CAC, ICD-10 and the Changing Role of the Medical Coder

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CAC, ICD-10 and the Changing Role of the Medical
Coder
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AGENDA

• Introduction to Computer-Assisted Coding
• The Coding Problems
• Definition of CAC
• Accuracy and Efficiency
• Changing the Role of the Coder
• How to use CAC for ICD-10 CDI ICD-10 Training
• Implementation examples
• Demonstrating coders work space
• Recommendations
• Question - Answer

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CHANGES IN TECHNOLOGY
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The Computer-Assisted Coding Concept

• Capture physicians typed documents
  electronically
• Automatically extract the clinical codes using a
  computerized mechanism.
• Deliver Results to the billing department real
  time
• Reduce the amount coding time and costs
• Utilize CAC for Clinical Documentation
  Improvement
• Capitalize on the Global experience of countries
  that already have electronic documentation,
  ICD-10 and CAC in the healthcare environment

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• Automated Coding Goals
• Streamline the process of clinical coding
• Reduce physician paperwork
• Increase coder productivity
• Offset qualified coder shortages
• Reduce denials increase consistency
• Create opportunities for peer review and
  physician-led quality review.
• Electronically advance CDI initiatives
• Address ICD-10 transition issues

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In 1996 AHIMAs Vision for 2006
Coding using ICD-10-CM and ICD-10-PCS
codes.......would be generated automatically at
the patients bedside from electronic
documentation with automatic queries to the
physician when inadequate or inconsistent
information was entered. - Available 15
years after AHIMAs prediction - US is the
last 1st world country to implement ICD-10
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The Coding Problem
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The Coding Problem
Mention the word "coding" to a physician,
and a clinically significant reaction occurs The
eyes widen, the neck veins throb. Teeth gnash,
fists clench. Cheeks flush, brows twist into
knots. A clammy dew of cold sweat spreads across
the forehead. Medical Economics
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The Coding Problem
"Clinicians are reluctant to change their
workflow on the clinical side. On the
administrative side, they understand they are
losing large amounts of revenue with the manual
process. The known problem of correct charge
captureis creating increasing anxiety in the
whole healthcare sector Health Management
Technology
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The Coding Problem
The coding task itself is daunting. Some
coders are extensively educated and have attained
certification in the field, but these coders are
in short supply .. These coders must rely
on the clarity and completeness of the
documentation and then apply countless rules and
interpretive bulletins-to identify and code all
the care a patient has received. Any activity
missed in either the documenting or the coding -
results in lost revenue. Healthcare Financial
Management
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Medical Coding Issues

• Rules changing all the time
• Coders highly skilled, scarce resource
• - 40 of AHIMA respondents agree they have a
  shortage
• Organizational success depends on timeliness and
  accuracy of coding
• Increased scrutiny with significant risk and
  penalties
• Incomplete/inaccurate results
• Inconsistent results
• Risk leaving money on the table
• Increasing calls to abstract for quality,
  outcomes analysis
• HIPAA regulations

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OIG Report on Improper Payments
Improper Payments for Services With Documentation
Errors in Five States Improper Payments
(in Millions) State
Documentation Errors All Errors A 3.19
3.38 B 25.32 28.56 C 71.78
77.91 D 24.18 26.98 E
13.42 17.88 Total 137,880,000 154
,720,000
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OIG Report on Home Health Agencies

• Office Inspector General (OIG) released a
  report that showed home health agencies submitted
  nearly 22 of claims in error because services
  were either not medically necessary (2.1) or
  were coded improperly (20.2). March 2012
• This is the first time OIG has significantly
  addressed home healths coding on claims. They
  stated that one of the factors for this review
  was the fast rise in Medicare home health
  spending84 from 8.5 billion in 2000 to 15.7
  billion in 2007which leads to concerns about
  the potential for improper payments due to fraud
  and abuse.

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OIG Report on Home Health Agencies

• More than 10 percent of claims (a value of 278
  million) were considered up-coded, and 9.8 of
  claims (a value of 184 million) were found to be
  down-coded. Net loss of 94 million for the
  Medicare system.
• The bright side? Just 2 of claims did
  not show medical necessity.
• Agencies
  are doing a great job ensuring services are
  needed.

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Payer-Provider Tension

• Advanced automation on the Payer side
• Full rule checking looking for objections
• Vendors excelling in this niche
• Software Vendors claiming ability to reduce claim
  payout by as much as 8 more using cunning
  strategies
• RAC Audits accelerating

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Provider Tools

• Scrubbers
• Identify code-sets that break rules
• Highlight them for finance dept
• Incorporate national, local and payer edits
• EMR/EHR point n click - drop down menus
• Coder tools
• Encoder products
• Incorporate CCI Edits
• Some incorporate local/payer edits
• Prompt the coder for action at code time

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Automated coding tools can

• Reduce detail work for the coder
• Increase throughput
• Reduce inconsistency
• Improve accuracy
• Reduce risk
• Increase billing opportunities
• Ability to flag encounters for RAC, ICD-10, CDI
• Leave less on the table

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Definition of CAC
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Computer-Assisted Coding
Computer-Assisted Coding (CAC) is generally
defined as the use of computer software to read
clinical documentation and automatically generate
medical codes which are then reviewed and
validated by a trained human coder. AHIMA
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Computer-Assisted Coding
Numerous dissimilar products out there Confusion
between EHR and CAC EHRs often have point/click
menus with codes Coding options that have
little to do with CAC (Options available whether
you use CAC or not) Such as viewing images and
links to references CAC Less useful as a term
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CBC is the new improved CAC

• CBC Coded by Computer
• Maintains the key elements of the original AHIMA
  definition
• Computer reads the charts and generates codes
• Human Coder audits the results
• The major benefit for CAC is EFFICIENCY.
• Efficient implementation, efficient training and
• efficient coding.

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Computer-Assisted Coding Natural Language
Processing Rules

• Mimics some clinical behaviour
• Quick overview of the document to get the gist
• Examination of key segments to understand events
• Analysis of whole document looking for extra
  detail that changes codes
• Words and sentences examined for clinical term
  matches to generate codes
• 2 common types Rules-based and Statistical
  processing

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A 3rd type of Clinically-Oriented Mechanism
Binary Pattern Filtering

• Binary pattern algorithms sent through one or
  more filters to derive codes.
• ICD9, ICD10, CPT, HCPCS, specialist research
  sets...
• No supervised learning process
• No gradual improvement as hundreds of thousands
  of documents flow through
• No need for vendor to retain documents as a
  statistical resource

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NLP Enhanced a clinically oriented mechanism

• The Binary Pattern Filtering Process converts
  your
• clinical documentation into a binary pattern
  that
• retains all of the rich clinical content and
  detail.
• Charts are coded passing their binary pattern
• through one or more Code Set Filters When a
• match is found, the correct code is displayed.
• Any Code Set that has an index can have a
• Binary filter, such as ICD-9, ICD-10, E M
• and CPT codes.
• An index is list of clinical concepts with
  their correct codes.

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Indexes for Codes with Descriptions
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Our Patented Process makes it easy for clients
to create and modify filters for their own unique
terms and coding conventions while maintaining
the highest CAC accuracy available today.
Dr. John Ryan
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Additional CAC Capabilities

• CCI edits
• LCD edits
• POA alerts
• RAC alerts
• Payer rules - All applied at coding time
• EFFICIENCY IS THE IMMEDIATE WIN
• Many other benefits which are easier to achieve
  once you have gained the efficiency

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Changing the Role of the Coder

• Speech Recognition Technology changed
• Transcription to make MTs Editors
• CAC transforms Coders into Auditors
• Coders become Verification Specialists

70450-RT
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Coders edit and validate the ICD-9 and/or ICD-10
codes found by the NLP engine -Saving time and
money
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Coder Benefits beyond production

• Speech Recognition Technology extended
• careers for some MTs with carpal tunnel
• - Spell check reduced errors
• CAC does the heavy lifting for Coders
• CAC reads 200 lines of text per second
• Reduced reading - reduced eye strain
• - reduces data entry by coder

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ICD-10 and CAC
The value of this transition will be broad and
far-reaching throughout the healthcare industry,
and will result in Greater coding accuracy
and specificity Higher quality information for
measuring healthcare service quality, safety,
and efficiency Improved efficiencies and lower
costs Greater achievement of the benefits of
an electronic health record Recognition of
advances in medicine and technology Alignment
of the US with coding systems worldwide
Improved ability to track and respond to
international public health threats Enhanced
ability to meet HIPAA electronic transaction/code
set requirements Increased value in the US
investment in SNOMED-CT Space to accommodate
future expansion
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ICD-10 and CAC

• Although ICD-10 has been used around the world
  for many years and it is due to be implemented in
  the US by October 1, 2013, for now.
• It is a brand new issue for the US system that
  already faces numerous challenges. However, this
  challenge does present several opportunities
  there is no reason to delay preparation.
• AHIMA August 2010 survey of 838 members preparing
  for 5010 or ICD-10
• 52 had not yet started preparing for ICD-10.
• Of that 52, 49 said they did not know when
  they would
• begin preparation
• 20 said they were still six months away from
  beginning

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ICD-10 and CAC
Jump to August 2011 85 percent of respondents
to the August survey said that their
organizations had begun work on ICD-10 planning
and implementation, a significant jump from 62
percent one year earlier. The will to win
is not nearly as important as the will to prepare
to win. - Bob Knight 76
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ICD-10 and CAC

• Basic Comparison of Codes
• Because of the significant increase of
  specificity over ICD-9, there is a large increase
  in the number of codes
• ICD-9-CM ICD-10-CM
  Change
• Diagnoses 14,315 69,101
  54,786
• Procedures 3,838 71,957
  68,119

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ICD-10 In Use for Over a Decade

• New Zealand
• One of the first countries to go to Electronic
  Health Records
• Transitioned to ICD-10 in 1998
• Coded ICD-9 and ICD-10 both for 1 year
• First 1st world country to use CAC in the 1990s
• US facilities can emulate the New Zealand ICD-10
  experience
• by coding ICD-9 ICD-10 simultaneously

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ICD-10 and CAC

• Introducing an ICD-10 CAC tool today would
  allow a facility to
• make rational decisions about documentation
  process
• changes between now and 2013.
• CAC allows facilities to assess the state of
  their electronic
• record. Coding to ICD-10 will reveal detail on
  unspecified
• codes, in which case documentation
  improvements starting now
• may be of great benefit to the facility in due
  course.
• In addition, if coders are able to review
  ICD-10 codes alongside
• ICD-9 codes starting today, by 2013 ICD-10
  will no longer
• represent the serious challenge that most
  professionals are
• expecting.

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Additional Benefits/Services

• CAC as a training tool for ICD-10
• Concurrently code ICD-9 and ICD-10
• ICD-10 and CAC as a judge of documentation
  quality
• Unspecified codes will always end in 9 and
  other specified codes will end in 8 - we will
  flag for CDIS
• CCI edits, LCD edits, payer rulesBUT
• INCREASED PRODUCTIVITY IS THE IMMEDIATE WIN!
• Other benefits are easier once you have
  efficiency

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Unique Characteristics of ICD-10
ICD-10 has moved entire codes into their own code
groups. For example, in ICD-9, left knee
osteoarthrosis would be coded as 715.16 -
Osteoarthrosis -Localized Primary Involving Lower
Leg. Now, looking at the equivalent codes in
ICD-10 we notice something is missing M19.01
Primary arthrosis of other joints, shoulder
region M19.02 Primary arthrosis of other joints,
upper arm M19.03 Primary arthrosis of other
joints, forearm M19.04 Primary arthrosis of other
joints, hand M19.07 Primary arthrosis of other
joints, ankle and foot M19.08 Primary arthrosis
of other joints, other site M19.09 Primary
arthrosis of other joints, site unspecified
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Do You Like Surprises?
At first glance it would appear that there is no
equivalent code for 715.16. A coder may be
tempted to use M19.08 instead. M19.08 Primary
arthrosis of other joints, other site This would
be incorrect indeed. The correct code to use
would be M17.1 - Other primary gonarthrosis
which is in an entirely different section! This
scenario is extremely common when changing from
ICD-9 to ICD-10 but if a coder has already
been exposed to these sorts of changes prior to
actually coding using ICD-10 then it wont be
such a surprise.
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Facility On-Site Database

• Facility drops HL7 records in a designated folder
• Cases submitted to Computer-Assisted Coding
  engine
• Documents and CAC codes are retained in customer
  database
• Codes and documents retrieved for display to
  coder/auditor
• Assisted process for variance analysis
• Productivity and other reporting tools.
• Comply with new HITECH/HIPAA PHI policies

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Efficient Integration

• Computer-Assisted Coding prefers to interface
  with your existing (or preferred) tools
• Example Encoder Computer-Assisted Coding
  solution pre-fills fields on the encoder screen
• No new process for the coder who is now an
  auditor/verification expert, not a data entry
  clerk.
• Resulting codes feed the billing system exactly
  as they do today
• Minimal disruption to the organization

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Coder's process without CAC
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Coder's process with CAC
CAC Engine
Electronic Documents are coded by the CAC engine
displayed to coders for validation before being
sent to Encoder for DRG and billing
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What will my work space look like?
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CAC Demonstrating the coder workspace
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Accuracy and Efficiency
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Accuracy has a special meaning in CAC

• AHIMA Paper 2009 Measuring CAC Accuracy
• reproducible method to measure complexity
• AHIMA Paper 2010 Using CAC for ICD-10 CDI
• method for documentation improvements
• Another due for AHIMA 2012
• Whitepapers Available upon request

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Efficiency Expectations

• Outpatient Diagnostic
• 100 efficiency improvement simply by dropping in
  CAC
• No process improvement, minimal training
• 100 after 1 month of experience
• Same-day Surgery
• At least 100 efficiency improvement
• Head in the Game can multiply improvements

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Efficiency Expectations

• Inpatient Charts
• - 200 efficiency improvement
  acheivable
• Depending upon electronic documentation
• POA, RAC, MNE all applied at coding time
• Large volumes no problem for CAC
• CAC reads codes a 250 page chart before a coder
  can finish page 1
• Concurrent Coding made easy
• CAC recodes the entire encounter

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Better deployment of Coders/Auditors

• Coder numbers will be reduced, not eliminated.
• Coders jobs will move on from data entry.
• Information management, accreditation, auditing,
  reporting, research.
• Teaching the clinicians.
• Capturing hand-written notes.
• Prompting coders for physician queries

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Reporting, Audits, Hospital-acquired..

• Concurrent coding
• Retention of source justification for Audit, RAC
• Flags for POA - HAC
• Alerts the Coders during review
• Scheduled Reports that automatically email
  supervisors, auditors and CDI specialists
• Complete Audit trail every action monitored

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Preparing your Organization for CAC

• Evaluate existing clinical documentation
• - CAC tools require electronic clinical
  documentation
• Assess current coding workflow
• - Assess what is being done currently, step by
  step
• - identify how use of a CAC tool would alter
  the current workflow
• Define expectations for balancing productivity
• and accuracy
• -Identify your gold standard for translating
  clinical data into medical
• codes. What level of productivity is
  acceptable?
• Define organizational goals and objectives
• - CAC may be necessary for an organization
  that is often short staffed
• - Or a Radiology practice that employs no
  coding staff looking to improve
• compliance
• Develop a testing and audit plan
• - perform random audits and consider
  complexity of coding

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Recommendation - Phased in Approach

• Start with SDS or Diagnostics
• Aim for 100 efficiency improvement
• Benefits flow back to all other coding
• Electronic documentation in most facilities
• Inpatient
• Process charts from day 1 for ICD-10
• Use ICD-10 results for advance training
• Flag/Audit unspecified codes for documentation
  improvement in 2013

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Questions?
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Answers
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For questions and information contact Leo Schafer
at lschafer_at_e-mtsonline.com 800-245-3195 Ext
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