Health Information Management

Is computer-assisted coding friend or foe?

JustCoding News: Inpatient, January 18, 2012

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by Robert S. Gold, MD, and Lori Cushing, RHIT, CCS

Computer-assisted coding (CAC) is a hot topic these days. Many articles and vendors sing its praises. However, is it really all that? Let's discuss some relevant concepts.

Many industry experts claim that CAC is the wave of the future—that its accuracy has been proven, and that humans cannot match its productivity. With CAC, elements such as fatigue, stress, and inexperience are no longer factors that can negatively affect code assignment. Thus, statistical analysis as well as physician and hospital profiling is accurate. It sounds wonderful, doesn't it?

Thoroughly investigate CAC vendors

Some CAC vendors say their products can decipher electronically transcribed physician-patient encounters via the Internet and appropriately code them for reimbursement purposes. These vendors may also claim they can expedite the reimbursement process by automatically suggesting compliant ICD-9-CM and CPT®-4 codes almost instantaneously. Other vendors may say they can accelerate the coding process without sacrificing accuracy.

Who wouldn't be impressed by all of this talk of increased coding accuracy and compliance as well as improved revenue streams?

Hospital administration will undoubtedly be amazed when CAC software instantly reads pages of text, recognizes the words, and assigns the correct codes. After being impressed that the software can correctly decipher between and assign codes for pneumonia, chronic obstructive pulmonary disease (COPD), hypertension, emphysema, dehydration, and chronic renal insufficiency, for example, administrators will probably start thinking about all of the money their hospitals can save. They might think they can accomplish these savings by implementing CAC and then eliminating or reducing coding staff positions.

Beware of CAC limitations

It's true that humans have some disadvantages when matched against computers. Computers don't get sick, they don't take lunch breaks, and they don't require benefits. However, computers also don't have the same analytical and intuitive skills that humans have.

Experienced coders can analyze a case to determine whether sepsis is evident but not documented. They can look for signs of acute and/or chronic respiratory failure even when it's not documented. Veteran coders know all the intricacies of national coding guidelines, including those that instruct them to combine ICD-9 codes such as 401.9 (hypertension, unspecified) and 585.9 (chronic kidney disease, unspecified), for example, as well as those that instruct them not to combine certain codes.

Computers may be able to combine codes, but they are not skilled at knowing when not to combine them. CAC software will assume that when COPD and a few other more specific terms are both documented, the code that should be assigned is that which denotes the specific condition (e.g., 492.8 for emphysema, not otherwise specified)—not 496 for COPD, not otherwise specified. CAC software may also assume that other conditions, such as pulmonary fibrosis (code 515), can be coded with COPD.

Conversely, coders will read documentation of dehydration and review creatinine patterns throughout the patient's stay to look for undocumented acute renal failure. Unlike CAC software, if coders see that a physician has documented acute renal insufficiency, they won't automatically assign code 593.9. Instead, they will consider acute renal failure (code 584.9) and look for a specific disease process that is hidden. When they analyze a chart, they may see documentation of Graves' disease in the patient's medical history along with Synthroid® listed on a patient's medication list. This will indicate that the patient may not have Graves' disease and that it is either post-radioiodine treatment or subtotal or total thyroidectomy. I'm not so sure that CAC can determine this.

CAC software will determine that a patient's record includes documentation of valvular heart disease. The CAC's encoder will then lead users to a diagnosis of endocarditis, which is not what the physician intended. The CAC software depends on encoders, but encoder logic can lead to more errors than any vendor may be willing to admit.

Some vendors prompt physicians to arrive at the proper code sets. However, no physician wants to pursue a complicated decision tree of questions designed for coding professionals, not clinicians. Physicians will likely quickly select a code and move on to the next case. This, in turn, may falsify patient data and even minimize the complexity of a physician's medical decision-making, the severity of illness, and the risk of mortality.

After the initial positive impression with CAC wears off, reality will start to sink in. When hospitals audit charts coded by CAC, they may find errors even when the coding pertaining to those charts is fairly straightforward. These errors can lead to fines, distorted core measures, and more negative consequences.

The bottom line is that hospitals should not underestimate coders' value. Before deciding to pursue CAC, review each vendor thoroughly and don't get swept away in each of the perceived benefits.

Editor's note: Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. You can contact him by phone at 770/216-9691 or by e-mail at rgold@DCBAInc.com.

Cushing is a coding supervisor at Redington Fairview General Hospital in Skowhegan, ME. She is a consultant and auditor who focuses on the accuracy of inpatient coding, and a clinical documentation improvement (CDI) educator.

This article was published in the January issue of Briefings on Coding Compliance Strategies.

To learn more from coding expert Robert S. Gold, MD, sign up to participate in The JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS, which will take place February 29–March 2. Dr. Gold will be one of the speakers during this three-day event, during which you will have the opportunity to hear from an array of experts, who will share guidance for the challenges of ICD-10 preparation and implementation. You will also be able to network with your peers and participate in question and answer sessions—all without ever having to leave your office.



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