Independent practices, medical groups, and hospital systems are all feeling the same pressure: mounting coding backlogs, rising denials, and escalating labor costs. At the center of this problem is a persistent medical coding and Health Information Management (HIM) staffing shortage that is not going away.
Vacancies sit open for months. Recruiters are recycling the same local candidates. Meanwhile, unbilled encounters grow, DNFB days creep up, and payer audits get more aggressive. Many organizations react with quick fixes such as overtime, temp coders, or pausing certain lines of service. These tactics may buy time. They do not solve the structural problem.
This article explains how to approach the coding and HIM staffing crisis strategically, with a specific focus on global and offshore resourcing as one part of a multi‑layered operating model. You will see how a modern staffing strategy can:
- Reduce backlogs and DNFB without sacrificing accuracy
- Stabilize staffing costs in a volatile labor market
- Protect against denials, payer audits, and compliance risk
- Create a more resilient, scalable revenue cycle operation
Connect the Staffing Shortage to Hard Revenue and Compliance Risk
Many boards and clinical leaders still see “coding backlog” as an operational nuisance rather than a material financial and compliance risk. RCM leaders need to translate the staffing crisis into clear business terms.
Why it matters
When coding and HIM teams are understaffed, three things happen quickly:
- DNFB and A/R days spike. Every uncoded encounter delays billing and cash. For a hospital billing 5,000 encounters per week, a 10‑day coding delay can add millions of dollars to DNFB.
- Denials increase. Overloaded coders rush, miss documentation nuances, or misapply guidelines. Payers respond with clinical validation denials, DRG downgrades, and medical necessity rejections.
- Audit exposure grows. Inconsistent coding and weak documentation increase the odds of take‑backs in RAC, commercial payer, or internal compliance audits.
Key metrics to quantify the problem
Before you redesign staffing, benchmark where you are today. At a minimum, track:
- Coding turnaround time (TAT): Average hours from final documentation to coded status by setting (ED, IP, OP, pro fee). Many organizations target 48 hours or less for the majority of accounts.
- DNFB days and dollars: Trend total DNFB and the proportion attributable to coding delays.
- Initial denial rate tied to coding / documentation: Look particularly at DRG downgrades, clinical validation, and coding‑related edits.
- Coder productivity and vacancy rate: RVUs or charts per coder per day, along with open FTEs and time‑to‑fill.
Use these metrics to frame the business case: for example, “Reducing coding TAT from 5 days to 2 days will remove 3 days from DNFB, accelerating X million dollars of cash each month.” That is the lens your CFO and CEO care about.
Redesign the Coding & HIM Operating Model Before You Add Headcount
Throwing more bodies at a broken process only scales the chaos. Before you rely heavily on global or domestic staffing vendors, clarify what work should be done where, by whom, and with what level of automation.
A practical operating model framework
Segment your HIM and coding work into four buckets:
- 1. High‑complexity, high‑risk encounters
- Examples: inpatient surgical DRGs, complex cardiology, oncology, neurology.
- Characteristics: nuanced guidelines, high revenue per case, high audit exposure.
- Recommended approach: Retain close to home with senior coders, strong CDI support, and robust quality review. This may be internal or with a specialized partner that supports complex coding.
- 2. Routine, high‑volume work
- Examples: ED, urgent care, primary care, basic imaging, common pro‑fee services.
- Characteristics: repeatable patterns, steady volume, well‑established templates.
- Recommended approach: Ideal for scalable global teams, with carefully defined rules, productivity targets, and QA programs.
- 3. Administrative HIM functions
- Examples: ROI processing, deficiency management, chart completion follow‑up, scanning / indexing, encounter reconciliation.
- Recommended approach: Many of these can move to global teams with strong SOPs and secure infrastructure.
- 4. Exception handling and denial analytics
- Examples: coding appeals, clinical validation responses, root‑cause analysis of denials.
- Recommended approach: Keep a hybrid model. Internal leaders own strategy and payer negotiation. Global analysts or coders can support data mining, draft appeal templates, and pattern analysis.
What providers should do next
- Map current workflows from patient discharge or visit completion through final bill drop.
- Identify which encounter types are creating the largest backlog and which are most exposed to payer scrutiny.
- Decide which of the four buckets above each major worktype belongs in, then design staffing models accordingly (internal, domestic vendor, or offshore).
Only once you have this clarity does it make sense to layer in global resources at scale.
Use Global Coding Resources to Stabilize Capacity and Cost
Global and offshore coding is no longer an experimental strategy. It is a core component of the staffing mix for many large health systems and billing companies. When implemented correctly, it can reduce backlogs, normalize labor costs, and provide coverage that local markets cannot support.
Advantages of a global coding bench
- Access to a broader talent pool. Many international markets have strong pipelines of AHIMA or AAPC‑certified coders with experience in multiple specialties. This is particularly valuable when your local market is saturated or noncompetitive.
- Labor arbitrage that protects margins. Offshore coders typically work at a significantly lower cost per FTE than U.S. staff. Savings can be reinvested into technology, CDI, and domestic leadership roles.
- Extended hours and faster TAT. Time zone differences enable true “follow‑the‑sun” workflows. Encounters closed in the evening can be coded overnight and ready for billing by morning.
- Scalability for surges. Seasonal flu spikes, new provider onboarding, or delayed chart sign‑offs produce short bursts of volume. A global partner can ramp staffing faster than local hiring cycles.
Risk management checklist for global coding
Global resourcing is not risk free. To reduce exposure, vet partners against a structured checklist:
- Compliance and security
- HIPAA‑compliant infrastructure with documented policies and BAAs
- SOC 2 or similar attestation for controls around data and access
- Facility controls such as restricted devices, access logging, and no‑paper or no‑USB policies
- Clinical and coding expertise
- Verified AHIMA / AAPC certifications with ongoing CEU tracking
- Demonstrated experience in your key specialties and payers
- Quality scores (accuracy, audit results) across other U.S. clients
- Governance and transparency
- Clear SLAs for TAT, accuracy, and productivity
- Real‑time dashboards or regular reporting on work queues and KPIs
- Named escalation paths for coding, IT, and operational issues
Start with a defined scope such as ED or pro‑fee coding for non‑complex visits. Measure performance for at least 60 to 90 days before expanding into higher‑complexity work.
Protect Data Quality With Robust QA and CDI Alignment
One of the biggest concerns executives express about global or outsourced coding is quality. The answer is not to avoid global staffing. It is to design a layered quality program that spans internal and external teams.
Build a quality framework that works across borders
At minimum, your quality model should include:
- Structured dual‑coding or sampling.
For new teams or new specialties, dual‑code a percentage of charts with internal coders for the first 60 to 90 days. After that, maintain ongoing random sampling, for example 5 to 10 percent of volumes, depending on risk. - Standardized coding guidelines.
Internal and global teams must work from the same playbook. Develop enterprise coding guidelines, specialty‑specific rules, and escalation paths for ambiguous documentation. Store them in a shared, version‑controlled repository. - Closed‑loop feedback with CDI.
When coders identify documentation gaps, there should be a consistent query process that feeds back to providers and CDI. Over time this reduces repetitive clarifications and improves physician behavior. - Root‑cause analysis of coding denials.
Do not just overturn denials. Classify them by cause such as guideline misinterpretation, missing documentation, or payer‑specific quirks. Use this to adjust training plans and rules for both internal and external coders.
Practical KPIs for coding quality
Track quality separately for internal and global teams, but under the same metrics:
- Coding accuracy rate from internal QA or external audits (target often 95 to 98 percent or higher depending on case mix)
- Percentage of accounts requiring coder queries to providers
- Denials per 1,000 encounters attributable to coding or documentation
- Successful overturn rate on coding‑related appeals
Report these KPIs alongside TAT and productivity. This keeps the message clear: speed cannot come at the expense of accuracy.
Automate the Routine, Reserve Humans for the Exceptions
Coding and HIM staffing is only one side of the equation. The other side is how much low‑value, repetitive work you can eliminate or streamline through technology so the coders you do have can focus on high‑value tasks.
Automation levers that directly relieve staffing pressure
- Computer‑assisted coding (CAC).
CAC tools read clinical documentation and suggest codes for human review. They are not a replacement for coders, but they reduce keystrokes and help standardize application of rules. CAC is particularly useful for repetitive outpatient services and can increase coder throughput significantly when tuned correctly. - Front‑end clinical documentation tools.
Smart templates, specialty‑specific order sets, and EHR nudges help providers capture the necessary specificity at the point of care. Cleaner documentation means fewer queries and faster coding, regardless of where the coder sits. - Work queue and prioritization engines.
Automate routing of encounters based on payer, patient type, or financial risk. For example, prioritize high‑dollar or timely filing sensitive accounts to your most experienced coders while routing routine work to global teams. - Robotic process automation (RPA) for HIM tasks.
RPA can support indexing, record retrieval, and some aspects of deficiency management, all of which reduce noise for your core coding staff.
How to decide where to automate first
Apply a simple two‑axis framework: volume and variability.
- High volume and low variability (for example routine imaging or labs) are prime candidates for CAC and workflow automation.
- Low volume and high variability cases should remain in the hands of top coders, supported by robust CDI.
Combine this with your staffing design. Routine work can flow to a blend of CAC plus global coders. Complex work flows to your internal experts. This structure uses each resource where it has the greatest impact.
Governance, Change Management, and Communication Make or Break the Strategy
Technology and offshore partners will not fix a staffing crisis on their own. Without strong governance and transparent communication, you risk cultural resistance, finger pointing between internal and external teams, and inconsistent performance.
Elements of effective governance
- Executive sponsorship.
Ensure a senior leader, often the CFO or Chief Revenue Officer, explicitly supports the multi‑sourced coding model and understands its financial impact. - Joint steering committee.
Include internal HIM and coding leaders, revenue cycle operations, IT, and your global partner. Meet regularly to review KPIs, upcoming changes such as payer policy shifts, and continuous improvement opportunities. - Standard communication cadence.
Use weekly operational huddles, monthly performance reviews, and quarterly strategic reviews. Share the same dashboards across internal and external teams. - Transparent change management with staff.
Explain to internal coders why global resources are being added: to relieve pressure, stabilize backlogs, and allow them to focus on complex, higher‑value work. If you skip this step, morale and retention can suffer.
What to do in the first 90 days
- Define governance structures and meeting cadences before the first offshore coder accesses your system.
- Communicate clearly with internal teams about what work is moving, what is staying, and what opportunities exist for upskilling.
- Pilot with a single service line or region. Track TAT, accuracy, and denials weekly. Make adjustments quickly.
Bringing It Together: A Resilient, Multi‑Sourced Coding Workforce
The medical coding and HIM staffing crisis is unlikely to resolve through local hiring alone. Demographics, burnout, and increasing documentation demands all point in the same direction: U.S. organizations need more flexible, global, and technology‑enabled models to protect revenue and compliance.
A strong strategy brings together:
- Clear visibility into backlog, DNFB, denial patterns, and staffing gaps
- An operating model that allocates work based on complexity and risk
- Global coding resources to handle routine, high‑volume work reliably and cost effectively
- Rigorous QA and CDI alignment to safeguard accuracy and audit readiness
- Automation of repetitive tasks to free human coders for true judgment work
- Governance and communication that keep internal and external teams aligned
If your organization is evaluating whether to expand offshore coding or re‑architect your HIM model, start by quantifying the financial impact of your current delays and denials. Then design a phased roadmap that pilots global resources in the lowest‑risk areas and scales based on data.
Choosing the right billing and coding partner is as important as redesigning your internal workflows. We work with platforms like Billing Service Quotes, which help healthcare organizations compare vetted medical billing companies by specialty, scale, and operational needs without weeks of cold outreach and RFPs.
To discuss how a multi‑sourced coding and HIM staffing model could reduce your backlogs, stabilize cash flow, and lower denial risk, contact us. A short conversation can help you translate these concepts into a realistic roadmap for your practice, medical group, or health system.
References
Centers for Medicare & Medicaid Services. (n.d.). Medicare fee-for-service improper payment data. https://www.cms.gov
American Health Information Management Association. (n.d.). Workforce studies and industry reports. https://www.ahima.org
