No matter how many certifications a professional medical coder may have, he or she cannot know every possible combination of codes. The days are over when a coder was given a set of books and told to get to work on a stack of charts. As medicine and medical documentation become more complex, so does the reimbursement process. New codes are added, modified or deleted every year, not just procedure codes, but diagnosis codes and quality measurement codes. When presented with a medical record, it can take a long time for even a certified medical coder to start to translate it into industry-standard code from scratch.
The drive to implement electronic health record (EHR) has eased a coder’s job of assembling the relevant documentation into a coherent, understandable claim. Computer Assisted Coding (CAC) software speeds the initial steps needed to translate the medical record into code. The program reads the electronic medical documentation, and other discrete data elements, and it assembles that information into SNOMED CT codified concepts. The program then takes the SNOMED CT information and assigns relevant CPT, ICD-9-CM, and HCPCS Level II codes. CAC can already assign ICD-10 codes, and it will assign those codes as the standard after the official implementation date in 2014.
Most professional medical coders do not have much firsthand experience with SNOMED CT. The acronym stands for Systemized Nomenclature of Medicine - Clinical Terms. It is a standardized, systematic collection of terms, definitions, synonyms, and codes covering the gamut of information used in the medical field. It forms the basis of aggregating the information contained in an electronic medical record into a standardized format. Computer Assisted Coding takes this SNOMED CT data, and uses it to assign appropriate codes distilled from the documentation included in the electronic health record.
A computer may never replace professional judgement. Every professional medical coder knows the limits of electronic edits when trying to submit a claim for reimbursement that accurately and meaningfully reflects what transpired according to the medical record. Procedure codes need to be modified, and units of service adjusted. Procedure codes need to be changed to exactly match what was performed, and Level I HCPCS may need to be substituted with Level II HCPCS. Diagnosis codes, cause of injury codes, and personal history codes need to changed to reflect the documented degree of specificity. Different payers have different coding requirements depending on the contractual agreements with providers.
Documentation, even the documentation included in EHR, starts with a human touch. It is dictated or entered by healthcare providers and their staff. When the documentation is assembled into a healthcare claim, it ends with a human touch as professional medical coders compare the data in the claim to the data in the record. Computer Assisted Coding is another tool in the professional coder’s kit.
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By making the initial translation from natural language to medical code, CAC reduces the initial steps in assembling a medical claim. The software employed, and SNOMED CT, are reliable and effective tools, but they cannot replace professional judgement and knowledge. Medical coders are familiar with the contractual obligations they have to the payers they serve. They also keep abreast of the relevant statutory requirements that change on a regular basis. Through continuing education to maintain their credentials, and ongoing professional study to stay on top of their field, professional medical coders are the last line of defense against charges of healthcare fraud and abuse. By ensuring that accurate medical claims are submitted according to the thicket of coding standards that apply to the healthcare reimbursement process, professional coders will never replaced by CAC, but the software serves as an important adjunct to make a coder’s job easier, more efficient, and profitable.