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September 2, 2008

Coding’s Support System
By Juliann Schaeffer
For The Record
Vol. 20 No. 18 P. 20

Coders concerned that computer-assisted coding will lessen or even eliminate their roles should relax, say experts.

With new diseases and procedures to learn each year, continuously changing regulatory requirements to comply with, and IT to implement, coders are likely to welcome any technology that promises to leave their jobs a little less complicated. But computer-assisted coding (CAC) has some in the industry wondering if the technology could completely wash out the need for coders’ human touch.

Mark Morsch, vice president of natural language processing (NLP) and software engineering at A-Life Medical, compares the impact of CAC’s introduction into the coding process with the advent of PC-based encoder software nearly 20 years ago. “The encoder software is a tool that coders use to help choose correct codes. Encoders have become a standard, indispensable tool of the HIM professional. In initial market specialties, computer-assisted coding also has become the standard, taking the process one step further by automatically selecting codes directly from the clinician’s documentation,” he says, adding that CAC reduces much of the paper handling in the coding process and eliminates most manual data entry tasks.

“CAC directly links codes to the supporting documentation, so coders take on the role of reviewer or auditor,” Morsch says. As he describes it, CAC includes two distinct types of technology: one using NLP and a second using structured input (SI). “NLP technology can read transcribed clinician notes, extract the key clinical facts, and map those facts to appropriate codes. SI applications link phrases or terms selected by the physician directly to codes. Physicians use SI to build their clinical documentation, which typically requires a change in documentation practices,” he says.

CAC Takeover?
The advent of computers in the healthcare arena have undoubtedly introduced efficiencies, but this expansive automation into the HIM environment now has some coders leery, especially in regard to CAC. As computer programs take over more manual processes, will coders slowly become extinct?

Gail I. Smith, MA, RHIA, CCS-P, an associate professor and the HIM program director at the University of Cincinnati, says this uncertainty is likely a fear of the unknown. “I believe many coders have heard the phrase ‘coding is going away,’ and they are not exactly sure what that means and feel threatened. Until coders have had experience with the technology, it will remain a mystery,” she says.

Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, chair of the allied health department at Herzing College in Winter Park, Fla., says that in addition to a fear about the technology’s accuracy, coders are also worried about shrinking job opportunities. But she believes CAC should be treated as just one of the many changes in the HIM industry—as a tool to increase efficiency and ensure accuracy. “Twenty-five years ago, reimbursement for claims averaged four to six months. Computerization of the process has reduced that to an average of two weeks,” she says. “For the most part, CAC is an additional tool that coders can use to ensure accurate reporting.”

Smith says coders’ concerns about CAC generally center around accuracy, productivity, and workflow changes. But she notes that coders are ultimately still in control of accuracy and suspects that the technology could shift coders from their traditional roles into something resembling coding compliance coordinators.

“Coders will have an opportunity to practice the skill of managing the accuracy of the coded data. Instead of the coder searching the health record for documentation to assign a code, the natural language processor will scan the report (similar to a spell checker) and produce a code,” she says. “Coding professionals will determine if this code is accurate based on analysis of the documentation. Similar to a spell checker, the coder will have the option to click ‘ignore’ or ‘change.’ [As such,] less time will be spent on assigning highly repetitive codes (eg, screening mammograms).”

Improving Workflow
Suzanne Lappen, director of corporate development at MedLearn, says the coding technology will actually aid workflow and increase productivity since coders are largely validating code assignments instead of manually assigning them. “Since the introduction of CAC, workflow efficiencies have improved. Coders no longer need to jump between systems (from the main medical record system to the lab-data system) because CAC helps to integrate several systems into one. Everything is now in one place, cutting down on the number of key strokes each coder must make,” she says.

“The concern about inaccurate code assignments results from the fear that inaccurate claims will go out the door and result in an audit that will uncover fraudulent claims,” Lappen adds. “Because coders would be responsible for those claims, their fear factor increases. Some individuals don’t have enough information to understand that a portion of their claims are still being audited. Therefore, the audit process is so important.”

Morsch says coders “are also concerned about using poorly designed software that impairs efficiency and does not accommodate the complete workflow. However, once coders embrace a good CAC system, their productivity improves because it automates routine tasks, provides a complete audit trail, and makes it easier to find medical record information.”

As an added benefit, Lappen says CAC can also help coders prioritize their work tasks. “For instance, a coder may want to work on one physician’s cases first thing in the morning because they are usually the most challenging. So each day, the CAC delivers that physician’s cases first. It can also prioritize them by modality, which helps coders focus on the same code sets until finished rather than having to jump from one set of codes to another,” she says.

While concerns certainly exist, Lappen says there are multiple factors driving CAC technology forward. “One is the growing increase in the demand for healthcare services from an aging population, which creates more patient records and thus more records to code. Another driving force is the new face of the U.S. healthcare system, which is being driven by two executive orders,” she says.

In 2004, President Bush appointed a national coordinator for the National Health Information Network, with an overall goal of transforming healthcare with IT. “Then in 2006, the president signed an executive order for value-driven healthcare, which encourages the adoption of IT interoperability. Once the healthcare system becomes totally interoperable, we will have better pricing for healthcare, quality of care, and efficiency of care,” says Lappen.

“In addition to the aging population, there is the need to control costs by reducing the proportion of administrative expenses in healthcare,” adds Morsch. “Also, the coding and billing process has become increasingly complex due to PQRI [the Physician Quality Reporting Initiative], MS-DRGs [Medicare severity diagnosis-related groups], POA [present on admission], NCD/LCD [national and local coverage determinations], CCI [the Correct Coding Initiative], etc for both inpatient and outpatient services,” citing the shortage of qualified coding professionals and the future implementation of the ICD-10 coding system as additional drivers.

Adopting and Embracing Technology
Morsch says CAC technology is currently being used for the coding of outpatient specialties, chiefly radiology, pathology, cardiology, and emergency medicine. “Inpatient coding applications are still emerging, but early adopters are now deploying CAC in the hospital setting,” he says.

Lappen says the enactment of the Deficit Reduction Act of 2005 drove radiology practices to be the most frequent implementers of CAC. “With the enactment of the Deficit Reduction Act of 2005, which cut Medicare reimbursement levels for imaging procedures, radiology practices had to improve efficiency and productivity in all aspects of their business. Computer-assisted coding has helped radiology practices streamline their coding operations and reduce administrative costs,” she says.

Safian believes CAC’s ability to integrate with electronic health records is driving its adoption but emphasizes that the technology doesn’t eliminate the need for top-notch coders. “The user still needs to be a knowledgeable, educated professional to provide the correct input and to evaluate the results. The old adage ‘garbage in, garbage out’ is still true. If the coder is not trained to properly abstract the physician’s notes and other documentation to identify the correct key components, then the CAC system cannot determine the correct code or codes,” she says.

While Smith believes in the benefits that CAC can bring to the healthcare system, she says training will be vital to the technology’s success. “Training should include hands-on use, discovering lessons learned from those who are piloting the technology, and involvement in workflow analysis,” she says. “Workflow changes with any implementation of technology. Coding professionals will be reviewing, editing, and making recommendations for system changes as the technology evolves.”

While Safian points out that training is always necessary with the implementation of new technology, “How much depends on the individual coder and their level of knowledge of coding and their adeptness at using the computer,” she says, emphasizing that while the coding process is essentially the same, all learning curves will decrease productivity at first.

Morsch says worthwhile CAC applications are easy to use and require only a few hours of training, adding that facilities will benefit from an enhanced workflow after all staff have successfully grasped the solution. “These systems often provide functions to detect and filter out duplicate documents, group together visits for the same patient, integrate documents from multiple systems into a single view, apply payer-specific edits, and upload charges directly into a billing system,” he says of some of CAC’s capabilities.

The ease of training, as with the introduction of any technology, is dependent on who is educating users, says Lappen. “This is no different than any other new software implementation. The key is how well the managers educate and train their staff on the system,” she says.

Safian believes training in both manual and digital systems will make for the most well-rounded coder. “This gives them the knowledge to have one system backing up the other for accuracy. CAC can provide some excellent prevention for coding errors, such as mistakenly using an invalid code or failure to include a manifestation code,” she says, adding that CAC could work great for remote coding. “Secure networks can carry the data from the HIM department or from the coder’s home office to the fiscal intermediary. The difference is the increase in availability of professional coders,” she says.

After staff are fully trained, Morsch says CAC will allow coders more time to focus on the more difficult aspects of their job, elevating the coder role to more of an auditor. “Using CAC technology, coders have more time to focus on the difficult cases that represent more complex coding scenarios. It can also be a very effective training tool, with the newest applications providing visualization and interactive assistance for the coding of complex surgical procedures, such as interventional radiology,” he says. “The role of the coder is elevated to auditor, and users of the technology have the opportunity to expand their role into other aspects of revenue cycle management and health information management.”

Lappen assures coders, however leery they may be, that CAC is not a replacement for the intelligence and thought processes of human coders. “Coders still need to have a strong foundation of knowledge and keep one step ahead of the technology, particularly for complex cases,” she says. “Routine or repetitive procedures, such as a two-view chest x-ray for chest pain, can pass through the system quickly, so they can spend their time on the complex cases. They will need to keep their thinking caps on, and it will be important for the manager to provide comprehensive, clear education and training so that the coders can use their coding tools in a smart manner.”

Looking Ahead
“The CAC technology will become as indispensable as the encoder is currently. It is a cutting-edge tool and learning how to use it now and using it on a regular basis will place those coders on the front end of a trend that will, eventually, become entrenched in the HIM workplace,” Lappen says.

Morsch says embracing CAC could also end up providing facilities with a more relaxed staff. “By making the coding workflow more efficient and outcomes more consistent, CAC technology can help reduce the stress level that is common in many coding operations that may be understaffed and struggling to keep up with complex reporting requirements from payers,” he says.

Looking Ahead
All in all, Safian says there just isn’t a good enough reason not to embrace technology that could play a part in improving the healthcare delivery system. “However, coders should not abdicate their obligation to accurate reporting by failing to participate in continuing education. The computer is still just a tool,” she says.

While coders may feel anxious about CAC’s effect on their job status, Safian gives the following advice for technology’s continuing role in healthcare: “Take a deep breath! Computers are a blessing and a curse. We must be patient. At the same time, remember that you are the authority and responsible. Your personal education and the improvement of your coding skills is an ongoing process.”

“One very basic tip is for coders to remember that they are ultimately in charge of the code assignment,” advises Lappen. “Coding is still based upon documentation. The final validation of the code assignment is still the responsibility of coders. The rules of coding have not changed. The new technology isn’t there to pull the rug out from under coders; it’s there to help them. Ask questions and embrace and network. Understand how it works and provide input to vendors, so they can make it work better.”