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CAC, ICD-10 and the Changing Role of the Medical Coder. AGENDA. Introduction to Computer-Assisted Coding The Coding Problems Definition of CAC “Accuracy” and “Efficiency” Changing the Role of the Coder How to use CAC for ICD-10 CDI & ICD-10 Training Implementation examples
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“Coding using ICD-10-CM and ICD-10-PCS codes.......would be generated automatically at the patient’s bedside from electronic documentation with automatic queries to the physician when inadequate or inconsistent information was entered.”
- Available 15 years after AHIMA’s prediction
- US is the last 1st world country to implement
“Mention the word "coding" to a physician, and a clinically significant reaction occurs: The eyes widen, the neck veins throb. Teeth gnash, fists clench. Cheeks flush, brows twist into knots. A clammy dew of cold sweat spreads across the forehead….”
"Clinicians are reluctant to change their workflow on the clinical side. On the administrative side, they understand they are losing large amounts of revenue with the manual process. The known problem of correct charge capture…is creating increasing anxiety in the whole healthcare sector”
Health Management Technology
“The coding task itself is daunting. Some coders are extensively educated and have attained certification in the field, but these coders are in short supply …..
“These coders must rely on the clarity and completeness of the documentation and then apply countless rules and interpretive bulletins-to identify and code all the care a patient has received. Any activity missed in either the documenting or the coding - results in lost revenue.”
Healthcare Financial Management
- 40% of AHIMA respondents agree they have a shortage
Improper Payments for Services With Documentation Errors in Five States
Improper Payments (in Millions)
State Documentation Errors All Errors*
A $3.19 $3.38
B $25.32 $28.56
C $71.78 $77.91
D $24.18 $26.98
E $13.42 $17.88
The bright side? Just 2% of claims did not show medical necessity.
Agencies are doing a great job ensuring services are needed.
“Computer-Assisted Coding (CAC) is generally defined as the use of computer software to “read” clinical documentation and automatically generate medical codes which are then reviewed and validated by a trained “human” coder.” – AHIMA
Numerous dissimilar products out there
Confusion between EHR and CAC
EHR’s often have point/click menus with codes
Coding options that have little to do with CAC
(Options available whether you use CAC or not)
Such as viewing images and links to references
CAC Less useful as a term
CBC: Coded by Computer
Maintains the key elements of the original AHIMA definition:
The major benefit for CAC is EFFICIENCY.
Natural Language Processing Rules
2 common types; Rules-based and Statistical processing
Binary Pattern Filtering
clinical documentation into a binary pattern that
retains all of the rich clinical content and detail.
through one or more Code Set Filters – When a
match is found, the correct code is displayed.
Binary filter, such as; ICD-9, ICD-10, E & M
and CPT codes.
makes it easy for
clients to create
and modify filters
for their own
unique terms and
coding conventions while maintaining the highest CAC accuracy available
today.” Dr. John Ryan
Transcription to make MT’s Editors
Coders edit and validate the ICD-9 and/or ICD-10 codes found by the NLP engine -Saving time and money
careers for some MT’s with carpal tunnel
- Spell check reduced errors
- reduces data entry by coder
The value of this transition will be broad and far-reaching throughout the healthcare industry, and will result in:
• Greater coding accuracy and specificity
• Higher quality information for measuring healthcare service quality,
safety, and efficiency
• Improved efficiencies and lower costs
• Greater achievement of the benefits of an electronic health record
• Recognition of advances in medicine and technology
• Alignment of the US with coding systems worldwide
• Improved ability to track and respond to international public health
• Enhanced ability to meet HIPAA electronic transaction/code set
• Increased value in the US investment in SNOMED-CT
• Space to accommodate future expansion
Although ICD-10 has been used around the world for many years and it is due to be implemented in the US by October 1, 2013, for now.
It is a brand new issue for the US system that already faces numerous challenges. However, this challenge does present several opportunities there is no reason to delaypreparation.
AHIMA August 2010 survey of 838 members preparing for 5010 or ICD-10
Jump to August 2011
85 percent of respondents to the August survey said that their organizations had begun work on ICD-10 planning and implementation, a significant jump from 62 percent one year earlier.
The will to win is not nearly as important as the will to prepare to win. - Bob Knight 76’
Basic Comparison of # Codes
Because of the significant increase of specificity over ICD-9, there is a large increase in the number of codes:
ICD-9-CM ICD-10-CM Change
Diagnoses 14,315 69,101 54,786
Procedures 3,838 71,957 68,119
by coding ICD-9 & ICD-10 simultaneously
make rational decisions about documentation process
changes between now and 2013.
record. Coding to ICD-10 will reveal detail on “unspecified”
codes, in which case documentation improvements starting now
may be of great benefit to the facility in due course.
ICD-9 codes starting today, by 2013 ICD-10 will no longer
represent the serious challenge that most professionals are
ICD-10 has moved entire codes into their own code groups.
For example, in ICD-9, “left knee osteoarthrosis” would be coded as
715.16 - Osteoarthrosis -Localized Primary Involving Lower Leg.
Now, looking at the equivalent codes in ICD-10 we notice something
M19.01 Primary arthrosis of other joints, shoulder region
M19.02 Primary arthrosis of other joints, upper arm
M19.03 Primary arthrosis of other joints, forearm
M19.04 Primary arthrosis of other joints, hand
M19.07 Primary arthrosis of other joints, ankle and foot
M19.08 Primary arthrosis of other joints, other site
M19.09 Primary arthrosis of other joints, site unspecified
At first glance it would appear that there is no equivalent
code for 715.16. A coder may be tempted to use M19.08
instead. ‘M19.08 Primary arthrosis of other joints, other site’
This would be incorrect indeed.
The correct code to use would be M17.1 - Other primary
gonarthrosis – which is in an entirely different section!
This scenario is extremely common when changing
from ICD-9 to ICD-10 – but if a coder has already been
exposed to these sorts of changes prior to actually
coding using ICD-10 then it won’t be such a surprise.
Electronic Documents are coded
by the CAC engine & displayed to coders for validation before being sent to Encoder for DRG and billing
“reproducible method to measure complexity”
“method for documentation improvements”
- 200% efficiency improvement acheivable
- CAC tools require electronic clinical documentation
- Assess what is being done currently, step by step
- identify how use of a CAC tool would alter the current workflow
-Identify your “gold standard” for translating clinical data into medical
codes. What level of productivity is acceptable?
- CAC may be necessary for an organization that is often short staffed
- Or a Radiology practice that employs no coding staff looking to improve
- perform random audits and consider complexity of coding