Implementing Computer Assisted Coding

Conversion to an electronic health record (EHR) has greatly contributed to data quality improvement of health information and has opened the door to countless technological advancement opportunities. Computer assisted coding (CAC) technology has been around for years; however, due to the future ICD-10 implementation, the use of CAC software is starting to increase rapidly. CAC software can be very beneficial to medical care providers if implemented efficiently and specifically built to meet the needs of the facility.

Why Implement CAC?
There are a variety of reasons why facilities are considering CAC implementation. Many are planning to use CAC to ease the transition to ICD-10-CM and ICD-10 PCS. CAC will boost coding productivity, identify documentation deficiencies, and improve code selection accuracy.

The main function of CAC is to use a natural language processing engine (NLP) to identify key terminology and suggest codes for particular treatments or services in the health record. It is sophisticated enough to analyze the context of the key words to determine whether certain diagnoses are pertinent to the visit. Currently, the available CAC products do not have the capability to pull information from handwritten documents. However, it is capable of linking specific documentation to the code selected by the coder from the handwritten documents.

What About Coders?
It is important to emphasize that CAC does not replace human coders. Human coders will review codes assigned by CAC and will make appropriate changes.

Involving coders in the CAC process from the very beginning will alleviate fears. Coders should be involved in all stages of the project. The purpose of CAC implementation and opportunities should be clearly communicated to the coders. It is essential for coders to recognize CAC software as a beneficial tool and resource. Attending vendor demonstrations and assisting in a final vendor selection will increase coders’ confidence in the product.

How Do I Choose a Vendor?
A vendor should be selected after a very thorough review. All questions and concerns should be addressed before finalizing the vendor. It is also recommended to network with other facilities similar to yours to get a better understanding of the product that is being selected. AHIMA’s CAC toolkit provides a great resource along with vendor websites.

Who Should be Involved With the CAC Team?
A project manager should be assigned to make sure the vendor is meeting the facility’s expectations. A timeline should be established and closely monitored by both the project manager and the vendor. Depending on the size of the organization, it might be necessity to assign an IT project manager from HIM. The project manager should work closely with information services team leads/analysts, and the coding manager/supervisor.

How do I Implement CAC?
Defining the project scope will assist in determining complexity and depth of the project. Some facilities prefer to implement CAC by taking a phased approach, whereas others prefer to implement all aspects of the project at go-live. Is your facility technologically advanced? Does the CAC product you are considering offer an encoder? These are some of the questions that have to be evaluated in the beginning stages of CAC implementation.

What Will be Interfaced?
Quality of data is vital when it comes to CAC product. All reports necessary for coding have to be interfaced with CAC. If coders are operating on multiple systems it will add to the complexity of the project. Coders’ workflow has to be evaluated and adjusted to meet the needs of the facility.

What About Testing?
User acceptable testing (UAT) is crucial when it comes to implementing a new system. Extensive testing should be completed to analyze and address concerns prior to the go-live date. UAT covers data quality and validation, end-to-end business processes, comparison of test results and expected results. All finding should be discussed to facilitate issue resolution. Coders should be extensively involved during the final stages of testing.

In conclusion, studies show that CAC software can improve coding quality and reimbursement. However, it is vital for a facility to build a product that is specific to their organization. The product should be 100% ready for the coders before going live.

Bella Logvinov is employed by University of Florida Health Jacksonville as outpatient coding supervisor where she manages over 15 employees in the outpatient area. She is a member of both the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Her experience includes 7.7 years of coding inpatient and outpatient records, 5 years of chart reviews and coding auditing, and providing continuing training and education to coders. She has extensive knowledge of outpatient and inpatient coding. Logvinov is an AHIMA Certified ICD-10-CM and PCS Trainer.


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