Coding Notes
Preparing for the CAC Transition
By June Bronnert, RHIA, CCS, CCS-P
OONE OF THE biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the “use of computer software that automatically gener- ates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare practitio- ners.” 1 AHIMA has monitored the changing CAC landscape for years and in April published the “CAC 2010–11 Industry Outlook and Resources Report,” which details important aspects related to an automated coding environment. The report examines the following topics: x Coding professionals in new roles x Natural language processing (NLP)
x Considerations when moving to a CAC environment
Transitioning to a CAC environment involves many compo-
nents, including people, processes, and an understanding of
the technology. This article discusses the factors organizations
should consider when preparing for the transition and key con-
cepts of the report.
Workflow in an Automated Environment
Organizations preparing for automated coding must evaluate their workflows. Reviewing current processes and defining
the desired future state are two vital first steps when evaluating workflows. In addition, organizations should identify any
current gaps in their coding process. The identified gaps may
resolve or improve with organizational modifications prior to
CAC implementation.
The review process should include identifying all systems anticipated to interface with the CAC engine. This is important
to ensure all systems are interoperable. If an organization determines a system is not interoperable with the CAC engine, it
should develop a contingency plan until the system can be interfaced or the system is no longer used.
Both coding and noncoding functions should be evaluated to
determine if and how they occur in an automated environment.
Organizations may also benefit from examining their documentation. This can lead to facility-specific policies that identify
what portions of the record are required to be present and complete prior to code assignment.
Organizations should include all forms of documentation in
the review, as well as how documentation will interact with the
CAC engine. For example, electronic documentation typically
requires an interface to the CAC engine. Organizations must
ensure the interface is available and properly working.
If the electronic documentation will not interface with the
CAC engine, organizations should document how it will affect
the coding workflow. If the organization uses handwritten documentation, it should develop a plan for how this type of documentation will be handled in an automated environment.
In addition, organizations should consider the following doc-umentation-related questions when examining their coding
workflows:
x Is the documentation necessary for coding?
x Is there a plan to convert to electronic documentation?
What is the time frame?
x Will the documentation need to be manually reviewed?
