Today’s HIM and coding professionals are faced with multiple challenges to increase documentation accuracy and specificity due to new rules and regulations. They also face financial pressure to accelerate billing processes, which can lead to errors and fraudulent claims. The federal government has taken notice and has started to investigate whether electronic health record (EHR) systems could be causing more hospitals and physicians to commit fraud because of upcoding.

In particular, the impending transition to ICD-10 has added new pressures on coding professionals and HIM departments by introducing thousands of new, detailed diagnosis and procedure codes, which will significantly impact all health systems throughout the United States.

The transition to ICD-10 coding standards, and achieving coding compliance, will improve patient care in the long-term. However, with eight times the codes of ICD-9 and significantly increased specificity, the standards will require a totally new way of coding in order for healthcare organizations to overcome productivity and financial challenges.

Computer-assisted coding (CAC) harnesses the power of natural language processing (NLP) by automatically reading and translating electronic clinical documentation provided by healthcare practitioners into the appropriate codes. An organization’s CAC solution of choice should automatically generate suggested ICD-9-CM and ICD-10-CM/PCS codes for review and validation by the coders. This new coding process in the workflow has the potential to accelerate code submission to patient billing systems and deliver a better result. This next-generation coding solution completely automates what was previously a resource-intensive process requiring manual interpretation of clinical documentation and coding input prior to billing.

Hospitals have reported that CAC has increased coder productivity by more than 20 percent, decreased coder overtime by as much as 80 percent, and decreased external audit fees as much as 50 percent. A CAC solution of choice should enable health systems to:

  • Mitigate the risk of productivity loss by improving coder throughput and accuracy
  • Accelerate claim submissions and billing processes
  • Improve cash flow and decrease accounts receivable days
  • Uncover issues in clinical documentation
  • Enable cross-departmental communication to better understand patient outcomes and share best practices
  • Improve coding compliance

 

Evaluating CAC solutions may seem challenging at first. In addition to the standard request for information (RFI) or request for proposal (RFP) vendor questions, the following questions can be used as a reference when evaluating CAC solutions:

  1. Describe how the NLP engine that powers the CAC learns, grows, and improves code assignment accuracy over time. How does it model concepts and relationships, and what is the size and strength of its ontology?
  2. Does the CAC application auto-suggest both ICD-9 and ICD-10-CM/PCS simultaneously for the same encounter in one view for the coder?
  3. Does the system contain all interfaces needed to provide the coder with a single workspace view and access to clinical documents that are needed for the encoder, CAC, and clinical documentation improvement (CDI)?
  4. Does the CAC auto-suggest outpatient codes for both ICD-9 and ICD-10 CM/PCS? Please provide each clinical areas covered (i.e., laboratory, radiological/imaging, same day surgery, cardiology, rehab, etc.).
  5. Describe the CAC (NLP engine) software’s ability to generate HCPCS and CPT codes, provide coding edits for medical necessity (local coverage determinations and national coverage determinations), and integrate with the charge description master. Are early warning indicators provided when documentation is insufficient to code in ICD-10?
  6. Describe the coding management tools of the system, such as the ability to:
    a)  Generate comprehensive management reports related to case mix trending and (coding or CDI) physician query management
    b)  Customize workflow queues across a department or a system
    c)  Report on encoder, CAC, and CDI access, utilization, productivity, and other activities
  7. Is there an integrated HIM software program that supports:  a)
    a)  Documentation improvement for the physician
    b)  Documentation improvement for case management and/or clinical documentation specialists
    c)  Computer-assisted coding
    d)  Compliance features in CDI, CAC, and encoder
    e)  Compliance audit reports (i.e., RAC audits) for inpatient and outpatient claims
    f)  Describe the patient data flow and your associated product application from pre-admission to registration/admission to CDI and/or concurrent coding to CAC to encoder/coder validation to abstracting and billing to reconciliation to compliance reporting and auditing
  8. Does the system enable simultaneous coding and grouping or grouping interfaced? What about auto shuffle capabilities?
  9. Does the system provide anywhere, anytime access to complete ICD-9 and ICD-10 coding guidelines and coding clinic references based on selected code set?
  10. Can the system workflow be configured to eliminate toggling among various screens/systems in order to access documentation necessary to validate demographics and to perform encoder, CAC, and CDI activities and processes? Please describe.

CAC can help your organization mitigate anticipated productivity challenges due to the transition to ICD-10, while increasing accuracy and accelerating billing processes. If it is the right time for your organization to consider CAC, then these questions can help  you leverage your information technology investment and select an integrated coding solution, coupled with automated workflow and compliance editing to ensure maximum productivity throughout all HIM processes.

Reference:  2011 Contributors to Top Ten CAC Questions: June Bronnert, RHIA, CCS, CCS-P Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS Shirley Eichenwald Maki, MBA, RHIA, FAHIMA Mark Morsch, MS Philip Resnik, PhD Rita Scichilone, MHSA, RHIA, CCS, CCS-P, CHC

Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS (http://twitter.com/BonnieSCassidy) is the Senior Director of HIM Innovation for Nuance Communications Inc.