Throughout history, clear-cut turning points have triggered surges in demand for technology. The introduction of personal computers, for example, was a watershed IT moment. In recent months, the federal economic stimulus program has been in the spotlight, with experts debating whether it could be a strong catalyst for a surge in adoption of electronic health records. But a much lower-profile health care industry development - the shift from ICD-9 to ICD-10 diagnosis and procedure codes for claims - also could prove to be a powerful technology catalyst, giving a boost to demand for computer-assisted coding systems.

Despite years of development, the use of automated coding systems is still far from commonplace. The technology is much more prevalent among physician group practices than hospitals, primarily because outpatient claims are so much simpler to code.

The looming shift to more complex ICD-10 codes in 2013 could stir up interest in the applications because all providers will use the new codes when filing claims with all payers. The greater level of precision in the codes likely will improve the performance of computer-assisted coding applications and make them easier to use, says Sue Bowman, director of coding policy and compliance at the American Health Information Management Association, Chicago. "We're going to see much better and more sophisticated inpatient computer-assisted coding once ICD-10 is implemented," she predicts.

For now, group practices and hospitals are using a wide variety of approaches to auto-coding. These range from coding functions embedded in electronic health records to freestanding systems that simply automate code checklists formerly found on paper "super-bills."

As these systems become more sophisticated, they could have a huge impact on the role of coders. Many now spend the bulk of their time manually selecting codes after reviewing paper or electronic records. "Our coders are going to be more like auditors, checking every claim before it goes out to a carrier," predicts Deborah Grider, vice president of strategic development at the American Academy of Professional Coders, Salt Lake City, Utah.

"Computer-assisted coding ultimately will remove the mundane, routine coding tasks," AHIMA's Bowen says. "Coders will become editors, reviewers and auditors who make sure the codes are accurate and the documentation is complete."

The shift to ICD-10 will mean big changes for physicians as well, Grider argues. Hospitals and clinics will have to offer extensive training to make sure doctors include all necessary information in patient records-whether paper or electronic-to support specific codes, she notes. Payers also will require more detailed documentation to support pay-for-performance projects that measure the quality of care, she adds.

But Bowman cautions that providers must be careful when shopping for "computer-assisted coding" software because vendors use the term loosely to describe a broad variety of applications. "Computer-assisted coding in its truest form is linked to an electronic health record system, and it guides you to the correct code by linking to documentation in the record," she contends. But relatively few organizations use such systems, which rely on a technology called natural-language processing. The technology translates readable information stored in EHR databases into related codes.

An Important Test

University of Washington Medical Center recently began tests of such a system. The three-hospital medical center in Seattle is helping Cerner Corp., Kansas City, Mo., integrate the firm's recently acquired coding software with its inpatient electronic health records system.

In the tests, physicians are using the coding software, formerly known as ß LingoLogix and now called Discern nCode, to automatically generate E&M codes for outpatient treatment of bone marrow transplant patients, explains Thomas Payne, M.D., chief medical information officer. E&M (or Evaluation and Management) codes are modifiers to CPT (procedure) codes that indicate the complexity of the case on a scale of 1 to 5.

The coding software uses natural language processing to "read" documentation in the Cerner PowerChart electronic record and then suggest an appropriate E&M code. But the software goes one step further, offering a "detailed markup of the document" that describes how the code was derived, Payne notes. "That's an incredibly powerful educational tool for physicians to bolster their understanding of how coding works," he adds.

In the months ahead, the hospital also expects to test broader applications of the coding software, both inpatient and outpatient, such as for generating diagnosis and procedure codes.

The coding software applies the standard clinical vocabulary known as SNOMED CT to the content of electronic records, easing the conversion to other coding methods, Payne explains. In addition to applying SNOMED CT, the hospital can create other rules within the coding engine for interpreting phrases or abbreviations with "special biomedical meaning" specific to the organization, he says.

Beyond improving coding, the experiment also could lead the hospital's physicians to improve the structuring of documentation in patient records so it can be used to support meaningful outcomes research, Payne adds.

Variety of Approaches

While computer-assisted coding is still relatively rare at hospitals, many physician group practices are using a wide variety of applications to assist with coding. Some of these applications, such as one used at Radiological Associates of Sacramento (Calif.), also use natural language processing to automatically suggest codes based on the content of records.

The 100-physician practice uses coding software from CodeRyte Inc., Bethesda, Md. At the end of each day, the practice sends a print image of its radiology reports to CodeRyte's server, where a coding engine applies criteria developed by the practice to generate diagnosis and procedure codes. The next morning, coders review the suggestions on a portal and make final decisions before submitting claims, explains Michael Gonzales, billing operations manager.

Before acquiring the software four years ago, the practice would print out radiologists' reports for painstaking manual coding, Gonzales says. Today, the practice is handling coding for 30 more physicians but has one less coder, thanks to auto-coding, he adds. That's because coders now serve as editors and analyzers rather than code-chasers.

While many practices are using niche coding software, some are taking advantage of the coding capabilities built into their electronic health records system.

For example, the 10 physicians at Roswell Pediatric Center in Alpharetta, Ga., use records software from Noteworthy Medical Systems Inc., Phoenix, to help support coding decisions.

The records system automatically generates CPT codes when tests, vaccines or other procedures are ordered, says Nancy Babbitt, the practice's administrator. Physicians use the software to select from displayed diagnosis code suggestions tied to EHR templates they use to build records for various types of visits, she explains. When the billing codes are transmitted to Roswell's practice management system, also from Noteworthy, coding functions within that application display color-coded assessments of the codes selected in the EHR. A green display means the coding looks good; yellow means the codes should be reviewed, while red indicates a potential problem.

Charge Capture

Perhaps the most common auto-coding approach at clinics involves using what are commonly called automated charge capture systems. These systems typically display a list of pre-selected codes that a particular physician uses most frequently, so he can point and click to choose them, rather than write on a paper super-bill.

Dana Farber Cancer Institute, a Boston-based clinic with more than 350 physicians, uses such a program from MedAptus Inc., Boston. Doctors can access the freestanding application via a link within the organization's home-grown records system or its scheduling system, explains Lori Buswell, R.N., director of nursing and patient care services.

"We have doctors who see breast cancer cases all day long," Buswell says. "Based on their population, we built commonly used diagnosis code templates into MedAptus."

Physicians generally use desktop computers to access the coding software because that's how they access all their applications, she says. Some select the codes immediately after seeing a patient, while others do their coding in one batch at day's end.

The coding software helps physicians select E&M codes as well as other modifiers, such as those for visits that involve teaching a resident.

At the Wilmer Eye Institute, part of Johns Hopkins University in Baltimore, physicians take a similar approach. They use charge capture software from Salar Inc., Baltimore, to select codes, which are later transmitted to a billing system, says Chris Albritton, professional fee supervisor. "We used to use pieces of paper, and then those got gathered up and sent to the billing office," Albritton says. "Charges got missed easily."

The charge capture software now reminds physicians to make sure their codes are complete, she notes. Plus billers can send an e-mail to physicians within the coding application to ask for additional information.

Similar charge capture systems can prove helpful to new physicians at hospitals as well. For example, some 22 hospitalists at Providence Sacred Heart Medical Center in Spokane, Wash., many of whom are new to practicing medicine, rely on coding software from Ingenious Med, Atlanta. The auto-coder is included in a broader application that also handles certain practice management functions. The application is particularly handy when selecting a level of service for a hospitalist visit, says Jeffrey Liles, M.D., lead hospitalist. For physicians with limited experience "this is a way to hold their hand" as they learn how to select billing codes, Liles says.

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