Among the wealth of challenges associated with the transition to ICD-10 is an expected dip in coder productivity, and this dip holds the potential to impact healthcare providers organizations’ bottom-line.

Computer-assisted coding (CAC) is one tool that is being regarded as a “quick-fix” for this potential productivity and financial-related loss. While CAC undoubtedly holds an important place in the overall documentation and coding of the patient encounter, relying on this technology as a panacea is a mistake.

Like most things in life, it pays to get to the heart of the issue vs. looking for duct tape solutions that solve bits and pieces of the problem. This same notion holds true when it comes to clinical documentation. CAC, on its own, cannot account for the disconnect that exists between some of the key clinical documentation players today – including physicians, coders, documentation specialists, clinical and ancillary staff, as well as the importance of creating an electronic record that accurately reflects the severity and care of patients. While CAC will play an important role in the transition to ICD-10, it should be viewed as part of an overall improvement process that has a clear starting point— improved physician documentation beginning at the point of care.

It’s no secret that current physician documentation processes are insufficient, and they face even greater hurdles in documenting the many details behind their decision making. This issue will only be exacerbated with ICD-10. Consider the concept of the “domino effect” and apply it to clinical documentation. For achievement of the desired outcome, the first domino needs to precisely fall. In the case of clinical documentation, the first “domino” is the physician’s documentation. If there is a breakdown at this stage, the clinical documentation process becomes both inefficient and frustrating for all involved parties. The point being, if you apply the “domino effect” to clinical documentation and pile on the additional specificity physicians are being asked to provide with ICD-10, you will end up with negative impacts on patient care, productivity, financial integrity and compliance.

So how can we address this issue in light of the transition to ICD-10? By engaging, educating and offering physicians clinical documentation improvement tips and tools, and also arming the entire care team with the technology – including CAC – they need to drive efficiencies and improved outcomes. Again, it’s important to remember that CAC is only as good as the information that’s fed into it. In order to derive the most value out of your CAC, you need to ensure that the documentation accurately reflects the degree of illness, correct diagnoses and related procedures.

In a recent conversation with EHRIntelligence, I had the opportunity to talk a bit more about this same topic. Here’s an excerpt from that article:

“CAC isn’t a complicated tool to use. I would say that if you’re considering CAC, consider it within the picture of what your CDI program looks like. If you put a CAC in, it’ll improve productivity for coding, but right now the priority should be improving your clinical documentation first and absolutely starting with ICD-10 education.  People think that ICD-10 is a coding issue.  That notion isn’t true.  ICD-10 is a clinical documentation issue.”

For more insight on what providers need to consider when it comes to CAC, these two articles from my colleague Bonnie Cassidy may prove useful:


Mel Tully

About Mel Tully

Melinda (Mel) Tully is the vice president of clinical services and education for Nuance Healthcare, overseeing the development and expansion of clinical documentation programs and clinical education best practices. Mel joined Nuance in 1998 and has more than 25 years of experience in multiple healthcare arenas as a provider, clinical manager in a large academic facility, and as an expert in clinical documentation improvement (CDI). Mel attended Emory University, where she earned her Master’s degree in Nursing. She has been certified through the Association of Clinical Documentation Specialists (ACDIS) as a clinical documentation specialist, as well as by the American Health Information and Management Association (AHIMA) as a documentation improvement practitioner.