What Is Computer-Assisted Coding?

Computer-assisted coding is a technological means of interpreting and sorting medical records. Medical professionals have been assigning medical charts, documents, and other records according to a uniform system of codes for decades. These codes are used in a variety of ways, including symptom and diagnosis management, insurance processing, and billing. With computer-assisted coding, a software program scans the relevant documents for keywords and critical phrases, then suggests a code that medical staff must only approve or correct. Used properly, it can save significant time and resources.

Coding professionals are an essential part of most health care teams. Doctors offices and hospitals frequently collect far more records on patients and their conditions than can be easily processed or read by any one person. One of the main goals of coding is efficiency — coders will read patient files and assign codes for conditions, treatments, and responses. Health care providers can glance at these codes and have a good sense of what they are dealing with without having to spend hours with a record book. As patients increase and budgets decrease, however, it is easy for coders to become backlogged.

Software programs known as computer-assisted coding systems, or CACs for short, were designed to help bridge the gap between increasing volume and staffing concerns. Most of the time, a CAC uses computers to perform preliminary coding work which must be approved by a trained professional. In this way, no medical charts or codes are disseminated without human approval, but staff are often spared hours of reading and categorizing.

A computer-assisted coding program usually works by electronically scanning, or “reading,” complete medical records that have been uploaded into its database. The program is trained to recognize certain language patterns and diagnosis keywords, which it uses to assign codes. A summary report detailing each proposed code is usually forwarded to the supervising coding professional, who must read the report, evaluate the highlights, and make a final determination.

The use of computer programs and computer technology to categorize medical records often carries more benefits than simply saving staff time. Most operate on an algorithm-based system that can be trained to detect any instance of certain diagnoses, drug facts, or contradictory treatments that might otherwise be missed by human readers. Computer-assisted coding programs are often also able to guarantee consistency and verification of assigned labels across records.

Many software packages can also be optimized to create practice or hospital-wide summary reports. These reports can be very useful for identifying patterns in treatment, diagnosis, and overall health care costs. Codes can often be divided by date, patient age, and even treating physician with little more than the click of a mouse. This adds an accountability and self-review capacity that might otherwise be too expensive and time-consuming to perform by hand.