Computer-assisted coding trims mundane tasks, aids in compliance

Artificial intelligence and machine learning technologies, buttressed with computer-assisted coding, can help a healthcare organization’s clinical documentation improvement program.

As a result, providers should start developing strategies and making investments to take advantage of new capabilities for improving documentation of care and coding, says Neil Shah, chief innovation officer at ezDI, a vendor of dictation, applications, transcription services and medical coding.

In some organizations, a coder can only process 1.5 encounters in an hour. But computer-assisted coding combined with artificial intelligence and machine learning can collect data, read the records for the coder and apply the appropriate codes.

That’s important during a time when the Centers for Medicare and Medicaid Services and health insurers are auditing providers more frequently and will not be impressed if a coder can’t tell why they used a certain code, or may not even be able to find the code.



Providers that automate the coding process can expect over time to realize improved processes, employee performance and quality by using key performance indicators that measure the degree to which the organization is meeting its most important business objectives, Shah contends.

During an educational session at the AHIMA Convention & Exhibit, September 22 to 26 in Miami, Shah will explain how computer-assisted coding works, the improvements it brings and process changes that will come with the software, particularly increased automation of processes that will free health information management professionals from mundane tasks and let them focus on improving system configurations, workflows, operational margins and, maybe most importantly, optimizing scores from CMS.

The session: HIM Transformation Before and After Computer-Assisted Technology, is scheduled on September 24 at 12:15 p.m., in Exhibit Hall-Theater B of the Miami Beach Convention Center.