Technology has radically transformed the process of medical coding in Health Information Management (HIM). Computer-assisted coding (CAC) generates medical codes automatically from clinical documentation. CAC technology enables healthcare facilities to streamline their business processes and achieve compliance with complex reporting requirements.
Electronic Health Records (EHR) are a valuable source of documentation but tedious to integrate with the coding process. CAC technology bridges the gap between the EHR documentation, financial and transcription systems. CAC empowers Health information managers to accurately code out-patient and physician services and communicate them effectively with insurance companies.
What is Computer-Assisted Coding?
A computer-assisted coding system first analyzes medical documents, produces appropriate codes for the medical terms and phrases in the document. An artificial intelligence system extracts data from scanned documents and transcribes this data into a set of codes.
The natural language processing feature in the CAC technology can scrutinize the unstructured clinical notes through specialized algorithms that can extract the facts corresponding to the assigned codes.
CAC is often deployed as a SaaS (Software-as-a service) model but can also work as a client-server software. CAC often utilizes cloud services for coding outpatient services, procedures such as cardiology, radiology, pathology, and emergency medicine. Installation requirements for CAC are minimal, and the software provides modules to manage the entire work-flow of health information management systems.
How CAC Can Transform Health Information Management
|Before CAC implementation||Post CAC implementation|
Average time to code will be more resulting in lower productivity
CAC automates the entire coding workflow eliminating or speeding up the manual tasks within coding such as storage, sorting, retrieval and data entry
There are chances of audit discrepancies and errors in important documents resulting in denials and lost charges
CAC ensures a high level of accuracy in medical documentation, capturing all charges that the organization is entitled to collect.
Without CAC systems, there may be inconsistencies in the coding process as employed coders will be of varying levels of qualification and experience.
CAC ensures consistency in the entire coding process as standard guidelines are applied across multiple resources. High levels of consistency make the coding results more reliable for performing financial and clinical analysis.
The coding process is highly subjective and it was impossible to trace any missing links.
CAC systems provide the transparency and traceability necessary to manage coding processes. There is evidence for workflow including links assigned and patient records.
Manual coding means additional work for audits, reactive measures, and rebilling.
CAC supports better compliance, a proactive and auditable coding process resulting in better audit outcomes. Compliance improvement is achieved due to more accurate, transparent. and consistent coding methods.
Data was drawn from diverse and disparate sources. Routine tasks such as user logs, authentication and so on were eating up valuable coding time.
CAC systems ensure access from centralized data sources facilitating real-time integration.
Collaboration between the coders and the CDI staff was often a challenge.
CAC systems offer an integrated platform for effective communication between all teams.
Difficult to adapt to changing technology
CAC supports cutting-edge technology, allows customization, and provides scope for unlimited training.
Recommendations for successful implementation of CAC systems in HIM
- The solution must fit into the existing workflow and the CAC applications must integrate with other applications seamlessly.
- Routine activities must be completely automated and complex tasks must be made simple. Coding tasks for few specific functions can be fully automated without requiring coder review.
- Redundant data must be eliminated, simple coding scenarios must be automated, and a comprehensive view of complete documentation must be made available.
- All coders and administrators must be trained to use the CAC system. They must be made aware of its quantifiable benefits and be motivated to accept the changes in the coding process.
- Data supplied to the system must be complete and meaningful. Complete and timely documentation is imperative to get accurate results from CAC systems.
- The CAC system must be capable of measuring productivity, monitoring performance, auditing results and training coders.
CAC- The Future of HIMs
Along with the progress of the CAC technology, health information management systems are bound to witness revolutionary changes in coding workflow. CAC brings the clinical and the patient related data all together on a single intuitive coding platform. With CAC implementation, it becomes easy to enhance coding accuracy, productivity and efficiency as coders become empowered to make quicker and well-informed decisions for optimizing workflows.