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Computer-Assisted Coding

By: Shaula Reyes

What is CAC?

As defined by AHIMA, Computer-Assisted Coding ...

As defined by AHIMA, Computer-Assisted Coding is 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.

Benefits of CAC

  • Productivity
  • Accuracy
  • Consistency
  • Transparency
  • Compliance

Productivity

Productivity

Productivity increases when the average amount of time to code a case decreases. An increase in productivity results due to the elimination or speeding up of particular manual tasks within the coding process, such as document sorting, storage and retrieval, duplicate identification, code lookup and selection, code ordering, or data entry.

Accuracy

Accuracy

Accuracy improves when the coding output better matches both official guidelines and payer reporting requirements. An improvement in accuracy can be observed through a decrease in denials, reduction in audit discrepancies, or finding lost charges that were previously under-coded. Increasing accuracy helps assure that an organization captures all of the charges that it is entitled to collect.

Consistency

Consistency

Consistency in the coding process ensures that guidelines are applied similarly over time and across multiple coding resources. A high level of consistency instills confidence in the coding results, supporting accurate clinical and financial analysis. This is particularly important when employing coders with differing levels of skills and experience.

Transparency

Transparency

Transparency and traceability enhance the manageability of the coding process by providing evidence of both the work flow and thought processes that went into the coding results. This may include links between the codes assigned and the portions of the patient records that support the codes, or an audit trail of all changes made to the coding or demographics.

Compliance

Compliance

Compliance supports a proactive and auditable coding process, which strives to “get it right the first time” and reduce additional work time and rebilling. Improvements in compliance are a result of more accurate and consistent coding, as well as transparency in the coding process. Together, these benefits reduce the preparation work for audits, while simultaneously improving audit outcomes.

CAC and the Healthcare Consumer

Computer-Assisted Coding can benefit not only t...

Computer-Assisted Coding can benefit not only the healthcare providers, but also the healthcare consumers. Since CAC can improve the quality of coding and documenting, it can benefit the consumer by reducing hassle to the patients and improving the quality of care.

For example, If the data are wrong, the payment ...

For example, If the data are wrong, the payment is wrong. If the data are wrong, the patient suffers.

CAC's Potential Advantages and Current Barriers

CAC's Potential Advantages and Current Barriers

the specifics that may be encouraging or discouraging to the progress of Computer-Assisted Coding

Potential Advantages

Potential Advantages

  • Increased coder productivity
  • Increased coder efficiency
  • More comprehensive code assignment
  • Consistent application of coding logic
  • Coding audit trail
  • Increased provider reimbursement

Current Barriers

Current Barriers

  • Hardware and software costs
  • Resistance to change
  • Existing problems with documentation
  • Variation in health record format
  • Technological limitations
  • Lack of industry standards

CAC and the role of HIM Professional

HIM professionals should be taking a leading role in education a...

HIM professionals should be taking a leading role in education and training, preparation and implementation of Computer-Assisted Coding system.

HIM professional need to take a proactive role in identifying ris...

HIM professional need to take a proactive role in identifying risks and making necessary changes in documentation improvement and coding quality.

HIM professionals should be actively involved in the transition to C...

HIM professionals should be actively involved in the transition to CAC in their facilities.

The work of HIM coders will change from generating codes ...

The work of HIM coders will change from generating codes to validating previously generated codes. This change should allow coders to spend less time reviewing each record and, thus, they should become more efficient in their work.

References

References

  • http://www.fortherecordmag.com/archives/101209p14.shtml
  • https://www.m-scribe.com/blog/bid/153655/Five-Benefits-of-Computer-Assisted-Coding
  • http://www.santarosaconsulting.com/SantaRosaTeamBlog/post/2012/09/05/Computer-Assisted-Coding-Is-it-Time-for-Your-Organization-to-Make-the-Transition.aspx
  • http://perspectives.ahima.org/computer-assisted-coding-software-improves-documentation-coding-compliance-and-revenue/
  • http://www.hfma.org/Content.aspx?id=46895
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