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October 12, 2009

CAC: It Still Needs the Human Touch
By Lindsey Getz
For The Record
Vol. 21 No. 19 P. 14

It’s called computer-assisted coding for a reason, right? Healthcare organizations sporting the technology have learned that coders are more essential than ever.

While technology such as encoders and remote coding has long been a part of the coding process, for many, computer-assisted coding (CAC) is still a brand-new, and maybe even scary, concept.

The AHIMA defines CAC 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.” There are currently two forms of CAC: natural language processing (NLP) and structured input. NLP electronically reads narrative text or voice documents and uses computer-based reasoning to identify key words, analyze their context, and come up with the appropriate code. Meanwhile, structured input allows the physician to create a record and pick specific diagnostic phrases to which a code will be automatically derived based on that phrasing.

An improvement in productivity is one of the reasons to implement the technology, says Jason Burke, CAC program manager at 3M Health Information Systems. “Each coder is able to code faster and code more and, at the same time, ensure that coding compliance and accuracy standards are met,” he says. Because there is a shortage of qualified coders and the need for coders is predicted to rise, CAC can help organizations do more coding with less staff and in less time, he says.

At Nebraska Orthopaedic Hospital, for instance, CAC has made it possible for physicians to work more efficiently. “Most of our doctors use an operative report template that automatically populates options each time they go into the system,” says coder Sally Roland, MS, RHIA, CPC. “The doctor can select exactly what procedure he or she is doing, and then it gives a list of diagnosis options from which the physician can select the appropriate one for the patient. Most of the things the doctor would have had to previously dictate are now in this preprogrammed template, making it easy to go in and click on the right option.”

Additional benefits include a boost in coding accuracy and more complete records, says Burke. “Coders can make good use of a system that can go in and read text documents or patient medical records and provide feedback to the coder to ensure they’re capturing all of the necessary diagnosis and procedure information,” he notes.

Rick Toren, founder and chairman of CodeRyte, agrees. “The efficiency of having a computer read simple and repetitive phrases and code them allows human workers to concentrate on the documents that are more in-depth and require more intelligence,” he explains. “In fact, a computer may be able to do it more accurately because as humans, we tend to make mistakes when we get into repetitive work. We’re not challenged, our mind wanders, and we are more likely to make keystroke errors. If the computer can take over these mundane tasks, it not only opens up more time for workers to focus on harder jobs, but it ensures better accuracy. At the same time, good NLP technology, the heart of computer-assisted coding, can also tackle harder reports.”

It would seem logical to assume that CAC would diminish the role of coders. Not so, says Toren. “Good NLP doesn’t impact the importance of coders; they will always bring value in their ability to edit and review technology’s coding performance because the more complicated reports are the ones with the greatest risk and reward,” he says.

A Human Eye
While vendors tout better accuracy as a primary benefit of CAC, not everyone in the industry is convinced. One of the biggest fears is still that computerized code selection may lead to substantial postpayment liability as a result of inaccurate coding. “Since the rules on how to code physician services are payer specific, where a practice deals with multiple payers and the software does not account for this, the result will likely not be accurate,” says Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, president of Practice Masters, Inc. “As such, a coder would be needed to correct the coding prior to claim submission.”

While the technology has been embraced at Nebraska Orthopaedic Hospital, coders there have found that anything beyond simple decision making may produce incorrect results if relying solely on the computer. Roland believes the situation illustrates the need for coders to be involved in the process. “Every provider has their own way of communicating, and this can lead to inconsistencies,” she explains. “A doctor may say his or her patient has an arthritic spine, but there’s no code in the system for this. In coding language, the term used is ‘spondylosis spine.’ Whenever I find something like this, I notify the staff member in charge of the system that there’s an error. I explain what I got when I coded it, what the doctor’s operative notes said, and what code the CAC system came up with—and we troubleshoot.”

In addition to an inability to handle some complicated cases, Miscoe points out that most of the CAC products for physician service coding focus on Correct Coding Initiative (CCI) rules. “While these rules certainly apply to Medicare billings, beyond that, they may be irrelevant as not all carriers tie their coding standards to CCI,” he says. “And even when used to bill services for Medicare, these programs will alert the coder that a modifier is required where bundled services are performed. I have not seen a program that attempts to incorporate the logical algorithms necessary to make a determination of whether use of the modifier was appropriate.”

Some believe that accuracy problems are a primary result of organizations turning to total automation. Having a trained eye review computer-generated codes before having them go through to billing is a necessity, notes Miscoe. “CAC can definitely speed up the process—maybe you don’t have to reenter information over and over or you could perhaps even avoid transcription—but you still need someone who is trained to put human eyeballs on the computer’s code suggestions,” he says. “It needs to be validated that the codes are in fact accurate for each particular payer. With that caveat, I do believe there is a future for CAC. But the idea that you can just take the coder out of the mix is completely false.”

Coders at Nebraska Orthopaedic Hospital never accept automatically generated codes, says Roland, adding that there’s always a human involved. “I personally don’t even look at the codes that are generated by the computer until after I’ve done my own coding because I worry it will lead me down the wrong path,” she says. “When I’m done, I look at the computer-generated codes and, if it’s the same, then great, I send it through to billing. If it’s different, it requires some investigating.”

Roland is a fan of using CAC as a sort of double check that helps her ensure accuracy. And she does believe it has made her more efficient at her job. “It streamlines the process, but I believe you still need an experienced, well-trained, and well-educated coder to review everything,” she continues. “I couldn’t imagine feeling comfortable just clicking away and sending it out the door without that review. Part of my job is to make sure we’re compliant and to make sure we’re not committing fraud, and that’s something that’s always going to require a human’s involvement.”

Still, there are some who want to adopt CAC with the intention of automating at least parts of the coding and billing process in order to boost overall productivity at a lesser cost. “There will always be people out there who want CAC to solve all their problems, and they’ll accept allowing the computer to come up with codes that are sent directly to billing,” says Miscoe. “But I believe they do so at their own peril. There will be potential errors going through unchecked. And you can’t blame it on the computer or the sales guy that sold you the system—you’re still responsible.”

Prior to letting a system code and bill directly, it needs to undergo relentless testing to enable coders to get comfortable with what will not be reviewed, according to Jean Bishop, MSPH, MBA, RHIT, CPC, CFE, CPhT, a consultant who has worked with healthcare organizations considering CAC adoption. “In the vast majority of the cases I have dealt with, the adoption of this technology is not yet at the level of having no [human] review at all,” she adds.

From Author to Editor
Keeping coders involved in the process appears to be the strategy adopted by most organizations, a circumstance that’s helped reduce the fear that CAC would eliminate coder positions. “Coders have expressed worry that they’re going to be replaced by a machine, and that makes them defensive about adopting the technology,” says Toren. “But there’s a place for computers, and when coders realize that adding this software to handle the mundane work allows them to focus on the more interesting and challenging tasks, they begin to accept it.” 

When the University of Pittsburgh Medical Center (UPMC) first brought its CAC product before its coding staff, one of the first questions raised was whether it would ultimately replace jobs. “We explained that coding started off 20 years ago with coding books and has now progressed to using an encoder, and that didn’t replace the need for the coder,” says Tammy Needham, RHIT, senior coding manager at UPMC. “Now we’re in the era of using CAC. It has helped and enhanced the process, but it hasn’t replaced the coder. It’s just made them more efficient and more accurate.”

CAC may not replace coders, but it will transform their responsibilities. The technology’s ability to derive codes directly from documentation upgrades the position to that of auditor or reviewer, says Mark Morsch, vice president of NLP and software engineering at A-Life Medical, the vendor for UPMC. “It’s important that people understand the complete picture. The automation role of CAC does not remove the role of regular auditing. I think it’s necessary for HIM to take a step back and look at how their current coding process, using only coders, could be improved through a combination of CAC plus human coders.”

However, job security does not necessarily mean making that transition to a new role will be simple for coders. “The role of the coding professional going from being the author to an editor can be a barrier to overcome,” says Bishop. “It’s not always an easy transition and can become a bottleneck in the adoption of a CAC system. It not only means embracing and learning this new technology but accepting what may be an entirely new function of their job.”

At UPMC, coders have embraced their new role. The coders are presented with codes generated by the A-Life CAC tool, and the codes are then validated by the coder. Accuracy is high, and the confidence in the technology has increased significantly. CAC has simplified the coding process which, in turn, has resulted in improved productivity. “We have a hybrid record with both written and electronic documentation,” explains Adele L. Towers, MD, MPH, HIM medical director. “Prior to implementing CAC, the coders had access to multiple systems to complete the coding process. What CAC has done for us is put all of this together in one place so that we don’t have to go into one system to look at dictations and another to look at scanned images. Everything is now in one place, from labs to orders. We have seen significant benefits in coder productivity, accuracy, and efficiency.”

Needham adds that coder satisfaction has been high. “They’ve gone from initially being apprehensive to now saying they couldn’t do without the product,” she says. “One coder in particular was extremely hesitant about adopting the technology at first. But we just had an incident where the server was down, and everyone had to go back and code the old way. That very same employee was incredibly unhappy about not having the software for the day. Everyone has found that it makes their job easier.”

Embracing Adoption
A smooth adoption process will require understanding what’s involved with training and implementation, a requirement that goes back to the relationship with the vendor, notes Bishop. “It needs to go beyond just a salesperson/client relationship,” she says. “Your relationship with the vendor is going to help you optimize that tool and walk you through potential barriers or even come up with better creative solutions that are tailored to your organization. Many people are hesitant to work with their vendors. A lot of my clients express concerns about how stable vendors are, whether they are going to go out of business and whether there can be a real partnership with them. This is something that needs to be addressed up front.”

Toren agrees, saying, “If you’re going to adopt a CAC program, make sure whatever company you look at has the support going forward because in the medical field things change all the time. Clients change their systems or they change doctors, and all of this has an impact. It’s important to ask potential vendors, ‘What are you going to do when there are changes? How will you support me in the future?’ It’s important to think of what’s going to happen after the sale is made.”

While the capacity in which it’s used may vary, CAC appears to be part of coding’s future. “This is not an industry where there’s a labor surplus, and the requirements of abstracting and coding will only increase,” says Morsch. “There will be a definite need for CAC as people want better, more accurate, and more complete healthcare information produced in an efficient manner. Coders should not be concerned about CAC as a threat to their employment but instead view it as a tool to move forward and address the new expectations and growing demands for health information.”

Adds Bishop: “Just like EHR technology, I think CAC is part of our future. I think it’s important for coders to have some introspective thought as to how they feel about technology and how it relates to their job. Technology is not going to go away—it’s only going to continue developing—so it makes sense to start a dialogue now.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.