Computer Assisted Coding

Computer assisted coding or CAC is an exciting technological development in the world of coding. Contrary to what some people may think, the implementation of computer assisted coding will not replace the need for certified coding professionals. The goal of computer assisted coding is to increase the accuracy, productivity and compliance of a coder’s every day workflow.

Computer assisted coding uses a process called natural-language processing (NLP) to automatically generate preliminary codes based on a review of the clinical documentation. The implementation of the electronic health record (EHR) has opened the door for the application of natural-language processing technology by allowing the utilization of computer assisted coding software, which is the vehicle for reviewing the clinical documentation.

The software scans the medical record for key words that generate preliminary codes. Typically, the codes are then displayed on the coder’s computer screen side by side with the medical record.  Coders can then review and if necessary modify the code selections made by the software. The software also matches the codes against regulatory and payer requirements which leads to more compliant coding.

At the current time computer assisted coding is most often employed for the coding of outpatient services such as radiology, emergency room and physician services

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