A Shortage of ICD-10 Workers Threatens HealthCare Bottom Lines

While changes are transforming almost every industry, perhaps no individual profession will be impacted with the next few years as much as healthcare. And within that industry, no single job will be revolutionized as much as the medical billing coder. The looming transition from ICD-9 to ICD-10 will alter the profession and those directly responsible for accurate and prompt reimbursement for services.

(Note: ICD is International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization (WHO). It is used by 25 countries to report medical diagnoses and inpatient procedures. Accurate and prompt patient reimbursement by both governmental agencies and insurance companies rely on correct coding by hospitals and physicians offices. Delays in coding may result in inaccurate payments, higher accounts receivable, and more out-of-pocket expenses by patients or write offs by offices and hospitals.)

It is estimated that the complexity of the work and scope of managing the addition of more than 56,000 codes, a 5+ times increase, will result in productivity drops of 50 percent or more.  As a result only half the work will get done or twice as many coders will need to be hired.  And there lies the first of several problems facing hospitals and physician offices.

A lot of coders currently have just basic medical knowledge. That isn’t going to be enough. It is estimated that half of the coders today do not have enough education to make it. This alone will change education requirements and, subsequently, the type of individual capable of the work and attracted to a career in coding. ICD-10 requires a higher level of clinical knowledge than many Certified Professional Coders (CPC) have. If they haven’t prepared for that, they will be left behind. It will be a completely different world in coding going forward.

The magnitude of the change is significant. ICD-10 is not merely a modification of ICD-9 – it’s a disruptive change that relies much more on tacit knowledge than explicit information, something largely ignored by administrators and human resources.

What coders see no longer results in the conclusions you want – coding is no longer plug and play. This creates a critical and dangerous environment since efficient and accurate ICD-10 is required if the medical community wants to get reimbursed what they are due in a timely manner.

To understand the difference between just explicit information (know-that) and implicit knowledge (know-what and know-why), the iceberg metaphor is often used. Above the water lies the information that we know and can articulate without prompting. It is visible, readily available and shared by whoever wants it.  It is simply explicit. Explicit knowledge is codified and easily transferable in systematic methods, such as rules and procedures.

You can ask a know-that question to just about anyone in a job and they can likely regurgitate it back even if it doesn’t have anything to do with their job. You can compare explicit knowledge activity to snorkeling verses scuba diving.  Snorkeling is relatively easy and safe and fun.  Most training programs and just plain old writing-down-what-you-do fits into this level of knowledge.

Most of us can articulate explicit knowledge, what we call knowledge at this surface level, if we are prompted. This is what most assessments for certification and skill proficiency evaluate.

Below the waterline lies tacit knowledge, or implicit knowledge. Employees floating below the surface are often the organization’s subject matter experts.  They hold the technical and some company and industry knowledge that is revealed when they are asked. Few employees actually live in this space. And this is where things begin to get a bit more complicated.  Knowledge near the water surface is still fairly easy to work with.

As outsiders or new employees enter an organization, they seek out these “snorkelers” to find out how to get things done. The problem with the ICD-10 transition is that there are few scuba divers and lots of snorkelers. And transforming knowledge from divers to snorkelers diverts the skilled from getting their jobs done at a time when productivity is already diminished by the massive requirements of ICD-10.

Tacit knowledge on the other hand is non-verbalized and intuitive. It is deeply rooted in an individual’s actions and experiences. Experts often arrive at problem diagnoses and solutions rapidly and intuitively without being able to report how they attained the result (tacit knowledge). 

As we dive deeper into the water, the nature of this tacit knowledge changes. The view becomes murkier. It is harder to see ahead and get a handle on things.   Like the iceberg, the deeper you go the knowledge becomes more complex and vast. At these levels, we begin to see all the different reasons why our tacit knowledge is unspoken. 

Tacit knowledge rarely if ever is recorded.  It often lies deep inside the minds of the employee.  It is difficult if not impossible to capture. It’s not as easy as saying “Let’s find out what we know and then document it.”

That poses a gargantuan problem. Tacit knowledge is what we know and believe but cannot articulate, often because it has become so ingrained in our minds that we cannot separate it from who we are. That means if skilled workers leave, they take institutional knowledge with them along with the skills to do the job.

The timing for  ICD-10 couldn’t be worse for healthcare. Complex, new problems need tacit knowledge to solve them but few people have the experience. A less experienced individual (which is nearly every coder at this point since ICD-10 is so new) have to rely on explicit knowledge.  But because a whole new pool of rookie coders will be needed to complement the existing shrinking pool of skilled codes, most coders will have to rely on what they know in a job that requires application and critical thinking skills to bridge the gap between data and conclusions.

Transferring essential knowledge to a horde of snorkelers (and likely even inexperienced swimmers) quickly seems to be an impossible task. This tacit knowledge however is exactly the knowledge that organizations need to capture. It is the competitive advantage of an organization, held by a few people who make the connections between all the content that differentiates your organization from the competition.

The bottom line is that essential and valued coder skills will be needed for managing, interpreting, validating, transforming, communicating and acting on ambiguous and fast changing information. And those skills are and will be at a premium.


Ira S Wolfe