Benchmark - Automated Coding Workflow and CAC

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Grand Canyon University *

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300

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Mechanical Engineering

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Dec 6, 2023

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docx

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Uploaded by DoctorWren1608

1 Sherry Pete April 23, 2023 HIM – 310 Professor Evelyn Thomas Benchmark Automated Coding Workflow and CAC Terminology refers to the use of specific words and phrases in the medical and health fields. Medical terms refer to anatomical structures, procedures, conditions, treatments, and procedures in the medical field. Terms can be applied to material objects, processes, properties, functions, or abstract concepts. The general definition of a classification system is: a way of categorizing and classifying things based on perceived similarities; a means of organizing disparate facts into groups. There may be similarities between groups or classes, or even synonyms between them. The ICD-11, the ICD-10-CM, the ICD-10-PCS, CPT, and HCPCS Level II classifications are some examples of classification systems used in the medical billing and coding field. The use of electronic health records (EHRs) is common in public health departments. Standard terminology facilitates communication, classification, and taxonomy by establishing a common language, nomenclature, and classification system. In order to ensure clear and unambiguous documentation of assessment and care of clients, it is essential for healthcare settings to use standard terminology. Benefits of standardized terminology in an EHR include: 1. Nurses and other healthcare workers should be able to communicate more effectively. 2. Interoperability requirements and mandated standards are met. 3. Outcome-based care measurement 4. Health data can be collected and shared within the community to improve healthcare.

2 5. Standardization of care and best practices through shared pathways and care plans. 6. Increasing your work's visibility. Medical algorithms and software are used to automatically assign medical codes to medical records through computer assisted coding (CAC). Healthcare systems can become more efficient and effective through the implementation of CAC technology. Coding professionals can compare data quality metrics and patient care standards to medical coding computer requirements in real-time. Medical codes are selected using an encoder, which uses terminology to select the medical codes for a medical record. This terminology is arranged in a manner that is like a tree. A diagnosis is a group of words or a phrase that refers to something in a specific area. It is important for health care providers to use code books along with electronic encoding software to guide them when trying to classify diseases. Just a little fact, an encoder in not CAC. A major challenge of CAC will probably be getting buy-in from hospital coding and HIM departments to make the program successful. Implementing the change means learning how to use the technology effectively, which requires HIM, coding, and clinical staff to be on board. Coders can utilize CAC solutions to make well-organized documents including critical-thinking, analytical, and health information management skills. In this way, facilities can be assigned DRGs more accurately and reimbursements can be allocated accordingly. There are several features and benefits promised by many CAC vendors:  Medical coding accuracy should be improved.  Billing medical services more quickly  Increased satisfaction among coders  Clinical documentation gaps are identified.  Productivity of coders increased.

3  Bills with more detail increased revenue Computer-assisted coding (CAC) has been a topic of discussion among healthcare information management professionals. It has been claimed that the technology will save coding- based bottom lines with the implementation of ICD-10-CM/PCS (ICD-10) to killing human coding jobs with automation. Increasingly, company executives are seeking answers on how CAC will benefit or damage their facilities as the technology becomes a "must-have" for the industry. In addition to its significant impact on productivity, ICD-10's implementation has caused many clinics to contact CAC. It is often questioned by HIM professionals whether CAC implementers have achieved all what vendors promise. Journal of AHIMA asked three representatives from the health information management industry to share their perspectives on how CAC technology is affecting healthcare and coding practices. There is no doubt that the benefits exist. Reference

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4 Standardized Terminology for EHRs - cdn2.hubspot.net . (n.d.). Retrieved April 23, 2023, from https://cdn2.hubspot.net/hubfs/3093662/eBooks/Evaluating%20Standardized %20Terminloogy%20in%20EHRs%202017.pdf Book Excerpt: The Pros and Cons of CAC . ACDIS. (n.d.). Retrieved April 23, 2023, from https://acdis.org/articles/book-excerpt-pros-and-cons-cac Crawford, M. (n.d.). Truth about computer-assisted coding: A consultant, him professional, and vendor weigh in on the real CAC Impact . Journal of AHIMA. Retrieved April 23, 2023, from https://library.ahima.org/doc?oid=106663#.ZEXA-y_MKTc