Application Of Computer Assisted Coding

In the health care system, there are a lot of codes that help diagnose, treat, and discharge patients daily. Codes help nurses

The new job title could be a medical coder 1. I choose this new title because the medical coder is a health care professional who analyzes the medical records, medical charts and assigns the appropriate codes. Most of the job’s responsibilities of a medical coder are required for the inpatient and the outpatient coder’s jobs. For example, medical coder’s responsibilities are: reading and analyzing patient records, determining the correct codes for patient records, interacting with physicians and assistants to ensure accuracy, using codes to bill insurance providers, and maintaining patient confidentiality and information security. In addition, the minimum required certification of this job is CPC or CCS and RHIT with at least 4 years of experience. Those certifications are given to a Coder who can read and assign correct diagnosis International Classification of Diseases or ICD-10-CM, Current Procedural Terminology or CPT, supply Healthcare Common Procedure Coding System or HCPCS code for a wide variety of clinical cases and services, and read and assign PCS codes. The skills of this job are same as the skills of the

Healthcare has evolved over past decades and continues to remain an issue of concern for individuals everywhere. Effectively managing data is important to improving the performance in the health care system. Accumulating, evaluating, deciphering and acting on data for particular performance measures allow health professionals to identify shortcomings and make the necessary adjustment, and track the outcome.

Apply accurate, complete, and consistent coding practices for the production of high-quality of healthcare data.

Coding professionals once looked upon computer-assisting coding as a threat. But rather, this technological tool is something that will support the coder to turn out to be more productive in the their day-to-day coding undertakings by making computer-generated proposals, permitting for more time to for data quality analysis rather than researching for diagnostic and procedural solutions that can be time consuming.

6. Why did the Centers for Medicare and Medicaid Services (CMS) implement the National Correct Coding Initiative in 1996?

Under the references comes the 3M Coding Reference Plus, and it contains AHA Coding Clinic for HCPCS, Coders’ Desk Reference for Procedures by Optum, Anesthesia Crosswalk, Faye Brown’s ICD-9-CM Coding Handbook, and ICD-10-CM and ICD-10-PCS Coding Handbook. The References include introductions, changes in the ICD coding, and guidelines for coders to find and better understand the coding process. For example, the Anesthesia section provides the section of the surgery and next to it the section where the right code can be assigned. Then, the Coding Clinic for HCPCS provide some articles and questions with their answers related to coding and the changes to some codes. These references are crucial in the coding sector, especially with the changes that occur on some codes and modifiers. Coders should be aware of the references and use them to avoid intention and non-intention mistakes, frauds or abuse.

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

-Inpatient coders have certifications allowing them to work exclusively for hospitals or facilities. An expertise in medical record review is a must, along with an up to date status with coding rule changes, regulations and issues for medical coding, reimbursements and compliance under MS-DRG and Inpatient Prospective Payment Systems (IPPS). Coders should have experience as well as expert knowledge in abstracting information from medical records for ICD-9CM vol. 1-3, specialized payment in MS-DRG and IPPS.

Due to the growing inpatient/outpatient requirements, as well as the impending update to the ICD-10 codes; the spearfish regional hospital is in dire need of a new Computer assisted coding system (CACS) with ICD-10 code language. This technologies will assist the coding department with their day to day processes, as well as allow the hospital to continue with its growth to meet the higher demands of our growing community. Included in this report will be a detailed report of the technologies being requested, as well as information on these vendors 3M, Nuance, and Optum who can supply these

The majority of the time the use of HIM coders are involved in billing and reimbursements. However, coding specialists are important players within the healthcare industry.(Davis, 2014,2007,2002) They certify that providers maintain accuracy with coding procedures and government rules. (Davis, 2014,2007,2002) HIM functions and complex of regulatory requirements where coding can be very challenging. (AHIMA, 2016) The coders follow guidelines of the American Health Information Management Association AHIMA) Code of Ethics. (AHIMA, 2016) On the patient level, it is vitally important for the coder to code accurately because this information will trail the patient success throughout their course of treatment and beyond.

Computer Assisted Coding (CAC) is “software that scans medical documentation in the electronic health record, identifying technology and suggesting codes for that particular treatment or service” (AHIMA.org). The CAC software uses either a natural language processing engine (NLP) or structured input to generate the codes. This NLP “electronically reads narrative text or voice documents and uses computer-based reasoning to identify, analyze and assign the appropriate code” (Getz, Lindsey), where

ICD-10 stands for International Classification of Diseases, Revision 10. ICD-10 is a revision of the ICD-9 system which physicians and other providers currently use to code all diagnoses, symptoms, and procedures recorded in hospitals and physician practices. There are two main types of ICD-10 coding books, the International Classification of Diseases, Revision 10, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Revision 10, Procedure Coding System (ICD-10-PCS). ICD-10-CM is a system used by physicians and healthcare professionals to code diagnoses and procedures that occur in American hospitals. ICD-10-PCS is a system of medical classification used for procedural coding. The implementation of

Over the course of this class, I have gained a lot of interest with the coding system especially with the ICD-10CM/PCS. I feel like I can easily code simple diagnosis without stress, however, I still need more practice to be able to code the most complex medical and surgical diagnosis. One thing for certain, I tried not to be intimidated by the enormous guidelines instituted for a successful coding and reporting of patients’ diagnosis. However, as I work through the remaining few weeks of this class, I am positive that the coding skills I have acquired throughout this class will definitely benefit me in my future career.

Health care systems are reporting and monitoring quality of care indicator data with increasing regularity.