lecture lesson 11 hot topics_october 2014-2

Lecture – Lesson Hot Topics

This lecture focuses on several important topics; ICD-10 information, Documentation Improvement, Data Analytics, and Computer-Assisted Coding (CAC).

ICD-10 Information

As of spring 2014, ICD-10-CM/PCS implementation in the US was pushed back. This was part of the Sustainable Growth Rate (SGR) proposed bill.

As a student and a future HIM professional, it is in your best interest to keep up with this developing story via information from AHIMA. Do not rely on news media to provide full and complete information on this aspect of the bill or its impact on the HIM and healthcare community.

AHIMA notes that there are 2 main reasons that the transition is necessary:

Payers cannot pay claims fairly using ICD-9-CM since the classification systems does not accurately reflect current technology and medical treatment. Significantly different procedures are assigned to a single ICD-9CM procedure code. Limitations in the coding system translate directly into limitation in the diagnosis-related groups (DRG).

The healthcare industry cannot accurately measure quality of care using IC-9-CM. It is difficult to evaluate the outcome of new procedures are emerging health care conditions when there are not precise codes.

Most importantly, we have a mission to improve our ability to measure health care services provided to our patients, enhance clinical decision-making, track public health issues, conduct medical research, identify fraud and abuse and design our payment systems to ensure services are appropriately paid.

Reference:

Why ICD-10 Matters. (2014). Retrieved from http://www.ahima.org/topics/icd10/stakeholders

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Documentation Improvement

Documentation Improvement (DI) or Clinical Documentation Improvement (CDI) is a very hot topic. For coding and coders it is the future, impacting documentation in the record to better capture coding and reimbursement. CDI is paramount for data quality, data stewardship, and quality in healthcare. CDI impacts “meaningful use” and EHR quality.

The United States is scheduled to transition to ICD-10-CM/PCS after October 1, 2015. One of the added benefits of these new code sets is the increased specificity. To assign codes that accurately reflect the patient's diagnoses and procedures, detailed provider documentation is essential. Clinical documentation improvement professionals are the ideal individuals to work side-by-side with medical staff to ensure that the documentation in the patient health record is complete and accurate, as well as detailed enough for accurate ICD-10-CM/PCS code assignment.

Purpose of the Acute Care Inpatient Record

In developing guidance regarding clinical documentation improvement (CDI), it is essential to remember that the primary purpose of the patient health record is for documenting the care of the patient. Regardless of the format of the record—paper or electronic—CDI professionals strive to ensure that the record accurately reflects the severity of illness of every patient.

Adherence to quality of care measures, substantiation of care to external entities, protection from liability, and providing valuable research and educational data are additional aspects to consider with documentation. All of the aforementioned meet the Joint Commission standards of care, which are included in below in Appendix A.

Every acute care facility must have guidelines that govern documentation in the patient health record. Ideally, these guidelines assure compliance with federal, state, and local regulatory requirements—such as the Medicare Conditions of Participation, compared with the Joint Commission standards of care in Appendix A. Addenda to the record should be carefully addressed within the facility guidelines.

Uniformity of the patient health record must be demonstrated through the use of time, date, legibility, and proper notation of credentials. While every note in the record is permanent, errors in documentation may occur and policy should dictate how the error will be noted in the patient health record. In addition, only approved abbreviations and symbols, as outlined in a clinical staff administrative policy, can be used in the patient health record. The health information management (HIM) department should develop polices related to analysis and completion of the record.

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Developing the CDI Profession

Clinical documentation improvement programs utilize professionals who focus on the accuracy of clinical documentation. The CDI professional, often referred to as a clinical documentation specialist (CDS), may have either a coding or clinical foundation but is able to mesh both skill sets. CDSs may come from diverse backgrounds and possess a variety of credentials, such as a Registered Health Information Administrator/Technician (RHIA/RHIT), a Certified Coding Specialist (CCS), a physician, or a nurse. In addition, the CDS may hold Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certifications. A CDS must be able to work cooperatively, building rapport and trust with providers and other staff.

The CDS performs a concurrent and/or retrospective chart review to determine if further clinical documentation is needed to capture the most accurate clinical picture of the patient. In order to accurately code the patient health record, the chart requires clear and specific documentation by the physician. The record review may include notes from diagnostics, emergency room, operating room, nurses, therapy, and other disciplines. The reviewer must compare these notes to the documentation in the history and physical, consultant notes, and physician progress notes. If the information is not complete or if there is a discrepancy in the patient health record, the CDS should query the physician for additional or clarifying documentation in the record. The CDS may need to query for reasons such as:

• Legibility • Completeness • Clarity • Consistency • Precision

The focus of CDI is improving the quality of documentation to help ensure an accurate and complete reflection of the patient's care, comorbid conditions, and treatment—which impacts severity of illness (SOI) and risk of mortality (ROM). For example, if the patient has a urinary tract infection (UTI) with kidney insufficiency, the SOI or ROM could be low. However, if the same patient has a UTI and acute kidney failure documented, then the SOI and ROM could be higher due to the greater specificity of the kidney diagnosis. Complexity and severity of illness is reflective of the supporting physician documentation provided.

For an additional example, consider a patient with shortness of breath that expires and has no other specific documentation to support a more clinically complex diagnosis. This case is classified to a Respiratory Signs and Symptoms Medicare severity diagnosis-related group (MS-DRG). However, if the documentation reflects acute pulmonary edema, the patient's acuity is more complex and this is reflected in a different MS-DRG assignment. If this same respiratory patient also has acute renal failure, the MS-DRG assignment will not be affected but the SOI and ROM for the case will be modified.

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This increase in relative weight correlates with the potential use of more resources and results in a higher reimbursement. More importantly, the MS-DRG represents the true clinical picture of the patient. This is why the CDS reviews not only the physician documentation, but also the supporting nursing documentation, diagnostics, and other areas in the patient health record.

There are several other factors impacted by documentation, including present on admission (POA), hospital-acquired conditions (HACs), and patient safety indicators (PSIs). Some secondary diagnoses are considered complications/comorbidities (CCs) or major complications/comorbidities (MCCs), both of which affect the MS-DRG assignment. The documentation must clearly indicate whether these CCs and MCCs were POA or HACs. If certain conditions were found to have developed while the patient was in the hospital, the MS-DRG assignment may disallow the CC/MCC condition that was acquired during the hospital stay. Examples of these conditions include:

• Certain fractures • Catheter-associated UTIs • Decubitus ulcers

Upon chart review, the CDS may find areas that impact other disciplines. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have developed a common set of measurements for specific conditions, known as Core Measures. Core Measures are evidence-based indicators for the clinical outcome of patients and help set a standard for care of these conditions. Some Core Measures include care for a patient who has congestive heart failure, pneumonia, or an acute myocardial infarction. While the CDS may not be responsible for Core Measure reviews, he or she may be the one who first sees the potential Core Measure diagnosis being documented. If the patient has a positive chest X-ray for a pleural effusion, an elevated BNP (brain natriuretic peptide), and is receiving an IV diuretic, the CDS may suspect the missing diagnosis could be congestive heart failure (CHF). The CDS should submit a query to the attending physician for clarification of the clinical indicators.

In addition, as the patient health records are coded, the ICD-9-CM data is collected and assists in generating the provider's report card. These provider profiles are available through public reporting sites and are used by consumers for a comparison of quality of care within provider services. Report cards can be critical to how a provider is viewed within the community, regionally, and nationally. Complication rates are an example of data being reported that can be easily miscoded and misinterpreted.

Documentation Effects on MS-DRG Assignment

The example outlined below illustrates how documentation can influence the MS-DRG assignment.

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Documentation MS-DRG FY 2013 Relative Weight

Shortness of breath 204, Respiratory Signs and Symptoms 0.6822

Shortness of breath due to acute respiratory failure

189, Pulmonary Edema and Respiratory Failure 1.2461

Transitioning to ICD-10-CM/PCS

The transition to ICD-10-CM/PCS is an across-the-board change for the healthcare industry that will require education from the top down within an organization. Major stakeholders who should be involved in the transition vary from facility to facility, and may include senior executives, HIM and CDI staff, medical staff, financial management, information technology, clinical department managers, quality data users, and business associates.

ICD-10-CM is the diagnosis code set that will be utilized in all healthcare settings. The structure and format of ICD-10-CM codes is very similar to the current ICD-9-CM diagnosis codes. However, ICD-10-CM codes include much greater specificity for capturing diagnostic data and also better reflect current medical terminology.

Procedure coding and data differences for hospital inpatient claims are reflected in the increased number of codes, rising from approximately 3,800 ICD-9-CM procedures to more than 71,000 codes in ICD-10-PCS. The structure and format of ICD-10-PCS codes allows for flexibility to add new codes and greatly increases the specificity of the code descriptions by identifying the specific root operation, body part, approach, and devices used.

ICD-10-PCS code structure is dependent on individual values (Body System, Root Operation, Body Part, Approach, Device, and Qualifier) rather than a fixed code as in ICD-9-CM. For ICD-10-PCS coding, in addition to documentation of laterality, an in-depth understanding of these root operations and approaches is critical to determine the objective of the procedure. For detailed guidance on these areas and inpatient procedural coding, refer to the CMS ICD-10-PCS Reference Manual.

CDI and coding professionals—as well as providers—should all be aware of Guideline A11 as outlined in CMS' ICD-10-PCS Official Guidelines for Coding and Reporting:

Many of the terms used to construct PCS codes are defined within the system. It is the coder's responsibility to determine what the documentation in the patient health record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

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Example: When the physician documents "partial resection" the coder can independently correlate "partial resection" to the root operation Excision without querying the physician for clarification.

Documenting Specificity for ICD-10-CM

This chart offers a comparison that illustrates the need for detailed and accurate documentation—which translates into data that reflects the patient's specific medical condition. ICD-10-CM will require additional terminology to enable documentation to be consistent, concise, and complete.

ICD-9-CM ICD-10-CM

427.31 Atrial fibrillation I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation

427.32 Atrial flutter I48.3 Typical atrial flutter I48.4 Atypical atrial flutter I48.92 Unspecified atrial flutter

Transitioning CDS to ICD-10-CM/PCS

CDSs already have a good understanding of anatomy and physiology. It will be important to remember in the transition to ICD-10, however, that the application of that knowledge is different in ICD-10-CM/PCS than it was in ICD-9-CM. CDSs will need to understand how documentation impacts code assignment in ICD-10-CM/PCS for both quality and reimbursement reasons. ICD-10-CM/PCS brings with it a higher degree of specificity in code assignment, which will require a higher level of specificity within the documentation. The CDS must possess strong critical thinking skills to be able to interpret the documentation provided, have an understanding of the disease process, as well as understand how a procedure was performed, what approach was used, and what type of repair was performed.

An example that illustrates the importance of CDSs understanding the unique coding rules for ICD-10-CM is the coding of an initial acute myocardial infarction (AMI) with a subsequent AMI. ICD-10-CM requires a code from the subsequent AMI category to be used with an initial AMI code when a patient who has suffered an AMI has a new AMI within the four week time frame of the initial AMI. This differs from the eight week time frame in ICD-9-CM.

ICD-10-CM/PCS implementation will continue to impact both CDI staff and providers due to the resource-intensive education required to add specificity and granularity to patient information. Provider education will be a primary focus in developing a greater

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understanding of how ICD-10-CM/PCS affects the documentation process. A critical step will be for the CDI staff to be involved in the same level of education as deemed appropriate for coding professionals. Following education of the CDI staff, development of the education process for providers can be initiated. Each provider specialty will require the assistance and direction of the CDI staff to ensure the level of detailed information has been documented. The transition to ICD-10-CM/PCS has altered the focus of the CDI program by adding the component of provider education beyond requesting clarification of information through the query format. Together with support from CDI staff, providers will be able to improve the quality and completeness of clinical documentation required by ICD-10-CM/PCS, opening the door for resulting positive effects on coding accuracy and quality reporting initiatives.

Providers need to be reassured that they are not expected to change their methods of documentation, only to add detail. Providers must understand the need for specific documentation and diagnoses supporting medical necessity and reducing denials. Furthermore, with the advent of value-based purchasing (VBP) many payers are looking at clinical outcomes to determine payment levels. Documentation will impact the outcome data. With ICD-10-CM/PCS, where complications are more distinctly identifiable, more granular data will be available to use when reporting quality results.

Building an ICD-10-PCS Code

This table illustrates the structure of an ICD-10-PCS code describing a skin excision of the left upper arm, 0HBCXZZ.

Section Body System

Root Operation Body Part Approach Device Qualifier

Medical and Surgical

Skin and Breast Excision Skin, Left

Upper Arm External No Device

No Qualifier

0 H B C X Z Z

Best Practice Recommendations

CDI plays a vital role to ensure a smooth transition to ICD-10-CM/PCS. For CDI staff, the education process should begin with examining the new ICD-10-CM/PCS coding guidelines and becoming familiar with the coding process. The next step is to assess current documentation and identify deficiencies. This gap analysis will demonstrate opportunities for provider education. Focusing education on the review findings will better utilize the time spent with the provider.

Provider Education

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Providers should receive education in short sessions. Documentation habits can be changed incrementally through education during times when it is beneficial to providers. One method is to review a sample of records per specialty on a routine basis for documentation discrepancies. The results would be shared at physician specialty group meetings. Focus on providing one to three important items related to ICD-10-CM/PCS documentation improvement examples. The message should be short, simple, and informative. Focusing on only documentation improvement supports a positive learning environment. Make sure to mention the added benefits of improved data, and how that data supports better hospital and provider profiles, reduces denials, and ensures timely reimbursement.

The following methods may be used to facilitate effective training sessions:

• Utilize real, practical examples • Compare the difference in verbiage between ICD-10-CM/PCS and ICD-9-CM • Create templates • Distribute handouts • Leverage newsletters • Hang posters throughout the facility for awareness • Hand out "pocket cards" for quick reference

CDSs should be sincere, confident, cooperative, and able to provide direct communication with case examples illustrating the impact of CCs/MCCs, principal diagnoses, and severity of illness. To gain physicians' trust, the CDSs should be thoroughly educated in ICD-10-CM and ICD-10-PCS.

Physician leadership and involvement is essential to a successful and sustainable CDI program. A physician "champion" (sometimes referred to as a physician advisor or physician liaison) should be a full-time employee of the hospital and must be involved in all formal training provided to physicians, as well as serve in a support role to the CDSs. Physician champions are imperative to documentation improvement, helping to encourage an effective peer-to-peer communication environment. The physician champion can conduct reviews, communicate with other physicians or providers about documentation issues, and promote open lines of communication—particularly when there is a lack of response to queries. The CDSs should work collaboratively with the physician champion to develop resources that can be provided to the medical staff. For example, creating a communication tool, such as a newsletter, to share pertinent ICD-10-CM/PCS information on a regular basis with providers is a great way to build rapport between the medical and CDI staff.

Review MS-DRG Implications

The clinical documentation improvement specialist role is certainly familiar with MS-DRGs. However, in ICD-10-CM/PCS, the role will require a new understanding of the impact of the new code set to the MS-DRG system. Additionally because of the extent of the changes to the procedure codes, those principal procedure drivers should also be reviewed in the ICD-

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10-CM/PCS MS-DRG system. Reviewing the frequently used principal diagnoses and principal procedures in today's environment, and then cross mapping that principal diagnosis to the ICD-10-CM/PCS MS-DRG system, will expose areas needed for education on the new diagnosis code system as well as an understanding of the financial impact of the code changes.

The CC/MCC implications under ICD-10-CM/PCS may make assigning the recommended MS-DRG more complex. Gaining an understanding of the changes to CC/MCC assignments and providing education on the differences in documentation for a MCC versus a CC in the new coding system will be an important part of ICD-10-CM/PCS training.

Examining the new coding guidelines is a good place to start the learning process for ICD-10-CM/PCS. Because principal diagnosis assignment is based on guidelines, the CDS will need to understand the revised guidelines for similarities as well as differences. The CDS should begin holding regular education sessions, along with the coding staff, through the transition to ICD-10-CM/PCS to discuss documentation issues and resolve discrepancies around code assignment.

Adding CDI Staff

An evaluation of the current staffing levels may help to uncover current deficiencies in reviewing the necessary charts each day for compliant and complete documentation. The CDI group should discuss with administration any plans to have more than the traditional number of charts reviewed for documentation in ICD-10-CM/PCS. Furthermore, CDSs should work with administration on a decision regarding ongoing levels of review and whether they should be short term through the transition or continue indefinitely.

A determination should be made about whether a documentation improvement initiative may be worthwhile in the outpatient setting. Substantiation of a recommendation could be accomplished through a review of current outpatient cases to identify documentation improvement opportunities that may exist under ICD-10-CM/PCS. The number of staff needed to review the additional charts should be evaluated and recommendations made to administration staff for additional resources.

Add or Revise Documentation Improvement Queries

CDSs who have had education on the new coding system should work with the HIM coding department to evaluate and revise current documentation queries as well as make recommendations for new query templates. Additional procedure templates may be necessary in cases where specificity will be vital to the code assignment. Coders who are currently cross coding in ICD-10-CM/PCS may be best leveraged to participate in this workgroup for their input regarding changes they have already identified as having an impact. Once revised, the templates should be evaluated for MS-DRG and SOI impact to the various responses.

EHR Templates

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If the facility is not using documentation templates, this may be a good opportunity to identify areas where a documentation template may be used to gather all necessary components for accurate code assignment. For those facilities already utilizing documentation templates, whether electronic or paper, the templates will require a review for ICD-10-CM/PCS documentation impact. CDSs should be an integral part of interdisciplinary committees working on templates and other tools for providers. Templates may be designed and used in the outpatient setting as well as the inpatient setting for consistency of documentation.

Once the documentation templates have been reviewed, the need for new templates should be considered. Some surgical procedures may be better served by documentation templates, especially orthopedic, gastrointestinal, and cardiovascular cases that use a number of devices.

Practice using newly designed templates to verify their effectiveness prior to implementation. Obtain feedback from the physicians and use their recommendations to make the templates clearer or more efficient. Involving coders to code using the documentation templates may also expose deficiencies in the design of the templates. Final review and agreement by all involved parties will gain acceptance of the templates for actual use.

CDSs are integral players in educating physician staff on use of the templates since they best understand how ICD-10-CM/PCS impacts clinical documentation.

Improving Documentation for Quality in ICD-10-CM/PCS

CDSs should understand how the coding, based on provided documentation, is impacting quality outcomes. A review of what sources of quality information are being used to report the facility and/or provider's results should be conducted. Identify the methodology used by the reporters and evaluate current trends for areas and providers that may be lacking due to documentation issues. CDSs also need to be knowledgeable of Core Measure data extraction, as there may be new impacts to the selection criteria.

It is imperative that CDSs understand how HACs impact the financial status of the hospital and where opportunities exist for more accurate and complete documentation. Finally, educate coders, care providers, and administration on the impact to the data outcomes in ICD-10-CM/PCS and what might be accomplished through improved documentation.

Relationship Between CDI and Coding

Successful CDI programs depend on open communication and respect amongst coding professionals, CDSs and providers. It is paramount that CDI and coding professionals work together to ensure high quality documentation is contained in the patient health record. The role of the CDS is not to "code" the record, but rather to enhance it to the level of specificity needed for final coding and billing.

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Appendix A: Joint Commission and Medicare Conditions of Participation Standards for Documentation

Documentation Requirements The Joint Commission

Conditions of Participation

The hospital plans for managing information. IM.01.01.01 § 482.24

The hospital plans for continuity of its information management processes. IM.01.01.03 § 482.24 (b)

The hospital protects the privacy of health information. IM.02.01.01 § 482.24 (b) (3)

The hospital maintains the security and integrity of health information. IM.02.01.03 § 482.24 (c)

The hospital effectively manages the collection of health information. IM.02.02.01 § 482.24

The hospital retrieves, disseminates, and transmits health information in useful formats. IM.02.02.03 § 482.24

Knowledge-based information resources are available, current, and authoritative. IM.03.01.01 § 482.24(c)(3) (ii)

The hospital maintains accurate health information. IM.04.01.01 § 482.24 (c)(4)(A)(B)

The hospital maintains complete and accurate medical records for each individual patient. RC.01.01.01 § 482.24 (b)(c)

Entries in the medical record are authenticated. RC.01.02.01 § 482.24 (c)(1)(2)

Documentation in the medical record is entered in a timely manner. RC.01.03.01 § 482.24 (c)

(1)(2)(3)(iv)

The hospital audits its medical records. RC.01.04.01 § 482.24 (c)(3) (iii)

The hospital retains its medical records RC.01.05.01 § 482.24 (b) (1)

The medical record contains information that reflects the patient's care, treatment, and services.

RC.02.01.01 § 482.24 (c) (4)

The patient's medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

RC.02.01.03 § 482.52

§ 482.51 (b)(6)

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The medical record contains a summary list for each patient who receives continuing ambulatory care services.

RC.02.01.07

Qualified staff receive and record verbal orders. RC.02.03.07 § 482.24 (c)(2)

The hospital documents the patient's discharge information. RC.02.04.01 § 482.24 (c)(4) (vii)

AHIMA. "Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS." Journal of AHIMA 84, no.6 (June 2013): 56-61 [expanded web version].

Data Analytics

The new era in quality measurement and improvement will require that we distinguish between measures for accountability and measures for improvement. Accountability initiatives are designed to reflect performance on aspects of care and segments of the patient population where everyone can agree on what care should be provided and what outcomes should be expected, based on agreed upon evidence whether that constitutes published clinical guidelines or expert consensus. These are measures of accountability Providers have agreed to be held accountable to these measures which are generally tailored to exclude complex patients.

But assuming risk under accountable care arrangements will effective and reliable management of complex patients and at-risk populations that often have multiple conditions and comorbidities. To improve care process and assume risk for managing populations requires advanced analytics that go beyond the customary measures of accountability.

Level I Analytics

The capture, analysis and reporting of discrete clinical and operational measures.

Most Level I measures are externally developed and are now being upgraded to make them more standardized and capable of being captured and reported automatically with minimal manual manipulation.

Level II Analytics

Comparative data to understand process and outcome variation to drive improvement strategies. Comparative data should include clinical and administrative data and be enriched by social and demographic data if possible.

Level III Analytics

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Population analytics to understand high risk, high impact conditions and patient populations. This requires the ability to work on longitudinal databases.

Level IV Analytics

Uses predictive analytics to identify and mitigate risk situations even before they may occur. Encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future events.

HIM professionals are experts in health care data, their characteristics, provenance and their uses. “HIM professionals are ... thinking critically about healthcare performance expectations and drawing informed conclusions from measurement data. HIM professionals are selecting process improvement tools appropriate to a performance problem and using these tools to facilitate improvements.”

HIM professionals are becoming certified as health data analysts and must lead the way in helping organizations to advance collecting and reporting quality measures for accountability to the more challenging work of understanding what the information says about opportunities for redesigning care and improving the health of populations and communities. The new era in QI heralds a new era for HIM as information is used to manage and improve health and healthcare.

Reference:

Kloss, Linda L. "Quality Improvement and Data Analytics in the Era of the Electronic Health Record." 2011 AHIMA Convention Proceedings, October 2011.

Computer-Assisted Coding (CAC)

Read below: “Transitioning to CAC” – Journal of AHIMA article – if you are new to the coding field this most likely will impact you especially if you are working in or want to work in acute care/hospital coding.

Transitioning to CAC

The Skills and Tools Required to Work with Computer-assisted Coding

By Gail Smith, MA, RHIA, CCS-P, and June Bronnert, RHIA, CCS, CCS-P

The coding world is not immune to technology advancements. Computer-assisted coding (CAC) technology is changing how the coding process is accomplished across all healthcare settings. CAC technology continues to integrate into a coding professional's daily life. This article focuses on the tools to facilitate preparation for a successful transition.

The Coder as Editor

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Just as word processing did not require individuals to relearn how to spell or create sentences, CAC will not require coding professionals to relearn how to code. Rather it allows coders to apply their analytical coding knowledge. The coding professional's role will transform to editor when working with CAC technology.1

Generally speaking, an editor reviews content to determine if revisions are necessary. A coding editor determines if the computer-suggested codes are ready for all downstream processes such as billing or public health reporting.

Coders determine the final code selection based upon their knowledge of coding guidelines, clinical concepts, and compliance regulations. They will have the opportunity to agree or disagree with the coding options provided by the software.

This transition from producing the code to editing codes requires critical thinking skills such as knowing why a diagnosis or procedure is or is not coded. CAC provides a link between documentation and a suggested code; however, coding professionals need to base their decisions on a combined knowledge of disease processes and coding principles. A common coding example that requires analysis is the determination of coding signs and symptoms.

Each health record is unique and requires coders to decide if the code assignment reflects the patient's clinical story (see "ICD-10-CM CAC Example," at right). Having a solid education from a reliable source in clinical foundations related to anatomy, physiology, and pharmacology, as well as a coding education, is important for coding professionals at all levels of their careers and can enhance their analytical skills.

Technology Skills

A qualitative research study revealed coding professionals support automation and technology advancements. In today's healthcare environment individual technology skills are important to assess.

Electronic health record systems are changing the way coding professionals perform the coding function, from accessing records remotely to determining if the documentation necessary for proper code assignment is present in the electronic record.

Working remotely without an on-site IT department requires that coders possess familiarity with technology, such as connecting through a virtual protected network, ensuring information security, and troubleshooting if the technology is not performing at the expected level.

Specifically, coders must understand the logic that supports how the computer generates a list of suggested codes. There is a difference between how systems determine a code. Two common ways are natural language processing and structured text input.

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A number of resources are available that outline the difference between the two methods. AHIMA's November–December 2004 practice brief "Delving into Computer-assisted Coding" provides an overview of the different technologies, and this month's practice brief provides further guidance for organizations looking to implement CAC.

Coders should be aware which type of system the organization is investigating, implementing, or maintaining because they will be responsible for validating the output from the system.

Computer-assisted coding technology is most efficient when interfaced with electronic documentation. Just as codes produced by coding professionals are dependent upon documentation, the computer-selected codes are dependent upon the available electronic documentation. The system receives documentation via system interfacing.

CAC systems typically interface with current encoding products, which interface with the organization's financial system. It is important to know which systems are interfacing with each other, as well as what information is part of the interface. Coders thus should assess their interface knowledge.

Next Steps

To prepare for CAC, coding professionals should create a continuing education plan based upon individual self-assessment. The plan should include specific actions, such as reviewing CAC articles or taking a class in anatomy from a reliable source.

Making a commitment to lifelong learning is important, because guidelines, regulations, and technology change the coding process. Integrating new and prior skills builds a coding professional's confidence in an ever-changing healthcare landscape.

ICD-10-CM CAC Example

In this example, the CAC software assigned the code T15.91A based on documentation in the emergency department record that states the patient had a "foreign body in the right eye." The coder is presented with the decision to accept the code or reject it based on further analysis.

Review of the documentation revealed that the foreign body was located on the edge of the cornea, which changes the fourth character in ICD-10-CM from 9 to 1. The coding professional replaces the T15.91xA code with T15.01A, Foreign body in cornea, right eye.

Emergency Department Record

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A patient is brought to the emergency department due to a foreign body in the right eye. He was working with metal, and a piece flew in his eye. He reports slight irritation to the right eye but no blurred vision.

A slit lamp shows a foreign body approximately 2–3 o'clock on the edge of the cornea. The foreign body appears to be metallic. The iris is intact.

Procedure: Two drops of Alcaine were used in the right eye. Foreign body is removed from the right eye.

Computer-Generated Codes: T15.91xA, Foreign body, external eye, right.

Final Coding Decision: Coding professional selects the more specific code for foreign body of cornea, T15.01xA.

Notes

1. Foley, Margaret M., and Gail S. Garrett. "The Code Ahead: Key Issues Shaping Clinical Terminology and Classification." Journal of AHIMA 77, no. 7 (Jul.–Aug. 2006): 24–30.

2. Stanfill, Mary. "Coding Professionals' Feelings toward Computers and Automated Coding." Perspectives in Health Information Management, CAC Proceedings; Fall 2008. Available online at http://perspectives.ahima.org.

Reference:

Smith, Gail; Bronnert, June. "Transitioning to CAC: The Skills and Tools Required to Work with Computer-assisted Coding." Journal of AHIMA 81, no.7 (July 2010): 60-61.

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