Spotlight:

Coding is a challenging job these days. With the adoption of MS-DRGs last year and the recently proposed regulation for adoption of ICD-10, the regulatory environment requires increasingly precise coding. Advances in medical care also mean a coder today must have a broader understanding of physiology and pharmacology.

According to Kim Rosier, RHIT, CCS, 3M senior nosologist, the complexity of a coder’s job is compounded by pressure for faster turnaround. “Not only are the rules changing,” she says, “pressures are growing, but the bills still have to get out. First there are lots of inpatient charts to get through, and hundreds of pages of documentation to read.”

Kim Rosier, RHIT, CCS
3M senior nosologist

Dave Bacon
New projects specialist

Given such pressures, 3M is developing a computer-assisted coding solution to help expedite the inpatient coding process. Currently scheduled for release in first quarter 2009, the 3M™ Codefinder™ Computer-Assisted Edition incorporates expert logic and intelligent mapping tools, uniquely integrated with the 3M™ Coding and Reimbursement System. It allows coders to validate, edit and perform final code assignment in a single, easy-to-use desktop view.

Dave Bacon leads the 3M team developing the new system. He emphasizes that computer-assisted coding will not change the coding process, it will enhance it. “The coder’s skills and clinical knowledge are very important,” he says. “Computer-assisted coding is not going to change that. It’s simply going to help coders get through the charts faster.”

The traditional coding process requires a coder, physically present on site, to organize, review and analyze clinical documentation as a preparatory step to assigning codes. For inpatient records, this step typically consumes 70 percent of a coder’s time. The record can be hundreds of pages long, and reviewing it requires the coder to switch focus between views of the record (paper or electronic) and the coding system.

According to Bacon, the 3M Codefinder Computer-Assisted Edition will make coders more effective. “It will expedite navigation to the most relevant information in the documentation,” he says. “Key clinical terminology and other information will be highlighted and uniquely integrated with the 3M Coding and Reimbursement System. The goal is a customized view that shows the relevant documentation together.”

Computer-assisted technology promises to compress the abstracting and coding processes by shortening steps in the process and streamlining the flow between them. The ideal solution would:

• Automatically organize the electronic record into user-defined views, annotate the record and identify the documents most pertinent to the diagnosis
• Decrease chart processing time with a customized view and uniform format for all documents in the medical record, whether they are electronic text or scanned images
• Simplify complexity by reading, understanding and mapping the diverse terminology used in inpatient documentation to appropriate diagnosis and procedure codes
• Integrate with systems for clinical documentation improvement, information and data abstraction, auditing, as well as pay-for-performance monitoring

“We are arming coders with tools to expedite the process and leverage their expertise to get the coding complete,” says Rosier. “We’re not taking coders out of the loop or inserting them after the fact to validate codes. Instead, we reinforce their value. We will make them more effective at what they do.”

Bacon agrees, adding that a significant benefit of the 3M solution is time— both time savings and more time for coders to address complex issues. “The coding process requires an expert coder using expert knowledge systems,” he says. “The 3M solution is a natural extension of the coder’s experience and knowledge base. It will help them spend their time on what is important. One thing we realize is that it truly is ‘all about time,’ so to speak.”

3M Codefinder Computer-Assisted Edition will be showcased at AHIMA 2008 in Seattle this October. Visitors to the 3M booth in the exhibition hall will be able to hear more about computer-assisted coding from Dave Bacon and Kim Rosier at hot topic briefings scheduled daily.

How 3M Codefinder Computer-Assisted Edition boosts productivity and efficiency:

• Coder view organizes and displays the original documents
• Annotation software extracts clinical terms
• The pharmacy enhancement to 3M™ Advanced Analyzer Software suggests possibly overlooked diagnoses codes based on the documented medications
• The result is faster generation of diagnosis and procedure codes consistent with ICD-9 and ICD-10, which translate into higher coder productivity, lower coding costs and improved cash flow and reimbursement. Furthermore, 3M Codefinder Computer-Assisted Edition can integrate with 3M dictation, transcription and speech recognition applications, as well as with case management and viewing applications, for a seamless system to capture complete documentation.

Remote Coding

The 3M Coding and Reimbursement System and 3M Codefinder Computer-Assisted Edition are supported on a web platform. As many hospitals face a shortage of experienced coders, remote technology is becoming a strong recruitment and retention incentive. Increasingly, the ability to work from any location, including home, will become an expectation for a large number of coders.

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