture of continuing your education. I also feel that knowledge-based coding is a good fit for me. It means that I’m coding by using my knowledge—my wisdom—in conjunction with a system that supports this in order to make the selection of the appropriate codes. I think a key benefit of knowledge-based coding is that it actively engages your brain to make decisions based on relevant resources, which strengthens the learning process. Over time it provides confidence which leads to stronger coders and better accuracy.

Becky Clark, RHIA

30 Years of Coding & Caring

Coder Turns Conventional Wisdom Into Smarter Medicine

This is one in a series of real life stories of how people like you improve patient care through the use of a more advanced and affordable encoder – TruCode. Whether your hospital is large or small, acute care or specialized, we’re sure you’ll identify with the people featured each month in these TruStories.

“When I went to the California Health Information Association (CHIA) convention a few years ago, I was on a mission. I went looking for a coding software system in a knowledge-based environment that wouldn’t lead a coder down the wrong path.

“I visited every coding software booth, gathered information and read through it all, then went back for more information on those that I thought would fit our hospital environment and coding staff.

“TruCode was the clear leader. I brought their information back to work, we had a few demos and the rest is history.

“Today, I feel we’ve been able to improve the tools and provide smarter information for our doctors, enabling them to do what they want to do: care for their patients.

“TruCode has also helped us create better coders by creating a better learning and working environment. Coding is a daily learning process. Every patient is different, so learning is daily and ongoing. TruCode facilitates that.

“It’s so easy to use. Coders love the way it interfaces with our system. They love the fact that it has links to all of the Coding Clinics and resources we need to select the right code. We’re using this feature all of the time. It either reinforces what the coder already knows or it gives them what they’ll need to know in the future. They love the way it presents itself on screen and that it doesn’t lead them down the wrong path.

“Because it’s knowledge-based, it’s also the best way to train entry-level coders and move them up. That’s why I love TruCode more than any of the other vendors out there.

“So what would I tell other health information directors about TruCode? I’ve already given half a dozen references and haven’t had one negative thing to say. So I’d just say, ‘You have to give it a try. Get a demo or go to their convention booth like I did. You’ll be surprised at how well TruCode will work for you”

– Becky Clark – Madera Community Hospital

Ruth Nater, RHIA

24 Years of Coding & Caring

Puerto Rican RHIA Wants No Coder To Be An Island.

This is one in a series of real life stories of how people like you improve patient care through the use of a more advanced and affordable encoder – TruCode. Whether your hospital is large or small, acute care or specialized, we’re sure you’ll identify with the people featured each month in these TruStories.

“Mennonite Hospital serves as the very center of care on our island. But with patients seeing a number of our facilities and various departments, coding was an immense challenge. Everything was so scattered and isolated.

“Fifteen years ago, we were a 116-bed facility, located in the center of Cayey. In 1999, we moved into a new facility handling three times the volume. With the acquisition of San Juan Bautista Hospital in Caguas, we’re now a group of four hospitals, numerous CDTs and a brand new, state-of-the-art cardiovascular unit in our Cayey location.

“With all of our growth and expansion, effective medical records processing became one of the biggest challenges I’ve faced.

“Also, coding is different in Puerto Rico. Although we fall under U.S. regulations and guidelines, insurance and reimbursements are processed differently than in U.S. hospitals. This can complicate things for billing and our medical records department. In our coding and billing process, effective communication between other departments and our extended facilities can also be challenging.

“But from my very first job in health care, I knew that I wanted to take on a leadership role that would empower me to implement the changes necessary to making a difference.

“Selecting and recommending a coding product that was brand new to our island was a bold step by Mennonite Hospital. Wisely, our administration made sure the Medical Records Department was included in the full evaluation process.

“I’m proud that they, after careful consideration and thorough evaluation, bravely voted to switch to TruCode. It’s allowing us to implement changes that will truly make a difference.

“Change can be intimidating, but TruCode made it easier than expected, right down to having a Spanish version of their Instructional Guide.

“We quickly realized we had a lot of benefits and tools that we didn’t have before — things that enable us to make better coding decisions.

“One of the things I love most about TruCode is that our coders now have everything in one place. They no longer have to leave a screen and go to another to do research. There are many references right at their fingertips. The live edits, alerts, coding advice are all combined to ensure they’ve considered all of the necessary codes.

“Today, we have better communication and, as a result, have a better understanding of the ambulatory and outpatient billing areas, too. So we’re able to keep more complete, overall patient records.

“The flexible TruCode licensing model also allows us to have the encoder tool outside of the Medical Records Department and in the service areas throughout the hospital. This makes it possible for our coders to assess the active medical record on the floor, prior to discharge, and proactively improve the overall coding and billing processes.

“As we identify discrepancies, we can communicate and collaborate with the appropriate hospital staff to minimize errors. Thus, the vital communication necessary between our staff and service areas has greatly improved.

“IDESS is the official TruCode reseller for Puerto Rico and the Caribbean and the help they provided, and continue to provide, is invaluable. Both IDESS and TruCode are prompt, friendly and effective in responding to any questions or concerns and needs we may have.

“But the change I like most is that our coders are no longer isolated. No longer an island. They’re connected.”

– Ruth Nater – Mennonite Hospital-Cayey

Jennifer J. Cline,

Coding/Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
9 Years of Coding & Caring

Coder discovers new code for productivity.

This is one in a series of real life stories of how people like you improve patient care through the use of a more advanced and affordable encoder – TruCode. Whether your hospital is large or small, acute care or specialized, we’re sure you’ll identify with the people featured each month in these TruStories.

“I’ve always loved the investigative aspect of HIM, with all of the researching and connecting of dots through coding and information. So when we switched encoders a year ago, I closely watched the effect on our staff and discovered an immediate increase in quality and productivity.

“While we haven’t done a formal audit yet, I can see the difference TruCode has made in my department and throughout the hospital.

“In outpatient coding and LCD edits alone, the impact has been enormous. LCD used to be a major challenge. Medicare has lists of CPT codes with diagnoses that have to be accurately documented for Medicare to pay for those services. So we have to be sure we not only code the proper diagnosis, but that the physicians are documenting properly for that code. Otherwise, the hospital won’t get reimbursed.

“We had two or three coders working on LCD errors every week. Now, it’s just me addressing them once a week with the Errors Report and TruCode even makes that easier to edit.

“TruCode has not only improved the productivity of our coders, but it’s helped our physicians be more productive, too.

“You can really see how well it works when we work with student interns. They’re trained with the code book. TruCode looks like the book when you choose a diagnosis, so with everything displayed in front of them, along with the TruCode research window, they instantly love it.

“I’ve worked with people who have used other encoders, too. When you’re just choosing a diagnosis based on what that encoder tells you to choose, you lose your coding skills.

“TruCode makes us better coders because it lets us learn and be more proactive and investigative. It helps us find the best diagnosis – not just the one we’re prompted to choose. It also won’t lead us down any wrong paths.

“Other service areas use it to be more efficient and productive, too. Our Pain Management Clinic, for example, uses TruCode like a first line resource. They don’t necessarily use it to code. They use it to determine early if the CPT code has an allowable diagnosis that coders and physicians can use. From the start, that helps physicians document properly and us code correctly, so that it gets paid.

“If I could give other team leads and coders only two reasons to investigate TruCode, they would be that you’ll have better coders all around and be more productive because of it.”

– Jennifer J. Cline, RHIT – Aultman Hospital

Karen Scott, MEd, RHIA, CCS-P, CPC

AHIMA Approved ICD-10 Trainer
Educator – University of Tennessee Health Science Center and Arkansas Tech University
CAHIM Commissioner

Educator uses encoder and infects thousands with passion for HIM

This is one in a series of real life stories of how people like you improve patient care through the use of a more advanced and affordable encoder – TruCode. Whether your hospital is large or small, acute care or specialized, we’re sure you’ll identify with the people featured each month in these TruStories.

“As an HIM educator and consultant, I’ve given full day seminars to nearly two thousand people, not counting the numerous webinar series I’ve conducted. I don’t market anything to them, but I constantly have people coming up to me afterward, asking me about the encoder I use in my presentation.

“People see the ease, simplicity and completely intuitive nature of TruCode, and they’re naturally curious. It’s unlike anything they’ve ever worked on, so they’re eager to know more and anxious to improve their hospital coding and HIM capability.

“I started using TruCode myself, as both a consultant and educator, and immediately fell in love with it. It not only helped me quickly and easily communicate key points in my seminars, but made me look great to my clients as a consultant, because it’s so responsive.

“People get comfortable with what they’ve used for a long time, and logic tree encoders have been around forever. TruCode doesn’t query the user and lead you down wrong roads like logic tree encoders; it prompts you with integrated coding advice, which can be customized to the facility and user level.

“All of the references that are relevant to what you’re working on are open and at your fingertips. Only TruCode does this.

“In short, TruCode puts the coders in charge, while helping them become more knowledgeable and more productive. It’s definitely the better encoder going forward.

“I love HIM. I never wanted to be in any other area of healthcare. It’s so exciting to be right in the middle of everything. Being able to fuel that passion in others and help them become better coders and HIM directors is incredible.

“I’ve personally used and recommended TruCode long enough that I hear the before and after stories. All I hear is how awesome TruCode is.

“In fact, I’ve had people move from a TruCode hospital to another hospital and call me to come in and give them a demo. To me, that says they love what I did for them, and that they believe in TruCode. As a consultant, it doesn’t get much better than that.”

– Karen Scott, Karen Scott Seminars and Consulting