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Intro to coding : Automated Coding, coding Encoders
Terms in this set (22)
a coding software that enhances productivity, these programs are widely used and offer great benefits to coders
Speed and Efficiency of Encoders
Code location is automated and can be achieved faster than manually searching through codebooks
Timeliness and Quality Control of Encoders
Coding software packages have updates that are available throughout the year with the newest information. These programs provide notes and edits that reveal the rules and guidelines associated with each code so they can be easily reviewed prior to final code selection.
Integration - Encoders
These programs run through computer systems and can be used to integrate medical records and insurance billing programs
Accuracy and Consistency of Encoders
These programs promote accuracy and consistency in coding the clinical diagnoses and procedures.
This type of software prompts the coder by asking a variety of questions. Firs the coder enters the diagnosis or procedure, then the encoder walks through a series of questions or prompts that the coder will answer, selecting the appropriate choice based on the documentation present. Finally the most appropriate code is narrows down and selected.
Encoder similar to an automated codebook
the computer screens mimic the actual format of the code sets. The reason to use this type of encoder over the actual hard copy book is that notes, loop-up tables, edits, guidelines, notations, hints and references are all built into this computerized process. This helps coordinate the process to select codes quickly and accurately
How do encoders(software programs) work
The medical coder reviews the medical record to locate the diagnostic or procedural statements documented by the provider. Terms from the diagnostic or procedural statements are entered into the designated box in the coding software and the search is initiated.
With some programs the software will return any diagnoses or procedures (codes included) associated with the search criteria and these will be presented on the screen. The search may yield one or two related diagnoses/procedures, or it may return many options. At this point the coder will review the available options and determine the appropriate code based on the documentation. Other encoding software will lead the coder through a series of terms or options that require the coder to make decisions along the way and will return an end result of a single code.
Finding the correct code
The correct code is then displayed and verified by the coder that the correct path has been followed and the correct selection choices made. The code will be dropped into the area of the billing program. It will then be placed onto the insurance claim form and submitted to the insurance company for reimbursement.
each patient with multiple diagnoses or procedures
This same process is used for each diagnosis or procedure to be coded for each given patient encounter.
Encoders also include grouping software to do what?
analyze and assign the MS-DRG or APC to the case
The specific resources available to coders in the 3M Reference tool
AHA Coding Clinic for ICD
AMA CPT Assistant
AHA Coding Clinic for HCPCS
Clinical Pharmacology Drug Reference
Dorland's Medical Dictionary
Elsevier's Anatomy Plates
Coder's Desk Reference for Procedures
Shortcut to CPT Lay Descriptions Section
Dictionary of Medical Acronyms & Abbreviations
ICD-10 MS-DRGs Definitions Manual
The Merck Manual
Dr. Z's Interventional Radiology Coding Reference
Medical Billing Software
this software is similar to medical coding software, it provides industry standard templates of forms needed to properly process and produce medical invoiced., including paper or electronic forms, and data necessary to file insurance claims and expedite payment
Medical billing software can double as what?
as the medical office's accounts receivables, invoicing, and collections. These systems are generally capable of communicating with insurance companies electronically to provide for electronic transfer of claims while generating invoices and statements to patients in paper format.
who generally ifentifies and provides the medical billing and coding software and systems that medical coders/billing specialist use on the job?
Computer-assisted coding (CAC)
is a technologically-driven approach to medical coding. There are two types of CAC. The first is structured data input and the second is natural language processing (NLP)
Structured data (text) input
a method of entering data by interacting with pre-defined forms through a data entry interface. Interfaces are integrated into the clinical documentation process. The result of using the application is the production of clinical documentation with embedded codes.
Natural Language Processing (NLP)
the process of a computer understanding relevance from the human language using artificial intelligence and computational techniques. From a coding perspective, NLP will parse (dissect) unstructured text in the patients medical record to identify words or phrases linked to diagnosis and procedure codes. It relies on grammar and semantics to do this.
what can NLP do?
It can analyze spoken words, or type text (transcribed discharge summary, for ex) for structure and meaning
When CAC with NLP is used, the role of the coder begins to transition into that of...?
An editor. Rather than coding from scratch, the coder is responsible for validating the suggested codes and either modifying them or accepting them as is.
will CAC replace medical coders?
They will no replace medical coders, but it can automate some of the coding.
Is CAC better used in inpatient or outpatient settings?
The use of CAC in the outpatient setting code with high levels of accuracy, experiencing significant improvements in productivity. But the use of CAC for inpatient hospital coding is limited.
Unless the hospital organization has a significant amount of their clinical documentation in an electronic format (EMR), the NLP will not be able to "read and understand" the handwritten clinical documentation with a high degree of accuracy, requiring more manual coding from the human coder.
inpatient coding can be more complex and difficult for CAC to handle than outpatient coding, requiring the coder to code manually. It is obvious that the more accurate the CAC becomes, the more productive a coder can be.
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