Page 237 - DCAP305_PRINCIPLES_OF_SOFTWARE_ENGINEERING

Unit 11: Coding Process

Pair Learning Notes
Knowledge is constantly being approved between partners, from tool practice tips to programming
language rules to design and programming techniques. The partners take turns being the teacher
and the student on a minute-by-minute basis. Even unspoken skills and habits cross partners.

Computer Assisted Coding for Inpatients

omputer-assisted coding (CAC) has often been marketed for its ability to increase
productivity. We undertook two studies to determine if productivity for inpatient
Ccoding was increased using CAC software. A number of significant problem areas
were identified and it was determined that the CAC software did not increase coder
productivity.
We have been testing computer-assisted coding (CAC) software since 2002 in order to
increase the productivity of our remote coding staff. This topic describes several of our
initiatives and the results.
‘The term computer-assisted coding is currently used to denote technology that automatically
assigns codes from clinical documentation for a human…to review, analyze, and use,’ explains
Rita Scichilone, MHSA, RHIA, CCS, CCS-P, director of coding products and services at
AHIMA.1 We became familiar with this technology and sought a way to harness its potential.
We did recognize that the development of such software was not mature, as results of other
projects have been reported in the literature. One example of the issues surrounding computer
assisted coding (CAC) was provided by Beth Friedman: ‘More often, questions were raised
about CAC quality and reliability. Results indicated that 29% of respondents are concerned
that CAC systems would result in high productivity but poor quality, and 38% expressed
concern that these systems were not yet proven.
There are a variety of methodologies employed by developers of CAC software to ‘read’ text
and assign codes. The software can use structured input (SI) or natural language processing
(NLP). Even within the NLP range of products, there are a variety of approaches with
varying levels of sophistication. The methodology used has a tremendous impact on data
transmission and the output reviewed by the coders.
Study Method
Our general study method consisted of selecting transcribed files for 100 patients. The files
consisted of the History and Physical report, any consultation report or operative report,
and discharge summary.

Not all reports were available for all patients. Both studies focused on inpatients because we
felt that if a company had developed software sophisticated enough to provide accurate code
assignment for inpatient records, they could easily adapt the software to handle outpatient
records.
We reviewed the software product on several criteria:
Accuracy of code assignment

Ease of use (including transmission of transcribed data, initial coder instruction, and
functionality of output information). Ability of the software and review process to enhance
coder productivity.
Contd...

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