Traditional coding software replaced coding books and acts like an electronic book. A coder no longer must leaf through a book, but scroll through lists to find an applicable code and enter it into the encoder.
ICD-9 has approximately 18,000 codes; ICD-10 has around 140,000, according to the Centers for Medicare and Medicaid Services. (Those numbers, however, vary widely. See sidebar on page 34.) So scrolling, already an exasperating task with I-9, simply isn't going to cut it with I-10 without a major reduction in coder productivity-if the coders hang around. "We've already had two people retire with ICD-10 coming," says Sue Trewhella, associate vice president of revenue management at Geisinger Health System in Danville, Pa. "ICD-10 is the biggest issue bringing computer-assisted coding forward."
Computer-assisted coding, or CAC, software analyzes documents and generates codes based on specific phrases and terms within the document. The secret sauce is the use of natural language processing technology to identify key terms and phrases
The software also analyzes the context of the wording to determine if a particular instance requires coding. For example, the software can deduce if the term "cancer" is being used as a diagnosis and needs to be coded, instead of being used in a different context, such as a physician noting a family history of cancer.
Coders initially don't view computer-assisted coding with any less apprehension than they do ICD-10, Trewhella says. "The biggest issue with staff is that they were convinced they were going to be replaced by a machine," she says. "I had to convince them that computer-assisted coding was a way to support expansion and keep experienced staff." Another pitch was the expectation of reduced overtime to get back to a work-life balance. "We're not there yet, but it's something to look forward to."
Play it again
The same story played out at three-hospital Akron General Health System in Ohio, which is implementing CAC from OptumInsight and expects to be live in September, says Karyn Keay-Otte, program manager. "There is a myth it will replace coders and that's simply not true," she adds. "We had to be very clear with our coders and schedule several demos so they could see that the tool will enhance their experience."
Even "superstar" coders with interest in CAC at the University of Pittsburgh Medical Center had worries about the technology, but with a different twist, recalls Nancy Soso, executive director of health information management. They told me 'Whatever you're doing, don't slow me down."'
So far, the superstars are fine with CAC, but it's the non-superstars showing the biggest bump in productivity. UPMC has CAC software in three hospitals, and after two years coding productivity is up 21 percent. The case mix index-payments multiplied by the weight of patient cases with complex cases weighed higher-rose 8 percent, a $22 million increase in revenue, just in those three of the delivery system's 20 hospitals.
Gwinnett Hospital System in Lawrenceville, Ga., got its first-year return on investment within six months of go-live and its expected five-year ROI after the first year-and none of that related to case mix index improvement efforts.
Those improvements had previously been achieved and case mix revenue still rose 3.8 percent in the first year. The ROI came from less overtime and use of outsourced coders, quicker auditing that resulted in better justification of higher codes, and higher coder productivity, says Carol Fowler, director of health information management.
Productivity is the real ROI of computer-assisted coding, say those using or implementing the technology. Based on Canada's experience with implementing ICD-10, hospitals can expect a 50 percent drop in coder productivity when the code sets arrive, says Trewhella of Geisinger.
CAC won't mitigate all of the productivity losses, but it can cut off a big chunk. Geisinger, for one, saw a 20 percent increase in coder productivity. Trewhella is confident that the ROI will outweigh the cost of computer-assisted coding, but that analysis will take time: CAC is a unit-by-unit and hospital-by-hospital project, not something that can be done in a Big Bang, she says.
At four-hospital MultiCare Health System in Tacoma, Wash., the cost of CAC was just part of the migration plan to ICD-10, says Jenn Mykland, administrator of revenue integrity. "Rather than a 50 percent ongoing hit to coder productivity, this would be 25 percent ongoing hit because of the scope of ICD-10. And that's the ROI."
The cost for CAC is variable with each vendor, since some price per bed while others price by charges, says Keay-Otte at Akron General. "Did the cost hurt? No, because we had it budgeted in our ICD-10 plan prepared in late 2010."
A common misconception in hospitals about computer-assisted coding is that physicians also need to accept and train on the system. But doctors don't code on the inpatient side, they document, "so this is not a tool for physicians," says Terri Mayne-Jarman, an ICD-10 consultant at Point B Inc., and working with MultiCare.
The natural language processing technology in CAC has several facets, explains Fowler at Gwinnett Hospital System. The software first does pattern-matching, searching for specific words and suggesting one or more codes.
Gwinnett's vendor, OptumInsight, operates a national database of its clients' CAC coding experiences, which provides a baseline for statistical probability.
The database "learns" over time based on the information being fed into it, so the terminology in a hospital's NLP is continually tuned with knowledge gained from the hospital's CAC and the software at other Optum hospital clients. So if a patient comes into Gwinnett with chest pain, its CAC knows that hypertension and high cholesterol are common in Southern patients and will consider those factors in recommending diagnostic codes.