You have been coding with CAC, but are you in the CAC mindset?

April 13, 2018 / By Katie Patterson, CPC

In my last blog, I discussed the golden rules for coding with CAC. This got me thinking, you really do need to shift your coding brain when working on a CAC system.

There are a few roadblocks that I have observed in CAC coders over the years. I have had to train my brain to steer around these in order to ensure I was using the system effectively. Let’s take a quick look at the most common issues.

  • Digging into the findings for additional diagnosis: While this may be tempting, keep in mind we need to code from the definitive diagnosis that is listed in the final impression. Stay out of the weeds!
  • Removing incidental findings: As coders we are not qualified to determine if a diagnosis is truly incidental. My rule is if the physician documents as a definitive diagnosis in the impression then I need to accept that code.
  • Pulling specificity from other sources: This habit not only reduces productivity but also puts you at risk. The documentation to support the code used needs to be in the report. This is a good reminder to educate your providers to document the highest specificity in the final impression.
  • Verifying codes in the code book, encoder, or code look up: This habit is a productivity killer. The code description is provided to you within CAC. You should be able to quickly scan the note to ensure that the auto suggested code is documented.

The primary function of CAC is to assist in increasing productivity. To make the most of the CAC environment you need to get in the CAC mindset. For me, this means knowing where to look for the information I need to get the chart coded quickly and efficiently. Let’s walk through my step by step process:

    • Check the CPT assigned by CAC.
    • Verify in the Procedure title that the CPT is correct.
    • Check the technique for any secondary documentation.
    • Check the ICD assigned by CAC.
    • Verify in the indication and impression that the documentation supports the code.
    • Approve the note.

While I understand that this may seem overly simplified, it is important not to get lost in the weeds of coding. Keeping yourself focused on a process will ensure increased productivity and accuracy.

Katie Kitchen is a senior coding analyst at 3M Health Information Systems.

As health care transitions to value-based payment models, providers are pressed to rethink their coding and documentation method. Learn more here.