Computer-assisted coding (CAC)—when paired with a credentialed coder—can help with faster coding of inpatient records without any reduction in accuracy, according to a recent study conducted by the American Health Information Management Association (AHIMA) Foundation.
The AHIMA Foundation conducted the research study in collaboration with the Cleveland Clinic to examine the impact of CAC on timeliness and data quality. It was published in an article in the July issue of theJournal of AHIMA.
To evaluate the timeliness and accuracy of the coding process, the study collected ICD-9 procedure and diagnostic codes on 25 Cleveland Clinic cases. Codes were assigned by 12 credentialed coders and the CAC technology. Six of the coders assigned codes without the assistance of CAC and six assigned codes with the assistance of CAC.
Phase I was conducted within weeks of implementing the technology. In the second phase, conducted six months post-implementation, the 12 coders recoded the 25 records. The codes assigned by the coder and CAC were compared against the “gold standard” to assess accuracy. The gold standard is the set of correct diagnosis and procedure codes for each medical record and was established and validated by the Cleveland Clinic coding leadership and quality team.
The AHIMA Foundation was able to validate that the time it took the study’s coders to code inpatient records using CAC was significantly shorter than those coders who didn’t use the technology, resulting in a 22 percent reduction in time per record.
“We’ve known for some time that CAC will dramatically change the way medical records are reviewed and coded,” AHIMA CEO Lynne Thomas Gordon, said in a statement. “This important research reinforces that HIM professionals must be involved in the process to ensure that it is being used efficiently and effectively.”
While efficiency gains are important, the accuracy of the diagnostic data identified by the CAC technology is the highest priority. The study validated that Cleveland Clinic was able to reduce the time to code without decreasing quality as measured by recall and precision for both procedures and diagnoses. However, the study also found that CAC alone—without the intervention of a credentialed coder—had a lower recall and precision rate. The addition of a credentialed coder to the CAC improved the precision for diagnosis coding and the recall for procedure coding over using CAC alone.
In April, a KLAS report found that a majority of providers are planning to purchase an inpatient CAC solution within the next two years in order to assist with the ICD-10 transition. The authors of the report said that providers view CAC solutions as a way to help make up for some of the lost productivity and reimbursement that ICD-10 will create.
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