Computer Assisted Coding (CAC) automatically generates medical codes directly from clinical documentation. With Computer Assisted Coding (CAC) technology, healthcare organizations can streamline their revenue-cycle processes while becoming more compliant with the increasingly complex payer and quality reporting requirements.
CodeRyte’s software enables identification and extraction for analysis of clinical information from free-text and structured medical records. The software supports the analysis of demographic and referral patterns, revenue optimization, payer mix, RAC preparation, clinical appropriateness, regulations, quality initiatives and clinical trials, according to the vendor.
Electronic health records (EHR) produce a rich source of electronic documentation; however, these systems can be difficult to integrate into the coding process. CAC technology provides a bridge between the documentation in EHR and transcription systems and healthcare financial systems.
CAC natural language processing (NLP) applications scrutinize and interpret unstructured clinicians’ notes using specialized linguistic algorithms, extracting the clinical facts that support the assignment of codes. Structured input applications integrate the coding into the clinical documentation process, producing clinical documents with embedded codes. NLP applications typically can work with current clinical-documentation practices that produce unstructured text, such as dictation, speech recognition and transcription.
CAC is frequently deployed using the software-as-a-service (SaaS) model but also can be handled as a conventional client-server software installation. With SaaS deployment, local installation requirements are minimal. CAC products often include a number of different modules to provide a complete coding workflow solution, including coding review, production monitoring, management reporting, coding automation and auditing.
Data interfaces are required to feed the clinical documentation into the CAC application and accept the coded data into the organization’s billing system. Standard interface formats such as HL7 or XML can be used to export the clinical documents. With NLP-based systems, however, virtually any document format can be used.
Web services are also an option for some environments, particularly if an existing programming interface is available. The output of the CAC work flow is coded records, including the CPT and ICD-9 coding and other information needed to file a complete claim, such as modifiers, units, code linkage, patient demographics and payer demographics. For optimum workflow that does not require data entry, the coded data transfers directly from the CAC system into the billing system.
CAC does not eliminate the need for medical-coding professionals to be involved in the coding process. It can make them more productive and accurate. To review the codes, coders use an application that displays the clinical documentation side-by-side with the medical codes. Coders can review and modify the coding in the application, and validate it against local and national coverage guidelines in real time. Coding managers and administrators typically require separate training for the reporting and production-monitoring modules.
Today, CAC is most widely used in physician coding for outpatient services. Some of the medical specialties that currently use CAC include radiology, emergency medicine, pathology and cardiology. Hospital coding applications have also gained momentum during recent years.