Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
By Elena Miller, MPH, RHIA, CCS
When computer-assisted coding (CAC) was first introduced to the industry, it brought with it a feeling of uncertainty among many coding professionals. Would this software be replacing them, akin to the loss of transcription jobs in the wake of speech recognition software implementation? The rumor mill was churning, with some concerned that the computer could do it “better.” The idea was that CAC would increase the speed and accuracy of coders, essentially by taking over the heavy lifting of code assignment, while the coder took on a role where they would simply review and edit the codes on a second pass. With the time per record shortened, less coders would be needed—potentially solving the coder shortage. However, as we all know… good quality coders are as in demand as ever, and the industry still faces a coder shortage. The question remains: has CAC lived up to its promise of changing coding for the better?
Perhaps a quick review on the background of CAC would be helpful here. The Computer-Assisted Coding Toolkit in AHIMA’s HIM Body of Knowledge defines CAC as the process for extracting and translating transcribed free-text data or computer-generated discrete data into [information] for billing and coding purposes. Health Management Technology’s 2010 article titled “Computer-assisted coding: the secret weapon” states simply: “computer-assisted coding…automatically generates medical codes directly from clinical documentation.” That is exactly what the CAC does; generate codes from text contained within certain fields in a document. These codes are to be taken by the coder as suggestions that must be validated before finalizing the account. CAC is great at picking up text and suggesting codes. However, it does not—nor is it designed to—make intelligent decisions about the context of the record.
With that said, that doesn’t mean that the CAC is ineffective. There are actually pockets of coding in which the accuracy of the CAC-suggested codes is extremely high, and accounts are finalized without any human intervention. But that is not the norm. The industry has definitely come to the realization that coders are still very much needed.
The question is: did the industry come to the realization too late? Let me explain. Initially, the primary focus of many when implementing CAC was to minimize the impact to production post-ICD-10 implementation. New inexperienced coders were brought into the industry trained to code using CAC. Remember—one goal of CAC was to reduce the amount of time that coders spent reading the records. By suggesting codes, CAC ensures the coders don’t miss anything while “skimming” the record. On the flipside, how does the coder validate the code without thoroughly reading the record?
Back in the day, most coders were trained using physical coding books. When the encoder went down, they were expected to pull out the code books and continue working. Then, there was a generation of coders that were only briefly trained on the books in school before diving right into the encoder to complete their coding course. Those coders weren’t as good at book coding during system downtimes. Finding a single code in a code book and coding a complete record using the book are two completely different things. Fast-forward to today, there is a whole generation of coders out there that have either only briefly been trained on coding without CAC or have never worked without CAC. How does this impact the development of the coder? Where the encoder can fully replace the book (i.e., access to the books are in the encoder), the CAC can NOT fully replace human interpretation of documentation. The coder must know how to interpret the documentation and apply coding guidelines.
Codes are highly scrutinized by everyone, from third-party payers to internal quality departments and physicians. Reimbursement and quality measures are dependent on the final diagnosis and procedure codes. Those codes need to be accurate and must be supported by documentation.
The question is not whether or not CAC is hurtful or helpful in general. There is no doubt that it can be very helpful to ensure all conditions are at least considered. However, with the reduced need to read the record, is CAC helpful or hurtful to coder development?
Elena Miller is the director of coding audit and education at a healthcare system.