Computer Assisted Coding Implementation

Lisa Hart, MPA, RHIA, CPHQ Karen Johnson, RHIT, CCS Stephanie Whetsel, RHIA

Not-forNot-for-profit, multi-specialty academic medical center multiIntegrates clinical and hospital care with research and education Consistently ranked as one of the nations top hospitals by US News & World Report heart and heart surgery program ranked No. 1 in the nation since 1995 9 regional hospitals in Northeast Ohio, Cleveland Clinic Florida, the Lou Ruvo Center for Brain Health in Las Vegas and Cleveland Clinic Canada 2,000 full-time, salaried physicians and researchers full35,000 employees

ComputerComputer-assisted Coding
Project Overview
Computer-assisted Coding (CAC) is the use of Computercomputer software that automatically generates a set of medical codes for review, validation, and use based upon provider clinical documentation. Successful automation of the workflow requires integrating people, defined processes, and suitable technology tools

Project Goals and Objectives

Implement computer-assisted coding software to achieve computercurrent HIM goals for improving coding accuracy and workflow efficiency Prepare for the expected productivity challenges of ICD-10 ICDimplementation in 2013 Integrate CAC with existing software applications for clinical documentation improvement, coding and reimbursement, and future applications to monitor readmissions and complications

ComputerComputer-assisted Coding Project Scope

CAC software implemented at Cleveland Clinic Main Campus for Coding (9/14/11) and CDI (10/10/11) Main Campus CAC will be used for inpatients, ambulatory surgery, emergency room, observation cases Weston - CAC will be used for inpatients, ambulatory surgery, emergency room, observation and ancillary cases. Additional CAC installations at Regional Hospitals will be determined as EMR implementation continues

CAC Enterprise Benefits

Reduce A/R days and discharge days not final billed (DNFB) Reduce coding labor and outsourcing costs Reduce denials Reduce compliance risk Capture accurate patient severity Improve coding consistency Increase coder satisfaction Leverage the investment in Epic

Prepare for ICD-10

Improve coder productivity

Increase coding consistency

CAC Coding and CDI Benefits

Allows coders to quickly navigate through the chart identifying relevant information Highlights diagnoses and procedures to help coders and reviewers consider additional topics for potential physician query Enables coders to bypass time-consuming sorting tasks timeand utilize their expertise more fully Improves productivity even as the EMR makes records exponentially larger

Project Team Membership

HIM Coding Leadership HIM IT Analysts Coding Representatives CDI Representatives IT Representation Interface Hardware Applications Clinical

Strategically Approaching CAC: The Big Picture

People

Technology

Processes

CAC Implementation Issues People

Transitioning to CAC can result in behavioral changes Project team must understand current coding practices to mitigate change management issues Coder training is a key part of the process; small groups work best Include experiential training and ask for onsite vendor support

CAC Implementation Issues People

Coder Validation Two Coders, two days Comparison of documents expected versus found Verification of document content Coder Training Four 90 minute sessions completed over two days In person training with post go-live support

CAC Implementation Issues Process

Successful automation of the work flow requires integrating people, defined processes, and suitable technology tools EMR creates much larger records for coders to sift through The value of CAC lies in its ability to reduce lengthy documentation review process

CAC Implementation Issues Process

Evaluate the current documentation available for coding Review current workflows to determine what if anything needs to change Identify specific criteria for evaluating code assignment functionality Develop baseline coding productivity to measure/monitor the change

CAC Implementation Issues

Managing the Change

Prepare the coders for the change - Changing role from coder to editor - Make sure they are computer literate - Provide tools such as dual monitors - Provide the coders baseline information to show incremental improvements made by system

CAC Implementation Issues Technology

Hardware Large hospital systems are continually growing and changing; plan carefully and allow for expansion Recognize that addition of new locations requires a transition period Deploying an enterprise-wide CAC enterprisesolution requires careful architecting of patient and visit identification across the system Assure data security for NLP processing

CAC Implementation Issues Technology

Interfaces Having to access separate systems reduces productivity Identify all potential feeds and how to filter relevant data Expand interface requirements to include documentation that both coders and specialists access Ensure ability to match results and encounters

Documentation MDM Examples

Transcription Type (101) Inbound
5-CNDS [Discharge Summary] 3-CNHP [H & P] 6-CNOP [Operative Report] 9-CNEX [Expiration Note] 18-CNECCNDS [ D/C Summary I/B] 19-CNECCNOP [Operative Report I/B] 20-CNECCNDSD [Discharge Summary Addended [InBasket] ] 21-CNECCNEX [Expiration Summary [InBasket] ] 22-CNECCNEXA [Expiration Summary Addended [InBas] ] 23-CNDSD [DC Sum-Addended] 28-CNECCNED [Emergency Department Report [Auth] ] 29-CNECCNEDD [Emergency Dept Report Addended [Auth] ] 30-CNECCNCD [Clinical Decision Unit [InBskt] ] 31-CNECCNCDD [Clin Dec Unit Addend [I/B] ] 38-CNPACTFU [Heart Transplant Note [PostAuth] ] 33-CNIN [Inpatient Progress Note] 624-Pt Video Req [Patient Video Request] 630-DOWNTIME NT [DOWNTIME NOTE PLEASE READ] 101-EMRCORRECTIO [EMR Correction Note] 648-CONSULTS [Consults] 126-Therapy [Therapy [PT/OT/Speech/Resp] ] 128-Pt Education [Patient Education] 150-CNNURSEI [ Nursing Progress Note (Rehab) ] ???-CNNURSEA [ Nursing Progress Note (Rehab) ] 151-CNSOCIALI [ Social Work Note (Rehab) ] 152-CNPHYSICIANI [ Progress Note (Rehab) ] 154-CNPHYSHPI [ History and Physical/Post Admission (Rehab) 155-CNPHYSCONI [ Consults (Rehab) ] 156-CNPHYSDSI [ Discharge Summary (Rehab) ] 157-CNPHYSPOCI [ Plan of Care (Rehab) ]

TXA-2 Value
CNDS CNHP CNOP CNEX CNECCNDS CNECCNOP CNECCNDSD CNECCNEX CNECCNEXA CNDSD CNECCNED CNECCNEDD CNECCNCD CNECCNCDD CNPACTFU CNIN CNVR CNDT CNEMR CNCON CNTHERAPYI CNEDUCATIONI CNNURSEI CNNURSEA CNSOCIALI CNPHYSICIANI CNPHYSHPI CNPHYSCONI CNPHYSDSI CNPHYSPOCI

INPT / OUTPT INPT/OPT INPT/OPT INPT/OPT INPT INPT/OPT INPT/OPT INPT INPT INPT INPT INPT/OPT INPT/OPT INPT/OPT INPT/OPT INPT INPT INPT INPT INPT INPT/OPT INPT INPT INPT INPT INPT INPT INPT INPT INPT

3M CAE Document Title DISCHARGE SUMMARY HISTORY AND PHYSICAL OPERATIVE REPORT EXPIRATION SUMMARY DISCHARGE SUMMARY OPERATIVE REPORT DISCHARGE SUMMARY EXPIRATION SUMMARY EXPIRATION SUMMARY DISCHARGE SUMMARY ED REPORT ED REPORT CLINICAL DECISON CLINICAL DECISON TRANSPLANT NOTE PROGRESS NOTE PATIENT VIDEO REQ DOWNTIME NOTE EMR NOTE CONSULTS THERAPY PATIENT EDUCATION Nursing Progress Note Rehab Nursing Progress Note Rehab Social Work Note Rehab Progress Note Rehab History and Physical Post Admis Consults Rehab Discharge Summary Rehab Plan of Care Rehab

x x x x x x x x x x x x x x x x x x x x x x x x x x x x

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Documentation ORU Examples

MSH 3 value AEGIS-CC_Outpatient_Notmain_CCF CARD_HOLTE_CCHS_CCF CARDCCL_CCF CARDCCR_CCF CARDHF2_CCF CCF_SECMCPPEDS CCF_SQLAB CCF_NEUROEEG EDBGLAB_RADIANCE EP_CCF INTERVENTI_CCF MUSEEKG_CCF NEUROTRONI_SleepLab ONBASE ORTHOMIDAS_ORTHO PACEART_CCF PATSUM_CCF PEDBGLAB_RADIANCE PEDSCARD_MEDQUIST PEDSTRESS_CCF PROVATION_ENDO PULMONARY_PULMJaeger PULMONARY_OXIMETRY RADIOLOGY_SYNGO RALS-CC_OUTPATIENT_NOTMAIN_CCF RALS-CC_INPATIENT_MAIN_CCF RALS-CC_OUTPATIENT_MAIN_CCF Result type Creatinine, Blood(POC) Holter and Telemetry Cath Lab Reports Cath Lab Reports Cath Lab Reports Peds Cath Lab reports Lab results - Micro Cultures EEG results Blood Gas Results Electrophysiology Cath Lab Reports ECGs EEG Studies Patient Reported Data Pacemaker Checks Patient Summary Reviews Blood Gas Results Pediatric Cardiology results Pediatric Stress Tests Colonoscopy, endoscopy Pulmonary Results OXIMETRY Report Radiology Results Blood Glucose Blood Glucose Blood Glucose Sending application Aegis GE_MUSE System Cardiology Database Cardiology Database Cardiology Database Secretary MISYS Neurology Database RADIANCE Cardiology Database GE_MUSE System Notes/Needed for Coding No No Yes Yes Yes Yes yes Yes Yes Yes Yes Yes No Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Ambulatory accounts - NO Inpatient accounts - Yes Yes Category Name

Cardiology Cardiology Cardiology Cardiology Lab Neurology Lab Cardiology Cardiology Cardiology Onbase Cardiology Lab Cardiology Cardiology Endoscopy Respiratory Respiratory Radiology Lab Lab

PACEART ADTR RADIANCE MEDQUIST Secretary Provation Jaeger Jaeger Syngodynamics Rals Rals Rals

Diagram provided by CCHS Interface Team

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3M CAE Overview - Coderview

Post Go Live Feedback

Positive feedback: - I like the ability to click on a diagnosis and get the code - The feature that brings up all documentation associated with a diagnosis is very helpful - When I use CAC exclusively, my productivity does increase A number of critical issues impacting productivity/usability need to be resolved: - Slow document load for large cases - Ability to view documents chronologically across document types - Missing documents - Irrelevant documents

Lessons Learned
Involve IT from the start Not every coder will embrace the change right away Assure coders they will not be replaced Just when you think you have found all documents think again! You are going to have implementation issues