Inside Angle
From 3M Health Information Systems
The golden rules of coding with CAC
Thinking back to my early days as an apprentice coder, I often remember the challenge in keeping all my coding guidelines straight as well as remembering the payer regulations, while struggling to keep my productivity up. Once I had mastered that challenge, along came computer-assisted coding or CAC.
Many coders feel apprehensive when working with a CAC system. There were the old rumors that we were all going to be replaced by computers, then came the daunting task of learning an all new process. When I faced this challenge, I felt excited to be part of the future of coding. I spent years learning the best coding workflow for a CAC environment. I was so happy to say goodbye to stacks of paper charts piling up on my desk.
During my time as a production coder I learned some great tips for increasing productivity and decreasing key strokes.
First, think of the CAC system as an already coded chart. You are not digging into the note to find the correct codes. You are simply verifying if what the engine suggests is documented. If it is, stop and approve the note. No need to keep digging!
Second, have faith in the system. CAC is highly developed to follow ICD and CPT guidelines. Allow the system to do the work for you. Remember you will be flagged when there is a CCI or LCD edit. Relax and enjoy coding.
Third, apply the golden rules for coding with CAC:
- DON’T CHANGE IT: If the coding isn’t wrong, and the documentation is present to support the coding, leave it alone.
- DON’T ADD IT: Even if the language is there, unless the claim would be denied without the additional code or if it would have an impact on quality measures.
- DON’T DELETE IT: If the coding isn’t wrong, unless the claim would be denied by leaving the code.
I look forward to seeing the world of CAC coding grow. It is time to embrace our technological coding buddy and grow together as a team.
Katie Kitchen is a senior coding analyst at 3M Health Information Systems.
2 thoughts on “The golden rules of coding with CAC”
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Katie Patterson, CPC
Clinical analyst
Katie Patterson began her career in 1997 as an X-ray technician in Fullerton California. After receiving her CPC from AAPC in 2005, Katie went onto to work as a radiology…
Thank you for the insight! I will have to agree to disagree on the Procedural Coding. As an Auditor, I have had to change procedures based on the bodies of the Operative Reports and not the headers used by the Providers. I always behoove my coders to review said bodies to ensure 100% accuracy.
Thank you for your comment. Please keep in mind I am coming from a perspective of productivity based coding. So, my golden rules are going to be applicable to more standard radiology notes. I do agree with you on procedure coding. You do need to review the entire note body. As a Coding Analyst this is always my recommendation to clients. I will make sure to clarify this in future blogs.