As healthcare takes more steps toward value-based care, provider organizations need to be capable of doing more accurate and complete coding. When providers don’t include all the right codes into a claim, they can end up not getting the correct reimbursement, because the patient’s situation will not seem complex enough to the payer.
This is where clinical documentation improvement (CDI) and computer-assisted coding (CAC) come in. CDI and CAC solutions work hand in hand to make the coding process easier. A CDI solution looks at the clinical documentation and makes sure it checks all the necessary boxes. Then a CAC solution looks at all the documentation of codes for what the physician did and makes sure the claims are coded correctly. This process ensures that when the insurance company receives the claim, the payer can actually see the holistic picture of how sick the patient is and what the provider did for him or her.
CAC also helps reduce the number of denials because it catches potential issues before the claims are even sent out. There are simply too many codes to remember. Instead, the CAC system goes through the documentation digitally to suggest what codes it thinks should be used. This doesn’t relieve the entire burden; the coder still has to make the final decision. But overall, the process saves coders time, as they won’t have to look for all the codes manually every single time.
KLAS last published a CAC report in 2016, around the time that ICD-10 was launched. At that time, providers mainly needed to have a solution to help with implementing ICD-10. Now we’ve shifted our focus to determining whether CAC solutions are worth the investment, and whether they provide outcomes for the facilities using it.
All Vendors Improving
I was actually surprised to see how all of the vendors had improved so much in the last few years; 94 percent of respondents told us they would purchase their CAC solution again. Even the big players, 3M and Optum, who were rated lower previously, both had a significant increase in their scores. This widespread improvement shows me that these vendors have started figuring out how to provide better customer service and improve their technology across a broader platform.
It was satisfying to see that all of the vendors have made improvements, including Dolbey and ezDI, who did well in our previous report. It seems like this group of vendors is pushing each other to get better, and lifting each other up.
Although most vendors in this space are doing well, there are still areas in which each vendor performs better. In the report, which clearly identifies the major players in the space, readers can get a feel for which vendors are delivering a better relationship and customer service experience, and which vendors have nailed the technology but are so big that they find it hard to support 700+ customer sites with a consistent level of service.
I recommend reading the report for a closer look at what sets each vendor apart.
Future Improvements in CAC
Machine learning and natural language processing (NLP) capabilities will start showing up more within CAC solutions. Most vendors are talking about these two things; the more CAC users implement NLP and machine learning, the more we’ll all improve. If NLP gets significantly better, a physician could, for example, mention that a patient’s spouse had pneumonia. And the computer would detect that even though the word ‘pneumonia’ showed up, it wasn’t actually referring to the patient. Coders would not have to make as many decisions as a result.
One potential area for improvement that came up in the report is that customers want more benchmarking capabilities so they can compare themselves with others. A facility might already see that they’re improving, but these providers want to know whether they are doing as good as the top-performing clinics. They want to benchmark coding accuracy and number of claims denials.