September 4 , 2007

Coding’s Little Helper
By Robbi Hess
For The Record
Vol. 19 No. 18 P. 20

Taking advantage of computer-assisted coding can make life easier for overworked HIM departments.

These days, it seems we automate anything and everything, from paper towel dispensers and assembly lines to parking garages and lawn sprinkler systems. The technology can be a tremendous time saver and provide unheard-of convenience.

Not to be left behind in the wake of all this technological progress is the coding industry, where computer-assisted coding (CAC) is gaining steam as a powerful tool.

Sheri Poe Bernard, CPC, CPC-H, CPC-P, vice president of member relations at the American Academy of Professional Coders, says the term computer-assisted coding is relevant because CAC is the difference between computerized coding and auto coding.

“When you add the term assisted—computer-assisted coding—the industry is building in the idea that it needs to have a manual review of what the computer has come up with,” she explains. “A coder needs to make certain that what the computer has come up with is correct. Were the correct codes selected? Were compliance rules followed? The idea of computer-assisted coding is more viable and more practical when put into use with the idea of it being looked at by a human.”

Because computers have yet to master the ability to extract inferences from information, there is a continued need for a certified coder to be in the mix.

“Having CAC in place will certainly streamline things because the coder can go through significantly more claims if using the computer as an assistant rather than coding from scratch,” Bernard says. “The interesting part of CAC is that it more easily employs rules based on methods and is much less subjective in coding it than what you get from human coders.”

As an example, Bernard says if Medicare issues a new rule effective April 1 and a claim was filed March 15, the new rules shouldn’t apply to that bill. In the auto system, it would be triggered by the date and would only apply rules that are date-specific to that procedure.

“People sometimes tend to muddy up the dates and will code using today’s rules rather than the rules in place on the date of the encounter,” she says. “CAC will clean up these problems, and we will see more consistency within organizations and industrywide.”

Beth Friedman, RHIT, president of The Friedman Marketing Group, says CAC is starting to be used extensively in niche, outpatient areas, with the most common being radiology. But she sees the technology expanding into the emergency department and other specialty areas.

“The areas where CAC is growing all have a few key things in common: Coding is performed from electronic vs. handwritten documents; there are a minimal number of documents used for coding; and there is a common set of appropriate codes,” she says. “I don’t see it used in inpatient settings yet, but eventually, it will get there.”

“CAC is very young, but it is poised to really start taking off,” Bernard says. “Taking off, though, is contingent on a facility needing an EMR [electronic medical record] in place. For CAC to work, the EMR has to be there—you can’t just have one piece or the other; they work hand in hand. ”Bernard says that between 25% and 50% of physicians’ offices currently have an EMR incorporated into their coding procedures.

Is It All About the Standards?
There is a developing consensus that CAC software standards should exist. However, according to Mark Morsch, vice president of natural language processing and software engineering at A-Life Medical, opinions vary on how standards should be formulated.

For example, “Should standards define the process under which the software was developed, or the essential performance requirements of the software, or the qualification of the organizations developing the software?” he asks. “Also, it is not clear who would administer and maintain these types of standards.”

Bernard says, theoretically, there should be standards “as long as they don’t cause a good system to fall by the wayside because of costs associated with getting the software up to those standards.”

Friedman agrees but expresses concern where standard terminology, language, and lexicons may be involved because the process would include linking medical terms with codes.

“From my experience, it is difficult to get a group of [doctors] within one hospital to agree to terms, much less an entire industry,” she says.

In conjunction with October’s annual conference, the AHIMA will hold a CAC software standards workshop to advance the work done at last year’s initial get-together. “The workshops have brought together healthcare providers, vendors, and regulators to forge an agenda as a precursor to a more formalized work plan for standards development,” Morsch says.

Decisions, Decisions, Decisions
Choosing the right software is an involved process, and many facilities often make their selection solely based on price. The experts agree that when it comes to making such an important decision, it’s all about experience.

“Choose a vendor that has experience in the specialty where the hospital wishes to deploy CAC. This is a must, as is talking to other users of the systems,” Bernard says.
“As with many things, try before you buy,” cautions Morsch. “Facilities should ask for and check references and carefully scrutinize how the software will be successful in their environment.”

A successful evaluation takes a lot of time and effort from all stakeholders, explains Taimur Aslam, vice president of technology at Catalisse, adding that it should be performed systematically to ensure the needs and concerns of all users are taken into account.

“A technical assessment must be performed where each potential user contributes his or her set of requirements, which must be written down and formulated so that different vendor solutions can be evaluated against these requirements,” he says.

Morsch says a facility must have a clear understanding of what it will use as metrics to measure successful CAC deployment before it begins the process.

“Are you looking for increased productivity, reduction in denials, reduction in coder overtime, reduction in audit costs, or something else?” he says. “These measurements should be understood upfront and tracked before and after deployment.”

Bernard says in order to successfully roll out CAC or any other platform or equipment, all departments affected by the procedures need to be involved in the decision-making process.

“Sometimes, departments operate independently, and sometimes, the CEO says yes to a software but doesn’t involve the people who understand the nitty gritty of how it all comes together,” she says. “The vendors need to speak with the coders and explain to the coders how the different algorithms and logics were developed. You want to make sure the coders on staff are asking questions and feeling comfortable with the changes.”

As the HIT industry continues to boom, vendors have invested heavily in developing best-of-breed tools to alleviate the physician’s every challenge, including tools to improve coding accuracy and efficiency. When looking at CAC software, physicians and medical professionals should research solutions that integrate EMRs, practice management tools, and CAC technology into a single unit for best results, Aslam says.

Data Mining
CAC applications can provide data that are not available in a conventional process, Morsch explains, adding that it includes detailed information on coder productivity, coding quality, documentation deficiencies, and operational workflow.

“Typically, CAC software will include a reporting module that helps coding managers interpret and act on the extensive data available,” he says. Friedman says the information captured by CAC applications is ideal for use in pay-for-performance reporting and quality indicators.

Aslam says different reports dissect the data according to practices’ needs, which can provide the practice administrator insight that may not be attainable by perusing huge volumes of data.

“Additionally, if coding technology works with the practice’s EMR or practice management system, the billing team can cross-reference charges that were coded with the physician’s schedule as a way to ensure that all patients on the schedule were billed,” he explains.

Bernard says some CAC programs help capture where coders are making mistakes, which the HIM director and coder can work on together to correct. Conversely, she explains that if a CAC application generates a high error rate on certain procedures, someone needs to tell the vendor and determine whether the staff isn’t aware of regulatory information or if the software is using outdated codes.

How can an HIM director measure CAC’s performance? Friedman says it is simple to benchmark CAC success compared with traditional coding. “Have coders code a set of charts without CAC, wait a month or so, and have them code the same set using CAC. You will see increases in productivity, consistency, and accuracy,” she says.

Measuring Accuracy
The short answer to whether there are independent accuracy rates available is “no,” according to Morsch. “Coding is notoriously difficult to measure as studies have demonstrated significant discrepancies among human coders, even acknowledged coding experts,” he explains. “Also, it is difficult operationally to separate the logic used in coding from the logic required for reporting to payer and regulatory agencies. However, statistical auditing techniques are available, and those hold promise to effectively evaluate any coding processes, whether CAC or conventional.”

Friedman says accuracy is always subjective, but she did say one hospital user told her its CAC accuracy was approximately 85% to 90%.

Bernard says the biggest thing that happens with CAC or any new procedure is determining how to make good use of the available data. Still, that data can prove to be invaluable from a production viewpoint.

“The mining of the clinical data that is captured in an EMR or CAC allows for benchmarks for the next step toward accuracy,” she notes. “It also allows the individual coder to keep track of the work [he or she is] accomplishing and his or her accuracy rates.”

CAC in Action
In an effort to streamline processes and improve efficiencies, New Jersey’s Robert Wood Johnson University Hospital agreed to serve as the marquee demonstration site for the Emscribe Dx system, a technology developed by Artificial Medical Intelligence, Inc. (AMI).

According to HIM Director Cecilia Hilerio, RHIT, the department started using CAC for outpatient referred/recurring cases, then moved on to outpatient same-day surgery cases. The results in those areas were such that now the department is using the technology to code some inpatient cases as well.

“We have some final technical interfaces to complete with our financial system and then we will submit and release accounts for billing directly from the Emscribe system,” Hilerio says.

“Our plans are also to use the system for POA, a new functionality AMI developed for electronic capture of diagnosis present on admission from the ED record and History and Physicical reports,” she adds. “Bringing the electronic ‘precoded’ documents to the coders’ attention allows them to consider all documentation and diagnosis already highlighted for them. The Emscribe system helps with capturing all diagnosis for reimbursement, as well as quality reporting, both of which are equally important.”

The department, which consists of a manager, three coders, and two consultants (one for inpatient coding, the other for emergency department coding), has adapted well to the technology. Hilerio has been involved with the AMI developers in developing and enhancing the business informations systems requirements and architecture.

“We have worked closely with the AMI developers. The coders have been involved in suggestions to enhance areas they see would make the system more efficient,” Hilerio says. “They were initially hesitant about the system until after they became comfortable using it and saw positive results.” The coders see that the system enhances the coding process; however, no matter what, the coders have to use their clinical and critical thinking and apply all the coding rules.

Overall, Hilerio says, “One of the biggest benefits is lessening the burden of the neverending paper chase. This CAC solution is a real asset to any HIM director. It has allowed me to manage the DNFB [discharge not final billed] and report positive results—which keeps the finance department happy.”

— Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.