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CACs vs Human Auditors & Coders

2018 is the year of the ICD-10 audit! Two years after ICD-10 was implemented, coding and documentation regulations have finally stabilized, after some providers experienced tumultuous transition periods. Now is the perfect time for providers to run ICD-10 audits to identify any current errors and opportunities to improve their coding practices for the future.

Providers looking to improve their coding practices may turn to automation systems after an audit delivers unfavorable insights into their coding practices. While automation systems such as CACs may appear cost-effective and accurate for coding and auditing, it is crucial that providers also realize the value of skilled human coders and auditors as a supplement to these systems. ECLAT Health Solutions offers ICD-10 coding and auditing services, provided by a staff of medical coding and billing experts. Below, we explore why providers who use automation systems must not forget the importance of human coders and auditors:

 

1. Coders & auditors may catch coding mistakes a computer may miss

Although automation software can certainly streamline parts of the revenue cycle, it cannot completely replace the human touch. Coders and auditors may be able to detect nuances and errors that a CAC may not pick up. CACs are designed to analyze the context around the keywords listed on documentation, which can prevent false codes from being assigned for symptoms that do not require codes, saving the provider from a coding mistake and potential claim denial. However, on the other hand, this also means a false code may be assigned when it is not required, which may also lead to a claim denial and lost revenue.

A coder or auditor will better be able to notice clinical indicators that define the severity of the illness and intensity of required service, along with the specificity of the type and acuity of the condition. This closer eye for detail is essential for minimizing coding errors as much as possible.

To ensure the utmost accuracy, providers must not strive to fully automate the coding process, but to instead supplement automation software with the assistance of a medical coding provider. ECLAT Health Solutions has a team of expert coders and auditors who are dedicated to providing our clients with accurate coding to prevent claim denials. We are skilled in CPT and ICD-10-CM coding and have a comprehensive 3-Tier Quality Assurance Process to ensure accuracy. We also offer thorough auditing services to identify our providers’ coding errors and identify opportunities for improvement. We offer support for all chart types, specific chart types, specific coders, high alert cases (RAC, OIG, etc.), or other focused areas (MS-DRG, ROM, SOI, APR DRG, APC, POA, etc.).

 

2. Coders & auditors may identify errors in clinical documentation

Because CACs analyze medical documentation to assign codes, they only review and understand the data provided on each piece of documentation. If a document was filled out incorrectly or inefficiently, the code that CAC assigns may not be the most accurate code for the diagnosis or treatment provided, and CAC may not be able to detect the flaw in the documentation. Similarly, to return to our example, if a document states that a patient exhibited symptoms of heart failure but did not in fact suffer heart failure, a CAC may code it incorrectly.

A coder, however, may better understand the context surrounding the patient experience and the data reported on the documentation, which will affect the code that will need to be assigned.  A coder will understand that the symptoms did not result in heart failure and should not be coded as such. Repeated errors or inefficiencies are best spotted with human eyes of a skilled credentialed coder. A seasoned coder or auditor will be better equipped to identify misinterpreted patterns and propose suggestions for how to improve to the proper staff.  They will also be more aware of any query or clarification opportunities that would lead to optimal quality statistics and accurate reimbursement. A CAC is not as capable of detecting these nuances and patterns.

The best way for providers to identify errors in their coding and documentation processes is to partner with a medical coding company like ECLAT. Our coding and auditing staff thoroughly reviews our clients’ coding processes to not only detect errors but make suggestions for improvement. Our clinical documentation improvement services are also designed to address issues in a provider’s documentation processes to help reduce coding mistakes and claim denials.

 

Facilities who are struggling to earn their full revenue or have coding errors should perform an audit through a medical coding provider. ECLAT Health Solutions’ auditing staff holds a wide variety of specialties, including inpatient medical records, outpatient same-day surgery, emergency department medical records, and clinical documentation improvement opportunities. We can perform audits for providers large and small and detect errors that CACs may not be able to. Our audit platform includes “audit to educate” and we pride ourselves in providing deliverables that include graphics, executive summary, audit details and education. Although complete automation may seem appealing to providers looking for cost-effective, productive solutions, we believe there is no complete replacement for human coding and billing staff. Our auditing and coding staff are here to ensure accuracy, efficiency, and a true ROI.