A new report from the American Health Information Management Association shows how computer-assisted coding – when used in tandem with a credentialed coder – can help with faster coding of inpatient records without a reduction in accuracy.
The study, conducted AHIMA Foundation in collaboration with the Cleveland Clinic and published in the July issue of the Journal of AHIMA, is meant to probe the potential impact of computer-assisted coding technology on workflow as the transition to ICD-10 proceeds, researchers say.
"We’ve known for some time that CAC will dramatically change the way medical records are reviewed and coded," said AHIMA CEO Lynne Thomas Gordon in a press statement. "This important research reinforces that HIM professionals must be involved in the process to ensure that it is being used efficiently and effectively."
To evaluate the timeliness and accuracy of the coding process, the research collected ICD-9 procedure and diagnostic codes on 25 separate Cleveland Clinic cases.
Codes were assigned by 12 credentialed coders and CAC technology. Six of the coders assigned codes without the assistance of CAC; six assigned codes with it.
Phase I was conducted within weeks of implementing the technology, researchers say.
In Phase 2 – conducted six months post-implementation – the dozen coders re-coded those 25 records. The codes assigned by the coder with 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.
While efficiency gains are important, however, AHIMA officials emphasized that the accuracy of the diagnostic data identified by 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, officials said. But it 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.
"When looking at the big picture, it is imperative that healthcare organizations plan their transition to ICD-10 with both efficiency and data quality in mind," wrote the study's authors, Michelle Dougherty, Sandra Seabold and Susan E. White. "Many organizations are evaluating CAC technology as a tool to mitigate anticipated productivity losses. Beyond efficiency, however, CAC technology should also be a tool in an organization’s information governance program."
They added that, "Using CAC will improve data quality with linkages to documentation improvement programs and analytics, since the technology uses natural language processing to automatically read and translate electronic clinical documentation that suggests appropriate ICD-9/ICD-10 codes."
[See also: CAC: The secret weapon for ICD-10]