Computer Assisted Coding

CAC is defined by the American Health Information Management Association (AHIMA) 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.” Currently, there are two technology options for CAC. The first is natural language processing (NLP)and the second is structured input. These computer assisted models relies on human intervention to review, validate and approve (or edit) codes generated by the computer system.

For each record, the The NLP system places these codes into a review queue for the coder to review, edit, approve and finalize. Coders begin the coding process by viewing “suggested” codes instead of working from scratch. As this white paper will discuss, coders starting with a list of recommended codes greatly improves productivity and elevates the coder’s role from researcher to quality data analyst. In order for NLP engines to be most effective, electronic documents (transcription or voice files)should be based on some type of template or standard format. NLP works best is outpatient. This is because clinical documentation
in these settings is often already electronic (dictated or template-based) and there are a limited number of medical terms.

Structured input for CAC is most commonly seen in the physician office setting. The clinician uses a hand-held computer system to document his or her visit. As the clinician points and clicks on words and phrases, sentences and paragraphs are created. Diagnoses and procedures that should be coded are automatically identified and mapped to the correct clinical code. Once the codes are assigned, they are then presented to the clinician for confirmation and may or may not be forwarded to a coder for manual code review.

Advantages of CAC
1. CAC makes the coder more productive, makes coding more consistent and further automates the coding process.
2. Using CACs coding backlogs can be avoided.
3. There are current and future anti-fraud initiatives that can be supported through the use of CAC.

Are CAC and medical coders compatible?
CAC is a technology tool that helps the coder become more productive. By giving coders “suggested” codes, the system expedites the entire coding process and transitions coders from researchers to data quality analysts. According to AHIMA, “CAC technology should be viewed as a tool to assist coding staff rather than as a replacement for coding staff.” At first, the coders admit that they were skeptical about the capabilities of the NLP engine. However,
once they became familiar with CAC’s capabilities, they became confident with the system. Coders who use CAC tools every day report that they would never consider going back to a manual form of coding.

Finally, Sandra Leonard, CCS, CCS-P, comments, “It was always my dream to work from home. CodeRunner(A CAC from medquest) made my dream come true. It is an extremely user-friendly system and an excellent coding tool – nothing better!”

With CAC, the coder’s role changes in a positive way. Coders are now focused exclusively on doing just one piece – the coding.


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