It is important that you are aware of what is available and what your specific needs are to meet the requirements of your setting. For several years now the American Health Information Management Association (AHIMA) has been studying the benefits of this technology. AHIMA has defined CAC as the “use of computer software that automatically generates a set of medical codes for review, validation and use, based upon clinical documentation provided by healthcare practitioners.”
Although it appears that CAC is primarily intended for use at the time of coding, its functionality as a RAC defense is also a great benefit.
Computers traditionally have assisted in the coding process, and there are software product applications that allow a coding professional to find information without the use of the ICD-9-CM code book (or in conjunction with the coding book). This process requires close review of the medical record documentation, both handwritten and electronic, although handwritten text sometimes presents its challenges with legibility. Knowledge of anatomy, physiology, disease processes, pharmacology and medical terminology are just a few of the competencies required. Electronic health records (EHR) can help with legibility issues in documentation, but trained coding and auditing professionals remain limited, and the actual reading and interpretation of the medical record required for accurate code assignment is a time-consuming process.
Natural Language Processing
CAC is achieved by natural language processing or NLP, which is a type of artificial intelligence that allows computers to decipher text to determine if it has the potential for an ICD-9-CM or CPT code assignment.
The computer engine will have programmed algorithms, edits and logic in place to allow it to interpret and assign a code or codes based on the translation by the NLP. CAC also can provide validation and an audit trail by identifying (or highlighting) where in the medical record the computer identified the text that represents the code(s).
CAC also is achieved through structured input technology, which is the process of having a menu with clinical terms from which a provider can select. Often structured-input CAC is seen in the physician setting. In addition, some CAC technologies develop and emphasize the actual content of text and documents. Improving the clinical documentation content can greatly impact the assignment of the code(s) assignment. Overall, CAC works best with electronic medical record text versus handwritten documentation.
CAC as a RAC Tool
Imagine, if you will, a 12-day hospital stay on which a RAC has requested a complex review. Most if not all of the documentation from the hospitalization – nursing notes, physician reports, the coding process, etc. – requires reading. Now the auditor has to apply knowledge and skill to interpret if the assignment of ICD-9-CM codes was correct. How long do you think all of this will take? Ten minutes, 15 or 20 minutes, or longer? Keep in mind that the complexity of the patient’s medical condition also impacts how long it is going to take.
Now imagine having CAC technology that can read the medical record text and interpret criteria, indicating where in the medical record the documentation cites relevant diagnoses or procedures to support the assignment of the ICD-9-CM codes. This can occur in a matter of seconds. The amount of time this saves is enormous, and with the accuracy of computer coding falling somewhere in the 95th to 97th percentile, the validation work of the professional auditor would be expedited.
An Audit Trail
The use of CAC provides an audit trail indicating where in the medical record text is located to support the use of a specific code. This can assist providers and institutions drastically in defending their coded data and reimbursement. It is also an excellent tool for internal audit processes and ongoing monitoring.
Using the CAC technology at the time of coding is not a threat to HIM or coding staff, but rather provides for more efficient use of coding professionals’ skills and knowledge by eliminating the time-consuming steps of reading and determining the code(s). Add to this the ability to track back the actual location in the medical record where the diagnosis or procedure is documented, and you have a win-win situation.
In summary, the benefits of CAC include:
-Reductions in overtime for coding staff – financial savings
-Reduction in use of external coding vendors – financial savings
-Achieving discharge not final coded (DNFC) goals
-Improved coding-related workflows
-Decreases in regulatory and compliance risks
-Traceable for auditing
It certainly would benefit you to check out some of these technologies, starting with a visit to some of the vendor sites. In doing so you will begin to gain greater knowledge and understanding about each of these new technology approaches to clinical documentation, coding, auditing and data quality. The advantages of CAC technology include helping healthcare providers improve coding productivity and accuracy while providing a regulatory or RAC defense for the different patient settings.
About the Author
Gloryanne Bryant, RHIA, CCS, CCDS, is the Regional Managing Director of HIM for Kaiser’s 21 acute care hospitals in Northern California. She Co-chairs the regional RAC Committee with compliance.
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AHIMA: Delving into Computer-assisted Coding (Practice Brief) 2004;
ProVation Medical; A-Life Medical, Dolbey, CodeRyte, MedQuist, Lynx Medical; 3MTM Corporation