G700 : Computer Automated Coding : Computer Software that Generates a
A large medical group practice is strongly considering the purchase and implementation of a Computerized Automated Coding (CAC) program. Upon the reading of the reference article “How to Conduct a Thorough CAC Readiness Assessment – A White Paper from Nuance Healthcare.” https://www.nuance.com/content/dam/nuance/en_us/collateral/healthcare/white-paper/wp-how-to-conduct-a-thorough-cac-readiness-assessment-en-us.pdf , create a request for proposal (RFP) as a measure to target potential vendors for a response. Your RFP must focus on the accuracy of the software (including documentation of accuracy statistics from providers who have implemented a CAC system), along with recommendations regarding proposed corrective actions.
Answer:
The main focus point of the software is the use of computer software that generates a set of code which is related to medical aspect which can be reviewed, validated and use which is based on the aspect of clinical documentation which are provided by the heath care practitioners. It can be stated here that the concept which is related to the CAC can be misunderstood as a concept of auto coding (Jones, Beecroft & Patterson, 2014). In the last few years the practices which are very little in limited selection of code for example radiology, laboratory and physical clinical practice – a CAC solution could be used which would be directly reducing the error which are human oriented to validate the code assignment. The aspect of the CAC would be directly reducing human intervention into the internal working of the system. The main advantage which can be related to the concept is that the CAC would be transforming the role and would be enhancing the sector which is related to the human coding professionals (Weinberg et al., 2015).
Recommendation
Recommendation 1: Taking into consideration the patients which only receive diagnostic service, the coder must review the documentation relating to the condition, diagnosis, problem and other reason for the visit. These aspect would be shown in the medical record for the outpatient service which is provided.
Recommendation 2: Taking into consideration the patients which would be receiving therapeutic service during their visit, it should be taken into consideration that the medical record should be corrected taking into consideration the problem or other reason which are related to the visit.
Recommendation 3: The emergency department coder should take into consideration the aspects which are related to the treatment interventions, nursing notes, physician orders, diagnostic interventions and progress note with principle diagnosis.
Recommendation 4: Taking into consideration the aspect which is related to observation record must contain the physical and history, progress notes which are handwritten, clinical observation and final progress notes or summary that majorly include the diagnosis and any procedures which are treatment rendered or performed (Rains, Skurka & White, 2017).
Recommendation 5: Taking into consideration ambulatory surgery it should be taken into consideration that the medical record of the diagnosis for which the surgery would be performed. If the diagnosis of the postoperative is known to be different from the diagnosis of the preoperative diagnosis the coder must directly review the physical and history of the examination, operative/procedure report, pre-operative report, progress notes, anesthesia record, encounter summary and face sheet.
Conclusion:
The system can be stated to be very much beneficial due to the factor that it would be involving less human intervention as a result of which it would be less error prone approach related to the normal functionality.
Introduction:
The main proposal which is taken into consideration is for a large medical group which is considering to take into consideration the implementation of a computerized automated coding (CAC) program. The main purpose of the aspect is to take into consideration a request for proposal (RFP) which is directed for the target potential vendor for a response.
References:
Jones, K. A., Beecroft, N. J., & Patterson, E. S. (2014). Towards computer-assisted coding: A case study of ‘charge by documentation’software at an endoscopy clinic. Health Policy and Technology, 3(3), 208-214.
Rains, S. K., Skurka, M. A., & White, M. (2017). Coding, Compliance, and Classification Systems. Health Information Management: Principles and Organization for Health Information Services.
Rastegar-Mojarad, M., Sohn, S., Wang, L., Shen, F., Bleeker, T. C., Cliby, W. A., & Liu, H. (2017). Need of informatics in designing interoperable clinical registries. International journal of medical informatics, 108, 78-84.
Weinberg, J., Peterson, S., Marc, D., & Sandefer, R. (2015). Aligning Computer-Assisted Coding and Information Governance Efforts. Journal of AHIMA, 86(10), 36-40.
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