January 16, 2012

The Coding Enabler
By Julie Knudson
For The Record
Vol. 24 No. 1 P. 10

If used correctly, computer-assisted coding can help hospitals alleviate inefficiencies.

As computer-assisted coding (CAC) is deployed by an increasing number of hospitals, its effect on coders is coming into focus. The evolution of workflow changes, productivity increases ahead of ICD-10, and fear of diminishing job prospects are all buzz-worthy topics.

Workflow Changes
The existing workflow within many hospitals could be slowing down coders. Chris Casto, vice president of Dolbey Systems, says coders are currently using what he calls “buckets” of information. “They’re working out of the HIS [hospital information systems], a lot of times they have to log in to nurses’ notes, and they log into billing systems to look at chargemaster codes, so the workflow is really disjointed in a lot of ways.”

Casto believes CAC adoption helps pull those buckets together, giving the coder one place to go for information. “In that fact alone, they really do see, I think, a streamlined workflow because they’re not in multiple applications,” he says. “They’re not logged in all over the place. Everything they need to see is in one place, and it has to be that way for CAC to function effectively.”

Accessing information from multiple sources is indeed an efficiency issue for today’s coders, says June Bronnert, RHIA, CCS, CCS-P, director of professional practice resources at AHIMA. “CAC has the capability to pull all that into one place. Coders may go to one place vs. going to three or four or five,” she says. “That part has increased their efficiency because now the information they need is in a single location.”

Bronnert says the effects of CAC implementation on hospital workflow may depend on how activities are structured and recommends facilities examine their processes. “Start with documentation,” she says. “How is it generated? Is it handwritten? How much is electronic? And what systems is it in?” This will help determine where productivity gains and efficiency improvement are most needed, Bronnert adds.
“[CAC] is going to radically change the overall workflow,” says Gail I. Smith, MA, RHIA, CCS-P, “because coders are not going to be producing the code—they’re going to be verifying what the computer gives them.”

Smith, president of Gail I. Smith Consulting in Cincinnati and an ICD-10-CM/PCS faculty trainer for AHIMA, believes CAC adoption will remove the rote work from coders’ plates. “That easy stuff that we waste our time on, the computer can assign it if it needs no human interaction,” she notes.

And because coders will be freed from baseline coding tasks, they’ll be able to take on what Smith describes as more of an auditing role where strong decision-making skills will be essential. “It really forces the coder to work at a higher level,” she says.

John Ryan, MD, president of PLATOCODE, whose US operations are based in Los Angeles, says many of the clerical portions of a coder’s job are removed in a CAC environment. “Rather than having to scuffle through documentation and enter codes, you become an auditor,” he says. “The case comes up, and it’s as if the gremlins have been through and assigned a whole lot of codes, and the coder’s job is to make sure they’re correct.”

Coders will no longer start from scratch, Bronnert says. “Now they say, ‘Yes, this is the valid code for that, and it should be assigned,’ and they identify it within the tool that it’s the appropriate code,” she says, adding that coders’ roles are changing from conducting initial read and scans to “becoming an auditor, a validator.”

Bronnert believes it’s important that coders understand the technologies involved, and that “CAC is not an encoder,” although the two tools can work together and “a lot of them are doing that now.”

“You’re almost a detective in a way,” Smith says. “You have to be willing to challenge what the computer comes up with and, in some respects, investigate why it led down that path.” She believes having a user-level understanding of how the software works would be beneficial. “It’s another skill set for coders,” she notes.

With the fundamental shift from code entry to code review, Casto believes coders “still need to be on top of their game because the software isn’t going to be as good as your best coder. It will make mistakes. We expect that, and that’s why we need the coder to catch them.”

Casto isn’t sure the audit function coders assume in a CAC environment is necessarily a new skill, but says, “It’s a different way to spend your day.”

Productivity Improvements and ICD-10
For hospitals whose documentation resides mostly in an electronic format, the adoption of CAC is likely to be less onerous, says Bronnert. “The CAC engines are designed to work with electronic documentation, so it’s a smoother initial process vs. if you have handwritten documentation that has to be scanned,” she says, adding that facilities able to avoid that extra step may gain greater efficiencies than those stuck with scanning handwritten material.

“There is certainly a direct correlation between the hospitals that have prepared to implement CAC and those that are well down the road with their EHR implementation,” Casto says, “because the technology they’ve needed to put in place and the processes they’ve needed to adopt to make their electronic health record work and to meet meaningful use are absolutely in line with what we need for CAC.”

Casto says hospitals that have either adopted EHRs already or are moving toward EHR implementation are “perfect candidates for computer-assisted coding.”

Mark Morsch, vice president of technology at OptumInsight, says CAC works best when at least some of the information is available electronically. “Most facilities today have a hybrid record, where some data is paperless, some may be scanned, and some may still be on paper. The more information that can be made available digitally, the more you can take advantage of automated coding,” he says.

By consolidating documentation into a single software platform, Morsch sees other benefits for coders. “Productivity gains from these new processes are helping hospitals now and will be imperative as we move to ICD-10 with an eightfold increase in codes,” he says.

Coders are presented with codes assigned by the system, and those codes include highlights that link each code to the supporting evidence in the clinical documentation. Coders then review the CAC-generated codes and accept or correct them based on their expertise. “CAC transforms the role of the coder from the task of full coding to a reviewer or auditor of coding,” Morsch says.

As an ICD-10 trainer who travels around the country, Smith says, “I’m seeing more and more hands go up when I ask, ‘Who’s implementing CAC?’”

Some of those decisions to adopt CAC are a result of the looming ICD-10 deadline. “[Hospitals] are trying to counteract the loss of productivity with removing those rote coding decisions,” she says, adding that there will likely be spin-off roles or entirely new areas of responsibility generated on the back end, including “looking at reports and looking at trending as another double-check” while the technology and its use mature and become more widespread. “There are lessons to learn, and we don’t know what those are yet,” Smith says.

Additional efficiencies generated by CAC adoption can be found elsewhere in the revenue cycle chain. Casto points to the technology’s ability to better “scrub” charts before they leave a facility as a way to reduce the number of disputed claims, citing one customer who experienced an 80% reduction in denials. “I think many of them have their eye on the future, which is ICD-10, and they know they’re going to have troubles there if they don’t get ready. But right now they can utilize the software to better prepare themselves and solve some immediate problems,” he says.

The Job Market
Let’s get to what, for some, is the elephant in the room: Does the adoption of CAC mean that a hospital needs fewer coders? “Every hospital has its own productivity standards on what they expect,” Bronnert says. “From what I’ve heard from those hospitals for years now is that it’s not that they need fewer [coders].” Instead, Bronnert sees coders being used more effectively and at a higher skill level. “They become even more valuable to a facility. I don’t see their roles or positions diminishing at all. I see them flourishing,” she says.

Smith says some early CAC adopters have reported demonstrable increases in productivity. “I think what’s going to happen is we’re going to need less entry-level coders, but we’ve been seeing that trend for years,” she says, adding that CAC will exacerbate the differences between new and experienced coders.

Although CAC and ICD-10 are “really two different subjects, they intersect with CAC,” Smith says. “Even if we didn’t implement ICD-10 in 2013, there’s definitely a need for increased productivity.”

Ryan doesn’t believe CAC reduces the number of coders a facility requires to stay on top of its workload. “CAC means they’re going to be able to cope with the changes in ICD-10, and clearly there are no fewer coders required if that’s the thinking you adopt,” he says.

Typically, when implementing CAC, hospitals don’t drop the number of coders on staff, Ryan says. Instead, coding departments are better equipped to handle vacations and other coder absences. “The second thing is that a lot of facilities are bringing on contract coders, who are expensive,” he says, adding that productivity gains brought about by CAC allow hospitals to “rationalize their use of expensive external resources.”

A third reason Ryan isn’t buying the idea that fewer coders will be needed with CAC is that existing coders may now finally have the time to make more use of their expertise and get involved in clinical documentation improvement.

“I think anybody who’s running a coding operation or has any oversight over a coding department knows that they certainly would not let any well-qualified coder out their door right now,” Casto says. Instead, he believes facilities that implement CAC “want to take the coders they have and get some extra bandwidth out of them.”

By implementing CAC, facilities may be able to work through backlogs, eliminate some outsourcing costs, and enable the existing workforce to be more productive. The software could also allow organizations to be better prepared for ICD-10 by affording them extra time for training. “A lot of them just don’t have that luxury right now,” Casto says.

New to Coding? Listen Up.
A handful of CAC providers are working with various educational institutions to introduce the technology into the curriculum, but the practice is far from universal. Ryan believes the number of available CAC products is too vast to make familiarity with any one platform a game-changer. “The CAC market, although I’ve been in it for 20 years, is still very young,” he says, “and people are still finding their way. I think it’s difficult for the training institutions because it’s the early days, and there are a number of competing models.”

“I think it’s a time of transition,” Bronnert says. “Right now, I don’t think [CAC training] is enough of a factor in the job market. Maybe in another three to five years it could be.”

While Bronnert hasn’t heard from students that a lack of CAC training has hampered their job searches, she says, “I think that students should learn about the technology because it’s becoming more mainstream.” From the educational provider’s standpoint, she believes schools “are becoming aware of the technology as well and starting to incorporate it at some level into their programs.”

Smith doesn’t believe adding CAC principles to educational programs would be much of an adjustment. “We can very easily change our focus in education to giving students the codes and saying, ‘Is this wrong or is this right, and why?’ It’s not like you have to throw your curriculum away,” she says.

Smith suggests that instead of focusing on efficiency during the coding process, educators could work on cultivating students’ ability to dissect documentation and work backward from the code itself. “I would love to see education programs transition to more CAC-simulated activities so the students feel more comfortable and confident in their role,” she says. “That can be done in the safe learning environment of the college, so they can practice their skills and there’s not such a gap between education and industry.”

— Julie Knudson is a freelance business writer based in Seattle.