For Lahey Clinic, which includes a hospital and a group practice, the missing ingredient was an automated charge capture system. Physicians use PDAs to access the software from MedAptus Inc., Boston, picking and choosing appropriate codes displayed on a shortcut list. The organization implemented the software as a precursor to electronic health records. "We thought that if we could gain some financial benefit from this, it would help pay for the other applications we eventually wanted," Trapp says.
Hospitals and group practices are taking widely varying approaches to automated charge capture. Some, like Lahey, are primarily relying on doctors to select the right codes, often equipping them with handheld devices. Others are implementing electronic health records systems that use natural language processing to automatically generate codes that later may be checked by professional coders.
Many provider organizations have focused their charge capture efforts in outpatient settings, where doctors routinely use a narrower set of codes. But others are automating professional and facility coding in inpatient settings.
But Does It Work?
Advocates for claims coding professionals, however, contend that the jury's still out on whether automated charge capture systems are reliable.
"More research needs to be done on how well these systems work," says Linda Kloss, CEO at the American Health Information Management Association, which represents coders and other health information professionals. AHIMA urges provider organizations to check the codes generated through automated charge capture to ensure accuracy before they send claims to payers.
"There's huge potential for technology to eliminate some of the more routine processing associated with coding," Kloss says. "It doesn't eliminate the need for knowledgeable coders. But it moves them into the role of data quality control."
An executive with the American Academy of Professional Coders, based in Salt Lake City, takes a harsher view.
"Doctors are not coders. There are rules around coding that are outside their responsibility. It's not the way they think," argues Sheri Bernard, vice president of member relations for the association.
Bernard advocates the use of "computer-assisted coding," software that coders use on the back-end to speed up the selection of codes for claims. She says automated charge capture systems can miss nuances, such as the use of modifiers to indicate a procedure was particularly complex.
Proponents of automated charge capture, however, contend that the systems enable physicians to easily select or verify accurate codes.
"Our physicians do a lot of the same tasks, so automated coding works very well for them," says Sarah Ligon, practice administrator at Old Harding Pediatric Associates, Nashville, Tenn. "Just because you have computers in the office does not make you robots. You can't be afraid of that. It's still humans making the decisions. How you use the software is the key."
Trapp of Lahey Clinic points out that many doctors are already accustomed to circling codes on paper when seeing patients. "We did audits of our existing coding practices, and this demonstrated to our doctors that they could code more properly with the software and generate some financial benefits," she says.
Truly Automated Coding
One of the more efficient ways to generate codes for billing is through a process some call "charge by documentation."
At Henry Ford Wyandotte (Mich.) hospital, physicians and nurses in the emergency department use an electronic records system that automatically generates codes as they build the record.
The clinicians use point-and-click clinical documentation templates that trigger codes in the ED PulseCheck system from Picis Inc., Wakefield, Mass. This results in far more consistent and complete coding, says Lois Vandercook, the hospital's EDIS coordinator. And the system paid for itself in six months by increasing revenue due to fewer missed charges, she says.
Physicians and nurses use a variety of devices, including Tablet PCs, computers on mobile carts and desktop PCs, to access the records system. "Everybody has their own preference, so we try to accommodate them," she says.
Vandercook created an electronic chargemaster, listing all potential charges related to the various clinical templates in the records system. "The very first time I did it, it took me two days," she says. Now, she updates the charges as necessary.
The records system, linked to the chargemaster, automatically generates billing codes for materials, such as IV bags, as well as diagnosis (ICD-9) and procedure (CPT) codes. It also assigns E&M (Evaluation and Management) Codes, the modifiers to CPT codes that indicate the complexity of the case on a scale of 1 to 5.
The codes are then reviewed by coders in the billing department before claims are submitted, Vandercook says. Although most physicians don't check the codes that are automatically generated, a few doctors take the time to double-check them, she adds.
Emergency department physicians were supportive of the electronic records effort, Vandercook says. "ED docs tend to be techies and like gadgets, so we had an easy time with them. The few doctors who had never used a computer were coached by the other doctors."
The software paid for itself in six months primarily through increased revenue as a result of more accurate charges, Vandercook says. Profitability of the emergency department increased more than $2.1 million from 2004 to 2006 thanks in part to the technology, she adds.
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