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Is Computer-Assisted Coding Ready For Inpatient Use?

June 25, 2010
by Ken Terry
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Computer-assisted coding for inpatient claims processing

Executive summary

More hospitals are taking a serious look at computer-assisted coding (CAC). While CAC still requires human input, the latest technology - natural language processing that extracts code-related terms from electronic text-has helped boost productivity. Both Eastern Maine Medical Center and Massachusetts General have documented shorter turnaround times in their coding tasks.

Computer-assisted coding (CAC), after making substantial inroads in outpatient departments, is starting to emerge on the inpatient side as well. While only a few hospitals around the country have rolled out CAC across the board, more facilities are beginning to look at it. That number is expected to rise because of the coding challenge posed by the changeover to ICD-10 diagnostic codes.

Due to the complexity of inpatient care, the vast number of medical terms used, and the prevalence of hybrid paper and electronic records, hospitals don't use CAC without human intervention, as ambulatory-care providers sometimes do. But the latest CAC technology - which employs natural language processing to extract code-related terms from electronic text - has been shown to raise productivity by automating portions of the coding process.

Rick schooler
Rick Schooler

As a result, CAC is breaking out of the radiology/pathology/ER ghetto and is crossing over to the inpatient arena. Among the institutions that are beginning to use it are Yale-New Haven (Conn.) Hospital, Baltimore-based Johns Hopkins Hospital, University of Pittsburgh (Pa.) Medical Center and Eastern (Bangor) Maine Medical Center. Vendors of CAC systems include 3M, St. Paul, Minn.; CodeRyte, Bethesda, Md.; A-Life Medical, Inc., San Diego, Calif.; and Artificial Medical Intelligence, Eatontown, N.J., now partnered with Medquist, based in Mt. Laurel, N.J. Health information services vendor QuadraMed has also just added a CAC module.

Another approach to CAC is to use electronic health record (EHR) documentation to generate some of the codes. Rick Schooler, vice president and CIO at Orlando (Fla.) Health, which uses Sunrise Clinical Manager, supplied by Atlanta-based Eclipsys Corp., on the inpatient side, says that the seven-hospital system has decided to move forward with this kind of CAC. As it rolls out its EHR, Orlando Health will use a term-mapping solution from Intelligent Medical Objects, Inc., Northbrook, Ill., that will be integrated with Eclipsys, he says. The structured input from the EHR will be combined with natural language processing.

“To the degree that the IMO product does natural language processing and electronically reads through the documentation looking for key words, we'll probably have EHR templates that generate the key words,” says Schooler. “It will help us move from ICD-9 to ICD-10, which is going to be a monster.”

Productivity gain at EMMC

CAC has already improved the productivity of coders at Eastern Maine Medical Center, says Mandy Reid, coding manager at the flagship of a seven-hospital system. After the hospital introduced the 3M product in August 2009, she says, the number of records processed per hour increased 15 percent in the first 45 days and 30 percent in the first 90 days.

Eastern Maine Medical Center also decreased its average turnaround time for coding records from five to four days. Its average days in accounts receivable dropped 7 percent, and it was able to reduce its coding staff by one full-time employee, says Reid.

When the hospital decided to adopt 3M's inpatient CAC software, Reid says, the goal was to “take the page turning out of the coders’ job.” By combining natural language processing with 3M's coding decision support tool, she explains, the CAC system enables coders to click on an annotated term, such as chronic obstructive pulmonary disease (COPD), and follow the decision tree logic as far as it can take them with a high degree of confidence. “Then it lets the coders make the final few decisions to get to the correct code. So compliance-wise, it only takes them as far as it accurately can without someone intervening.”

CodeRyte, which supplies 3M's natural language processing, has added a quality assurance module that enables the program to learn from its mistakes. Essentially, the software registers how often coders follow its recommendations on a particular code and adjusts its approach accordingly. For example, it can figure out when it's misinterpreting unfamiliar terms that physicians sometimes use. Over time, “training” the software in a particular hospital should make it more reliable.

Schooler compares the evolution of CAC to that of voice recognition software, which is widely used to transcribe medical dictation with some editing by transcriptionists. “Coding will go down the same path. There will be certain technologies that will allow the coders to transition to more of a review function, as opposed to bottom-up coding on every patient. And there will be technologies that capture the codes 100 percent upon documentation. I think it's going to be a combination of the two. Will we ever eliminate the need for coders? I doubt it.”

Kelly Taylor, an Atlanta-based consultant with CSC in Falls Church, Va., agrees that, though CAC can increase productivity, it requires human intervention in the complex hospital environment. “According to the American Health Information Management Association (Chicago), CAC technology should be viewed as a tool to assist coding staff rather than as a replacement for coding staff,” she says. “I don't think you can ever take the human coder out of the equation.”