Sunday, October 2, 2016

Computer Assisted Coding – Where are we today?

Some good Information for us that actually work with computer assisted coding.  

*********************************************************************************Originally posted from August 19, 2016 (as written by me!) 

In our computer-saavy 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 , (aka CAC)  has been touted to boost coding accuracy and productivity, in addition to being a terrific tool for the “remote” or “at home” HIM/inpatient coder. 

“The term computer-assisted coding is currently used to denote technology that automatically assigns codes from clinical documentation for a human…to review, analyze, and use.”   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, the data driven documentation (eg.  dictated/typed etc.) is more accurate from the CAC than documents that are scanned into the matrix for the CAC to utilize.   

CAC software works on a recognition premise, and “learns” words and phrases, as well as “learning” the areas within a  specific document as to where standardized words and phrases appear, (eg similar to a macro).  CAC software also has the ability to discern the context and or “meaning” of specific words and phrases.   The CAC then analyzes and predicts what the appropriate codes (ICD-10cm and pcs) should be for the documented procedures and diagnoses it finds within the specified documents.  

Computer-assisted coding (CAC) software has been available for over 10 years, but has really come to the forefront of inpatient coding with the implementation of ICD-10cm and ICD-10pcs and a way for hospitals to reduce charge lag-times and enhance DRG’s and find those “missed” MCC/CC diagnoses.  The usage and integration of an electronic health record (EHR) into a CAC has also been a factor for better code assignment and usage by the CAC for data analysis and outcomes.  However, it is yet to be shown that a CAC actually “enhances” a coders’ productivity rate.  On the up-side a CAC does give the coder a great place to “start” when working on a large difficult inpatient record.   A CAC is now where we were 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 used, many hospitals don't have,  or only use the CAC with “real coder”  intervention.  However, the latest CAC software technology employs a type of natural language and syntax processing to compare, contrast and extract specific medical terms from the electronic data or typed text.   The CAC stand-alone technology does exist, however in studies by AHIMA, the “combination” of a CAC with a coder/auditor has been proven to be as good or better than a “coder” alone,  or a “CAC” alone. 

Yet, the biggest Pro/Cons of a CAC is getting the buy-in of the hospital coding and HIM staff.  As the medical field is ever-changing; the HIM, coding and clinical staff must all be a part of the changes and be on-board to this new technology enhancement to their job.  In the past, there has been some uncertainty and fear related to job-elimination of coders in regard to a CAC implementation at the facility.  However, a good CAC  in conjunction with  HIM management utilization of both, allows coders to apply their critical thinking and analytical coding knowledge skills to create a well coded documentation of the patients’ care.  This in turn,  relates to better DRG and reimbursement for the facility. 

The HIM and coding staff responsibility and role in the fiscal revenue stream will change.  With this change 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 coding documentation.  

Coders are quick to agree that the final code selection for inpatient records should be based upon their knowledge of coding guidelines, clinical concepts, and compliance regulations.  When working in tandem on a CAC, the coder has the ability to override and agree/disagree with the codes that the CAC determines.
Coders have the education to understand why a diagnosis or procedure is, or is not coded, and with that by using the CAC, they can help the CAC “learn” to distinguish the importance of specific documentation and it’s relation to ICD-10 cm/pcs codes. 

Many CAC vendors will try and “sell” their product based upon this listing of “Pros”…

·         Increased medical coder productivity
·         Return on investment that quickly pays for CAC system
·         Faster medical billing
·         More revenue from more detailed bills
·         Greater medical coder satisfaction
·         Better  medical coding accuracy
·         Identification of clinical documentation gaps
It has been highly touted that CAC’s in optimize coder productivity.  However, in reality, productivity will probably stay the same, as the coder will still have to “audit” the information to determine if, in fact, the CAC code is correct.   In regard to the other “pros” on the vendor list, coder satisfaction should not be overlooked. 

According to AHIMA’s pilot testing of CAC’s , they weighed in on some of the potential issues with a CAC use only.  However, these potential areas of concern can be addressed quickly if the coder uses the CAC to audit the case prior to any claims sent to insurance carriers.   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 did not accept 90% of the procedure codes presented within the ICD-10cm and ICD-pcs codesets.   However, the information that the CAC presented, did give the coders a good “starting” reference to drill down to a more comprehensive code for both diagnosis and procedures. 

Coders and CDI personnel will still need to be the ones charged with
·         Ensuring clinical documentation is complete and query when appropriate. 
·         Ensuring complete coding (eg for 4th and 5th digits/specificity)
·         Ensuring correct sequencing of diagnosis and procedures
·         Reviewing of correct MCC/CC’s  and DRG assignments with case complexity and severity

CAC, Clinical Documentation, EHR, and Providers’

Integration of clinical documentation by provider and physicians has always been a challenge combined with the  and the implementation of ICD-10 in 2015  has been a huge impetus for CAC utilization for hospital and facility based organizations.  Unfortunately, physicians still don’t provide thorough documentation and rely on CDI and coding staff to guide them.  There has always been a HUGE disconnect in the language spoken by “providers” and the language spoken by “coders”.  Physicians document in their comfort zone, and fall back on those terms such as “pneumonia”.  Whereas a coder, they are looking for much more specificity.  The integration of an EHR based program for the physician/providers to use and a CAC providers a good “team relationship” for both parties. 

Many CAC programs extend out and integrate well with hospital based CDI programs and EHR’s.  These combination computer interfaces allow more “real time” processing of “possible” code selection prior to the final code selection being audited and reviewed by the coder.  When the CAC identifies these “possibilities” the opportunity exists to identify and improve the DRG’s with MCC/CC’s , and address more quickly areas for query, and missed procedures or diagnoses. 

Case Study to make It work:

The scenario below (provided from  Smith, Gail I.; Bronnert, June. "Transitioning to CAC: The Skills and Tools Required to Work with Computer-assisted Coding" Journal of AHIMA 81, no.7 (July 2010): 60-61.)

ICD-10-CM CAC Example
In the example below, the CAC software assigned the code T15.91A based on documentation in the emergency department record that states the patient had a "foreign body in the right eye." The coder is presented with the decision to accept the code or reject it based on further analysis.

Emergency Department Record
A patient is brought to the emergency department due to a foreign body in the right eye. He was working with metal, and a piece flew in his eye. He reports slight irritation to the right eye but no blurred vision.

A slit lamp shows a foreign body approximately 2–3 o'clock on the edge of the cornea. The foreign body appears to be metallic. The iris is intact.

Procedure: Two drops of Alcaine were used in the right eye. Foreign body is removed from the right eye.

CAC: Computer-Generated Codes: T15.91xA, Foreign body, external eye, right.
Final Coding Decision: T15.01xA. Foreign body of cornea,

Review of the documentation in the record by the coder and then the information from the CAC,  revealed that the foreign body was located on the edge of the cornea, which changes the fourth character in ICD-10-CM from 9 to 1. The coding professional replaces the T15.91xA code with T15.01A, Foreign body in cornea, right eye.

Wrapping it all up

The above scenario is a very simplistic case study, but an important one, as it shows and validates the importance of the coder as the “knowledge” behind the “technology”.   Coders and HIM professionals need to make a commitment to embracing change which includes “new” technologies and integration of learning processes and opportunities.  A hospital’s success depends on the “knowledge” worker as part of the ongoing and ultimate team member for successful outcomes for both patients and hospital fiscal solvency. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

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