Study Reveals Hard Facts On Computer-Assisted Coding

Adding a credentialed coder to CAC improves precision coding over CAC alone

Computer-assisted coding (CAC) can help coders code inpatient records more quickly and does not reduce accuracy when paired with a credentialed coder, a recent study conducted by the AHIMA Foundation indicates. The study was described in an article in the July issue (http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050230.hcsp?dDocName=bok1_050230) of the Journal of AHIMA.

The AHIMA Foundation conducted the research study in collaboration with the Cleveland Clinic to examine the impact of CAC on timeliness and data quality.

“We’ve known for some time that CAC will dramatically change the way medical records are reviewed and coded,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA. “This important research reinforces that HIM professionals must be involved in the process to ensure that it is being used efficiently and effectively.”

To evaluate the timeliness and accuracy of the coding process, the study collected ICD-9 procedure and diagnostic codes on 25 Cleveland Clinic cases. Codes were assigned by 12 credentialed coders and the CAC technology. Six of the coders assigned codes without the assistance of CAC and six assigned codes with the assistance of CAC.

Phase I was conducted within weeks of implementing the technology. In the second phase, conducted six months post-implementation, the 12 coders recoded the 25 records. The codes assigned by the coder and CAC were compared against the “gold standard” to assess accuracy. The gold standard is the set of correct diagnosis and procedure codes for each medical record and was established and validated by the Cleveland Clinic coding leadership and quality team.

The AHIMA Foundation was able to validate that the time it took the study’s coders to code inpatient records using CAC was significantly shorter than those coders who didn’t use the technology, resulting in a 22 percent reduction in time per record.

While efficiency gains are important, the accuracy of the diagnostic data identified by the CAC technology is the highest priority. The study validated that Cleveland Clinic was able to reduce the time to code without decreasing quality as measured by recall and precision for both procedures and diagnoses. However, the study also found that CAC alone—without the intervention of a credentialed coder—had a lower recall and precision rate. The addition of a credentialed coder to the CAC improved the precision for diagnosis coding and the recall for procedure coding over using CAC alone.

Complete results from this study will be published in a future issue of Perspectives in HIM (http://perspectives.ahima.org/), AHIMA’s online research journal.

Also in this issue
The July issue of the Journal of AHIMA also includes:

• A consultant, HIM professional, and vendor weigh in on just how CAC technology is changing healthcare and coding in “The Truth about Computer-Assisted Coding.”
• A new practice brief highlights guidelines for the ideal successful recruitment, selection, and orientation process for clinical documentation specialists in the development of a sustainable and high-quality program.

Read these articles and more in the July issue of the Journal of AHIMA or online at journal.ahima.org.

About AHIMA
Celebrating its 85th anniversary this year, the American Health Information Management Association (AHIMA) represents more than 67,000 educated health information management professionals in the United States and around the world. AHIMA is committed to promoting and advocating for high quality research, best practices and effective standards in health information and to actively contributing to the development and advancement of health information professionals worldwide. AHIMA’s enduring goal is quality healthcare through quality information. For more information, visit www.ahima.org.