August 16, 2016
Michael Damrich

With the increasing emphasis on the importance of specific documentation by healthcare providers, it is natural to use all means necessary to achieve that goal. Hospitals and doctors are being analyzed and scrutinized in order to compare the services they provide. Third party payers are interested in costs associated with care and the results that are produced. Consumers are only now experiencing increasing copays and even co insurance policies, which increase out of pocket expenses when they use more expensive providers.

CAC Technology Weakness

Computer-Assisted Coding (CAC) software improves the detection of words and phrases used by physicians to create the most accurate picture of a healthcare event. A notable weakness in this system is that ultimately when words are omitted because the provider does not realize their importance….CAC cannot solve this.

Physicians often comment that it is not their responsibility to worry about the documentation and reimbursement issue however this is exactly how they are compared to their peers. The optimum scenario is to provide physicians a rules engine while creating their documentation to show the choices and detail that professional CDI are looking for.

The common phrase “garbage in / garbage out” may be used to describe what happens when poor habits infiltrate documentation. Correcting this creates a level playing field on which care can be assessed and a single pass of information from provider to coding to billing.