There is a technology that is rapidly changing medical coding in health information

management. Computer-Assisted Coding (CAC) accurately generates medical codes

directly from clinical documents. With computer-aided coding, healthcare organizations
can better meet payer and quality reporting requirements while improving their bottom
line.
Electronic health record (EHR) systems are an important source of electronic
documentation. However, integrating EHR data into the coding process can be a
complex process. Computer-aided coding provides the intersection between data in
EHR and transcription systems and healthcare financial systems.
CAC medical coding using natural language processing (NLP) techniques can analyze
and interpret unstructured healthcare data using specialized algorithms to extract the
facts that support the assignment of codes. Applications that process structured input
can integrate coding into clinical documents and produce clinical documents with the
correct embedded codes. Most NLP techniques can be used with current clinical
documentation practices that generate text from unstructured data, such as speech
recognition and computer-assisted medical transcription.
A data interface is required to provide clinical documentation to medical coding
software and to receive encrypted data into an organization's billing system. Interface
formats such as HL7 FHIR or XML can be used to distribute clinical documentation.
With an NLP-based platform, almost any document format is accepted.
In some environments, web-based services are a popular choice, especially if existing
programming interfaces or other medical coding automation tools are available. The
output of the healthcare coding software workflow is a coding record, including the CPT
and ICD-10 codes required to submit a full claim, such as code links, patient
demographics, modifiers, and units. Optimal workflow options should not require data
entry by transferring computer-assisted coding data directly from the medical coding
software to the billing system.
Computer-assisted coding does not eliminate the need for medical coding specialists
to be involved in the process. It can make medical coders more efficient. Coders can
view and modify coding in computer-aided coding software and check against standards
in real time.
Today, computer-aided coding techniques from CAC providers are most widely used in
outpatient coding and use cloud computing in healthcare. Some medical specialties that
use CAC medical codes include radiology, cardiology, pathology, and emergency
medicine.