Using computer-assisted coding (CAC) in the provider office setting comes with a unique set of challenges. Providers begin this workflow by utilizing algorithms in the electronic health record (EHR) system to select diagnoses and their corresponding diagnostic codes through natural language processing (NLP) embedded in the EHR. Once the note is completed, CAC tools launch to read the encounter documentation and suggest the E/M level to the provider for processing to the claim.
These providers, both physician and nonphysician, have little or no formal education in coding guidelines. Because of this, providers can be led by both accurate and inaccurate suggestions for coding assignments by the CAC tool and not have the expertise or confidence to override the suggestion when making a final submission to the claim.
Even more critical is the situation where even the opportunity for overriding the suggestion is not apparent. Health information management (HIM) professionals play an important role in educating these providers and monitoring the CAC tool supporting the reporting of these codes to claims.
Upcoding and Unbundling Violations
Two types of coding violations that are often brought forward under the False Claims Act are “upcoding” and “unbundling.”
In the Evaluation and Management (E/M) coding process, upcoding is what happens when a provider assigns a higher E/M level code than what is supported by the documentation. A common marketing objective for CAC is the realization of increased reimbursement based on perceived greater accuracy from the use of the tool. From a coding professional’s viewpoint, there still remains some level of subjectivity among the various E/M codes, and upcoding may be in the eye of the beholder, but it should definitely not be an identified pattern within the CAC tool.
Unbundling in the provider office/outpatient setting are billing separate procedures that are typically performed together rather than following edits that specifically identify one coded unit as being included with the other (a combined one unit reimbursement).
Both of these situations are fraudulent. The CAC tool may not have the level of intelligence to determine whether it is upcoding or unbundling, suggesting coding assignments that reflect higher medical-decision making than the documentation supports, or automatically adding modifiers or separating procedures into multiple codes. An intelligent language platform that connects provider entered search terms with ICD-10-CM codes can unintentionally lead clinical providers without coding skills to inappropriate hierarchical condition category (HCC) assignments, fraudulently affecting reimbursements for risk adjustment.
CAC Applications Can Increase Accuracy
Better and more comprehensive EHR documentation that may support higher E/M levels does not necessarily correlate to fraudulent billing. Used properly, these EHR and specifically CAC applications can and do increase the efficiency and accuracy of the non-coding professional responsible for selecting the E/M level and diagnostic codes that are dropping to the claim. E/M CAC tools should support physician/nonphysician practitioner (NPP) charges by a workflow that:
- Requires submission of E/M level for the visit.
- Produces a suggested code from the CAC software after crawling through the note.
- Allows the provider to compare the suggestion prior to assigning the final code to the claim.
CAC Auditing Process
HIM professionals can help to facilitate that level of accuracy through audit and education with the physician/NPP who is interacting with the tools.
Auditing steps that should be taken to validate the E/M level assignment include:
- Reviewing a sample of encounters from each provider interacting with the tool to measure accuracy of the coding suggestion versus selection of the correct code following through to the claim.
- Auditing alerts built into the system to identify dual charges for the same services on the same DOS, perhaps linking the primary reason for visit diagnostic coding assignment.
- Limiting programming and monitoring the automatic assignments and drop of modifiers to CPT codes and E/M levels based on encounter audits.
- Verifying accuracy of display of insurance information and connection to coding rules (e.g., use of consult codes).
- Logging service tickets to the software vendor to identify and correct patterns of inconsistencies or inaccuracies noted within the application.
HIM’s Role as CAC Educator
Physician/NPP education is crucial to the success of a CAC tool in the provider office setting. These providers should understand how the CAC tool calculates the suggested E/M level and feel confident in overriding suggestions for both undercoding and upcoding. CAC software supporting E/M levels is not going to produce 100 percent accurate suggestions/assignments, and HIM staff can play a vital role in the success of the tool in the revenue cycle for the organization. By identifying limitations of the CAC software assignments, HIM coding professionals can educate the providers in key areas with strategies for overrides.
Physician education objectives supporting the correct use of CAC software can include:
- Establishing a provider “champion” in each professional office to support the CAC and its use by other providers in the office within their same specialty.
- Identifying the importance of documenting what they are doing to monitor, evaluate, assess, and treat a condition or identified diagnosis at the time of that encounter/service. This prevents conditions documented as resolved or followed elsewhere from potentially artificially inflating the problem complexity as read by the CAC software.
- Understanding the definition of time under the 2021 guidelines to ensure that the minutes documented are an accurate representation for the visit when correlated with an outline of activities supporting the time spent.
- Clearly documenting and identifying discussions with providers outside of their group/specialty versus discussions within their own group practice, as most CAC applications will not be able to interpret this correctly without careful creation and consideration of template design. This is also true for the accurate documentation of external review of data.
- Correctly using templates, autotext, and headings by scribes, as poorly written or grammatically incorrect sentences with erratic punctuation and misspellings can often affect how the CAC software reads the encounter.
- Using consistent terms to clearly identify the patient’s condition such as stable, chronic, acute, chronic with acute exacerbation of symptoms, unstable, etc.
- Avoiding potential “trigger” words within the CAC application that may affect how the visit is leveled. Conversely, educating providers on the proper use of trigger words when appropriate to assist the CAC tool to more accurately suggest a code can be helpful.
- Illustrating the importance of viewing the CAC level as a suggestion that can/should be overridden using their provider expertise and understanding of coding education.
Unstructured data still represents the majority of healthcare documentation. CAC tools can assist with consistent reading and assignment of diagnoses/procedures, which is valuable to coding; however, HIM professionals must play a role in solving inconsistencies, inaccuracies, and educating toward both the tool and the guidelines. Using CAC in the office to support coding professionals, no matter their level of expertise, instead of replacing the coding function should be the objective of implementing these systems. HIM professionals can and should lead the evaluation of the code to claims process, audit the CAC suggestion results, and provide the necessary education to any level of user in the provider office setting responsible for this workflow.
Mona M. Burke is a profee auditor at Fisher-Titus Medical Center in Ohio, an emeritus senior Lecturer at Bowling Green State University, and a faculty liaison to the VLab at AHIMA.