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Technology continues to change the face of professionals within the HIM sector. Embracing technology that makes our departments more efficient and cost-effective and helps us to keep up with continuing demands is paramount.

Computer-assisted coding (CAC) is among the latest emerging technologies to assist HIM departments in their quests to increase revenue, improve coder productivity, assist in coding audits and prepare coding professionals for ICD-10. It is believed that CAC will change the way coding professionals work in the future.

As the American Health Information Management Association (AHIMA) CAC workgroup defined several years ago, it is "the use of computer software that automatically generates a set of medical codes for review/validation and/or use based upon clinical documentation provided by healthcare practitioners." (Delving into Computer Assisted Coding, AHIMA Practice Brief)

CAC technology takes text documents, runs them through a Natural Language Processing (NLP) engine that reads physician documentation, identifies key clinical facts and maps those facts to ICD-9-CM and/or CPT codes for the coding auditor to either validate or deny the codes presented. The coding auditor experience and expertise is still required to complete the coding process because they play a critical role in the development of the NLP engine and how it learns and recognizes text. CAC will improve the efficiency, reliability and consistency of coding professionals.

Why CAC now?
Over the years, coding has continued to evolve into a role where experience and expertise has become more important. Unfortunately, there continues to be a shortage of experienced coders within the U.S. To compound this, it is anticipated that the pool of experienced coding professionals will retire with the transition to ICD-10, leaving an even larger void in the coding community.

Currently, HIM managers typically cope with a lack of coding professionals and backlogs in two ways: 1) by offering or mandating overtime with existing coding staff, or 2) by outsourcing to other companies and/or consultants. Either of these choices comes with a large cost to a facility and also jeopardizes coding accuracy, which can affect reimbursement.

Technology is among the solutions for issues that continue to plague HIM departments. Traditional solutions will not suffice. CAC technology for coding and reimbursement is a pioneering approach that is being adapted by many HIM departments. Although CAC has been available for a decade, its main dominance has been in the physician setting. The main reason is that early CAC technology could only read and understand one document, but that is no longer the case. With the improvements in CAC of late, HIM professionals need to realize that it can be a tool to assist coders with productivity and accuracy, eliminating backlogs, providing traceability for audits and assisting with the transition to ICD-10.

Which criteria are important when evaluating CAC?
Prior to beginning the evaluation process of CAC technology, the selection committee should decide which criteria they will be utilizing for the selection process. With CAC technology, there are several criteria that should be prioritized. These include the NLP approach, workflow, coding accuracy, traceability of codes and ease of use and coder adaptability. Each facility needs to rank the criteria that are most important. Some may say the accuracy of the NLP engine is key while others may consider workflow, ease of use or deployment speed the priorities. The committee should discuss all criteria that are important to the facility, prioritize and then give each a value for the rating process. Ranking the criteria and providing a value to each will allow the rating total to assist in the selection process. This will provide peace of mind in knowing the best selection was made using a strategic method.

Why is the NLP engine approach so important?
There are several different approaches to the NLP engine technology as shown in Table 1 below. It can be as simple as Medical Dictionary Matching or as sophisticated as allowing the technology to read and understand all the text documents -- known as Symbolic Rule and Statistical Components. The simplest approach is similar to a Google search function that matches an ICD-9-CM or CPT code to any medical terminology. The disadvantage with this type of approach is that too many medical terms can be identified; therefore, coders spend more time deleting codes than actually validating them. An example of this approach would be if a physician dictated that the patient had no history of breast cancer, the simple NLP approach would identify all necessary breast cancer ICD-9-CM codes when no code should have been presented.

Employing a more complex NLP approach such as Symbolic Rules & Statistical Components would read and understand the words associated with breast cancer and not provide a code for breast cancer. This more sophisticated approach did not waste the coder's time finding, reading and deleting the code presented by the NLP engine.

Table 1

Approaches to evaluating CAC technology with vendors

The following are considerations to review when evaluating CAC vendors:

• Vendor Profile:

1. Is the vendor going to continue to invest in their technology?
2. Is the vendor profitable?
3. Are their investors willing to be patient with their investment?
4. Is the vendor's business approach one that matches the best method for your facility?
5. How does the vendor handle implementation?
6. Is there 24/7 technical and user support?

• Technological Approach:

1. Which NLP engine approach does the vendor use?
2. How does the vendor train the NLP Engine?
3. Where does the NLP engine reside?
4. Is the engine for our facility only?
5. What is the vendor's plan to support the transition to ICD-10?  
6. How does the vendor handle updates?

• Functionality:

1. How quickly can your coders learn and use the technology?
2. Is the software intuitive?
3. How long does the training take?
4. Can the supervisor assist the remote coders with ease?
5. How does the vendor handle suggestions for improvement?

• Hardware:

1. What additional hardware needs to reside in the facility data center?
2. What are the hardware specifications?

• Pricing:

1. Do we need additional software on our workstation or servers?
2. What is the initial cost of the technology?
3. Does the vendor offer a onetime cost to invest in their technology?
4. Is there a software maintenance fee each year?
5. Do the costs go under capital budget?
6. Is there a subscription model that can go under my operating budget?
7. What additional costs are associated with using or owning the CAC technology?  
8. Will our IT department charge back for their time?

Effective ways to conduct evaluations
The evaluation of a technology vendor is the most critical and time-consuming component of the selection process. Follow-through on all the steps must be performed to assure the selection committee made the best decision for their respective facility.

Below are some of the steps that can assist in the evaluation process:

• Evaluate all CAC vendors.
• Make sure the committee's criteria were reviewed and each component rated.
• Have each company present to the same committee members each time.
• Prepare a list of questions to pose to vendors.
• Ask for a Return on Investment (ROI) associated with the technology -- (inpatient or outpatient).
• Complete at least one site visit and/or conduct a conference call with a current client of the product under consideration. During the call, ask client to:

1. explain what they like most and least about the technology.
2. define the ease or difficulty of implementation and training.
3. advise as to how quickly the coders learned and accepted the technology.
4. describe how the technology works for each department.
5. specify what departments are using the technology.
6. be open to your following up when the vendor is not present.

In conclusion, CAC can truly assist in increasing revenue, improving coder productivity, assisting in coding audits and preparing coders for ICD-10.

Currently there are several vendors offering CAC technology while others continue to emerge. Ensure that appropriate criteria for evaluation are set and that each vendor is evaluated similarly. It is key to understand what the most important criteria are for a facility when reviewing CAC technology options. By understanding the facility's exact needs and the capabilities of the technology, realistic expectations can be set. There is always a risk when adopting emerging technologies, but with the right assessment criteria, success is achievable.

Lorri Luciano is senior hospital product specialist at A-Life and has more than 20 years of experience working in the HIM sector. She is based in Pittsburgh.