Request for Proposal Computer Assisted Coding

In the health care system, there are a lot of codes that help diagnose, treat, and discharge patients daily. Codes help nurses

The new job title could be a medical coder 1. I choose this new title because the medical coder is a health care professional who analyzes the medical records, medical charts and assigns the appropriate codes. Most of the job’s responsibilities of a medical coder are required for the inpatient and the outpatient coder’s jobs. For example, medical coder’s responsibilities are: reading and analyzing patient records, determining the correct codes for patient records, interacting with physicians and assistants to ensure accuracy, using codes to bill insurance providers, and maintaining patient confidentiality and information security. In addition, the minimum required certification of this job is CPC or CCS and RHIT with at least 4 years of experience. Those certifications are given to a Coder who can read and assign correct diagnosis International Classification of Diseases or ICD-10-CM, Current Procedural Terminology or CPT, supply Healthcare Common Procedure Coding System or HCPCS code for a wide variety of clinical cases and services, and read and assign PCS codes. The skills of this job are same as the skills of the

As viewed by many HIM professionals Computer-assisted coding is a valuable tool for enhancing the effectiveness of coding and billing. CAC software scans medical documentation in the electronic health record (EHRs) using a natural language processing (NLP) engine, identifying key terminology and proposing codes for that specific treatment or service. Human coder then revised these codes. CAC can also investigate the background of key words to conclude whether they need coding.

In the daily changes of healthcare, health information technology is evolving rapidly. The generation of coding is making significant developments along the years as well. The 3M-encoder system provides number of essential options to coders in just one click. It provides sophisticated, easy-to-learn solution for accurate, complete, and compliant coding and grouping. Coders need to be acquainted with these references because they provide back up through the articles in each one of them. 3M Coding and Reimbursement System, 3M Coding Reference, and 3M Coding Reference plus have articles for coders to read and get answers to use the appropriate codes. (Prophet). Due

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

-Inpatient coders have certifications allowing them to work exclusively for hospitals or facilities. An expertise in medical record review is a must, along with an up to date status with coding rule changes, regulations and issues for medical coding, reimbursements and compliance under MS-DRG and Inpatient Prospective Payment Systems (IPPS). Coders should have experience as well as expert knowledge in abstracting information from medical records for ICD-9CM vol. 1-3, specialized payment in MS-DRG and IPPS.

In this case, CAC technology also provides a connection between EHR documentation and transcription systems. Primarily, CAC technology in a healthcare environment has rapidly and drastically changed the process in which medical coding in health-information management. This is handled for a better productivity and efficient workflow solution, including production monitoring, coding review, management reporting, computerization of coding and auditing. Clinical documentation is ensuring that it has routinely generated medical codes from computer assisted codes (CAC). In addition, CAC technology has enabled healthcare organizations to recognize the revenue-cycle process as they increase their requirements towards improved quality. The complete implementation of the CAC technology is essential when improving the main necessities towards patients, such as the efficiency, quality, productivity, and management of their care. Last but not least, CAC technology has produced one of the best strategies for the challenges that the HIM professionals face as coding becomes one of the most important aspects of transitioning to

This article discusses how the implementation of the new ICD10 codes are costing more than originally planned. All practices are required to use 2014-certified electronic health-record technology in order to receive funding from a federal electronic health record incentive program. The new estimates for the ICD10 implantation include the cost of such things as education, IT and documentation

Are you and your staff anywhere near ready for ICD-10’s October 1st deadline? Maybe you’ve been overwhelmed just trying to implement all of the other changes happening in healthcare thanks to the Affordable Care Act, EMR mandates, increased Medicare audits, and value-based purchasing penalties; you’ve hardly had time to prepare for this latest coding switch.

I am very familiar with medical coding and understand how it is used because I worked in the medical field for many years, and I used those codes for much of that time. At my last job, I helped with the billing for some time, did the insurance referrals for several years and got the insurance pre-authorizations/pre-approvals

Over the past decade, virtually every major industry invested heavily in computerization. The heath care industry was no exception to the rise in the use of technology. These technologies are starting to allow health care practitioners to offer faster, and more efficient patient care than ever before. No doubt this is the right direction we expect health care to follow.

Jones Regional Medical Center is a huge academic health center with 900 beds and are known for its research and teaching hospitals. Additionally, the IT staff at Jones supports 300 applications and 12,000 workstations. The center uses Technology Med (TechMed) for their admitting system. The system includes registration, inpatient charge, payment entry, master patient index, admission, hospital billing, and more. The TechMed system has been accessible since 1998; Jones is beginning to plan a replacement of this systems because of the fragility of the software (Wager, 2013).

Medical coding, on the other hand, deals more closely with patient medical records. Medical coders work in the billing office, or “back office” of medical practices or hospitals. Alphanumeric codes are assigned to all illnesses, injuries and treatments. Medical procedures are coded for the purpose of classifying diseases in numerical sequences for identification and data collection purposes, similar to the Dewey Decimal System in libraries. Coding specialists review medical records and assign numeric codes for the diagnoses identified and procedures performed. Each medical procedure and patient encounter has a number (CPT code) associated with it which corresponds to an ICD code. These

Cerner integrates patient information throughout all of the departments within a hospital setting. This program also has the ability to expand into other health care facilities within a community, such as long term care, hospice, and home health (Cerner, 2015). Cerner offers community hospitals solutions in their “Software as a Service” model. Cerner will host the software program, provide upgrades, and monitor performance to ensure stability. This will allow community hospitals to have a predictable cost for the software (Cerner, 2015). Another advantage of this system is the “Smart Room”. Wireless devices such as infusion pumps, and vital sign monitoring devices can access the system. This allows for instant documentation of this information into a patient chart and will alert if abnormalities are noted. Bar code scanners and carts are available as well. These items improve patient safety (Cerner, 2015). Cerner is capable of CPOE, electronic prescription transmitting, and has the ability to capture data and immunization statuses to meet reporting regulations.

Computer-assisted coding is defined as the “use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare practitioners”