Computer-assisted coding: Where are we today?
by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
In our computer-savvy tech world, the medical field has been notoriously slow to respond to newer technologies and applications of computer-assisted enhancements. However, in the HIM market, computer-assisted coding (CAC) has been touted to boost coding accuracy and productivity, in addition to being an important tool for the remote inpatient coder.
Background
The term CAC denotes technology that automatically assigns codes from clinical documentation for a human to review, analyze, and use, according to the Journal of AHIMA.
Currently, there are a variety of methodologies, software, and integration interface applications that enable a CAC application to read text and assign codes. This type of software reads the information in a similar way to how a spell-check application works on a traditional computer. According to some users, data-driven documentation (e.g., documentation that is dictated or typed) is more accurately processed by the CAC software than documents that are scanned into the system for the software to use.
CAC software works through recognition; it learns words and phrases, as well as learning the areas within a specific document where standardized words and phrases appear. CAC software also has the ability to discern the context or meaning of those words and phrases. The program then analyzes and predicts what the appropriate ICD-10-CM/PCS codes should be for the documented diagnoses and procedures it finds within the specified documents.
Software providing CAC functionality has been available for over 10 years, but it has come to the forefront of inpatient coding with the implementation of ICD-10-CM/PCS. CAC has allowed hospitals to reduce lag times and enhance DRGs while also finding missed MCC/CC diagnoses. The usage and integration of an electronic health record (EHR) has also played a role in better code assignment and usage for data analysis and outcomes.
It is yet to be shown whether CAC actually enhances a coder’s productivity rate. On the upside, CAC does give the coder a great place to start when working on a difficult inpatient record. CAC is now where we were more than 20 years ago when encoders were first introduced into the inpatient hospital marketplace for coding, abstracting, and data analysis.
Pros and cons of CAC
Due to the complexity of inpatient care records, clinical documentation, and the complexity of medical terms and abbreviations, many hospitals only use CAC together with intervention by human coders. However, the latest CAC software technology employs a type of natural language and syntax processing to compare, contrast, and extract specific medical terms from electronic data or typed text?so CAC stand-alone technology does exist. In studies conducted by AHIMA, though, the combination of a CAC with a coder/auditor has been proven to be just as good, or better than, a coder or CAC alone.
The biggest challenge CAC poses might be getting buy-in from the hospital coding and HIM staff. The HIM, coding, and clinical staff must all be a part of the changes and be on board with learning how to use this technology enhancement. In the past, there has been some uncertainty and fear related to CAC eliminating coders’ jobs. However, a good CAC solution in conjunction with HIM management allows coders to apply their critical thinking and analytical skills to create well-coded documentation of patients’ care. This, in turn, results in more accurate DRG assignment and reimbursement for the facility.
HIM and coding staff’s responsibility and role in the fiscal revenue stream will change as a result of CAC and similar technology. With this change must comes the acceptance that it takes both a human and a computer to successfully transform a CAC product into good financial outcomes and even better documentation.
As coders will surely agree, the final code selection for inpatient records should be based upon coders’ knowledge of coding guidelines, clinical concepts, and compliance regulations. When working with CAC, the coder has the ability to agree with or to override codes that the software determines.
Coders have the education to understand why a diagnosis or procedure should or should not be coded in a specific situation, and by using CAC, they can help the software learn to identify the importance of specific documentation and its relation to ICD-10-CM/PCS codes.
Many CAC vendors will try and sell their product based on the following list of features and benefits:
- Better medical coding accuracy
- Faster medical billing
- Greater coder satisfaction
- Identification of clinical documentation gaps
- Increased coder productivity
- More revenue from more detailed bills
- Return on investment?the CAC system quickly pays for itself
As we’ve said, it hasn’t been shown that CAC actually increases coders’ productivity. In reality, their productivity will probably stay the same, as a coder will still have to audit the information to determine whether the code generated by the software is correct. But in regard to the other CAC benefits on the above list, coder satisfaction should not be overlooked.
During AHIMA’s pilot testing of CAC software, the organization weighed in on some of the potential issues with using CAC software alone (with no human intervention). AHIMA noted that within specific areas of the pilot CAC testing in ICD-10, the coders did not accept 75% of the diagnosis codes presented, and they did not accept 90% of the procedure codes presented within the code sets. However, the information that the CAC software presented did give the coders a good starting reference to drill down to a more comprehensive diagnosis or procedure code.
Coders and CDI personnel will still need to be in charge of the following:
- Ensuring clinical documentation is complete and querying when appropriate
- Ensuring complete coding (e.g., for specificity)
- Ensuring correct sequencing of diagnosis and procedures
- Reviewing CCs/MCCs and DRG assignments with case complexity and severity
CAC, clinical documentation, EHR, and providers
Integration of clinical documentation from providers and physicians has always been a challenge, and combined with the implementation of ICD-10, it has presented a huge impetus for the adoption of CAC technology in hospital- and facility-based organizations.
Unfortunately, physicians still don’t provide thorough documentation, instead relying on CDI and coding staff to guide them. There has always been a disconnect in the language spoken by providers and the language spoken by coders. Physicians document in their comfort zone and fall back on terms such as "pneumonia," whereas a coder is looking for much more specificity. The integration of an EHR-based program and CAC for providers can lead to a good team relationship for both parties.Many CAC programs integrate well with hospital-based CDI programs and EHRs. These combination interfaces allow more real-time processing of possible code selection prior to the coder’s audit and review of the final code selection.
When the CAC software identifies these possibilities, there is an opportunity to identify and improve the DRGs with MCCs and CCs, as well as more quickly address areas for query and missed procedures or diagnoses.
Wrapping it all up
It is evident that coders and HIM professionals need to make a commitment to embrace change, which includes new technologies and integration of learning processes and opportunities. A hospital’s success depends on the coder acting as part of a team that will strive for successful outcomes for both the patient and the hospital.
Editor’s note
Webb is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist with more than 20 years of experience. Her coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at [email protected], and you can find current coding information on her blog at http://lori-lynnescodingcoachblog.blogspot.com. This article originally appeared on JustCoding, and opinions expressed are those of the author and do not represent HCPro or ACDIS.