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Computer Assisted Coding (CAC) is a transformative technology

June 16, 2012

Computer-assisted coding (CAC) has long been touted as a transformative technology capable of accelerating workflows, increasing accuracy and completeness, overcoming the chronic coder shortage, and freeing resources to focus on more complex coding and data analytics. Yet it wasn’t until recently—as ICD-10 inches toward reality and HIT adoption exponentially increases the volume of clinical documentation flowing through coding departments—that CAC has taken hold in the inpatient setting.

For the RecordAs hospitals begin evaluating the role CAC fills within the larger enterprise HIT strategy, they are discovering that maximizing the technology’s benefits requires integration with systems far beyond the encoding programs that are commonplace in most facilities. These typically include clinical documentation improvement (CDI) and voice, text, and speech recognition systems. If a hospital’s abstracting system features a workflow engine, it too should integrate with CAC.”

A recent article Written By Elizabeth S. Roop in For The Record magazine.

Key Points:

1. To get the maximum benefits of CAC capabilities, the results from CAC engine has to be fed back to EHR or Practice Management software.

2. Most clinical information systems have the ability to integrate with CAC and pull in text for processing through HL7 interfaces.

3. The key to succeed in CAC solution is the accuracy of the NLP engine. And outcome of CAC should be verified by the coders before fed back to EMR.

4. So, CAC is not a replacement of Coders. Properly integrated CAC solution could increase coder productivity as much as 100% on the outpatient side and 20% on the inpatient side.

5. Interfacing CAC with documentation improvement tools addresses two of the most significant challenges confronting today’s coders and CDI specialists—challenges that are exacerbated by the transition to ICD-10. The first is specificity and completeness of clinical documentation. The second is the pressure to maintain productivity.

6. ICD-10 requires lot more details in terms of patient encounter documentation. The challenge of the new ICD-10 code set, which not only requires increased specificity, but also is based on a completely different coding structure, making it impossible for coders to memorize codes. The only way to manage this is by automating clinical documentation improvement and coding.”

Very nicely written article about CAC benefits. With so many advantages of CAC workflow solution I don’t think it need to be always interfaced with HIMs system. An independent dictation / documentation solution with built-in Speech Recognition, NLP workflow and EMR access can work with CAC work flow which will be much more simplified and can be used very efficiently in Outpatient settings with many different specialties like Radiology, Emergency Medicine, Pathology, Cardiology, Gastroenterology, Pulmonary etc. 

M-Scribe Workflow diagram of Computer Assisted Coding (CAC)

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