Encoder

Automated Codebook Encoder

An encoder lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the ICD-10-CM and CPT codebooks.

Grouper

Assigns the codes entered into the encoder into the appropriate MS-DRG. Uses appropriate grouping software for the insurer assigned to the patient Most common grouper is the MS-DRG grouper Code selected is only as good as the data entered into the system

Encoder & Grouper

Linked to hospital's financial information system Codes automatically transferred to system for billing Linked to MPI Demographic information automatically transferred to encoder system

Encoder Functionality

Prompts Computer will ask the coder for additional information Allows coder to resequence the prinicipal diagnosis when more than one meets the definition of principal diagnosis

Rules-based Encoders

Requires user to type in the name or portion of the name of the diagnosis or procedure This entry into the encoder generates a list of suggestions from which the coder selects Pneu- Pneumonia Pneumonitis Coder selects the proper code

2 Types of Encoders

Rules-based encoders Automated codebook encoder

Common Data Elements

Admitting Diagnosis Principal Diagnosis Secondary Diagnosis Principal Procedure Secondary Procedure Age of Patient (DOB) Discharge Disposition Gender Patient Name Medical Record Number Account Number

CAC Example

For example, consider the following sentences that would appear in a typical radiology note: 1. I see a coin lesion on the patient's left lung. 2. The patient's father has a coin lesion on the left lung. 3. I have confirmed that the coin lesion is now absent in the patient's left lung. 4. I have ruled out the presence of a coin lesion on the patient's left lung. 5. There is a questionable coin lesion on the patient's left lung. (1. I see a coin lesion on the patient's left lung. Coin Lesion - Codeable 2 - 5 - Coin Lesion - Not Codeable The mere presence of the words "coin lesion" is insufficient to code the note correctly)

Codes built in

ICD-10-CM ICD-10-PCS CPT HCPCS Codes are validated through (scrubbing) Medicare Code Editor NCCI - National Correct Coding Initiative Other edits

Edits: Look for

Invalid codes Illogical codes Nonspecific codes Other possible errors Example: Hysterectomy code to a male Newborn code to adult

Computer-assisted Coding (CAC)

Traditional clinical coder's role is aligned with a clinical coding editor role Accuracy of codes assigned by a computer-assisted coding tool must be validated The coding professional as editor will recognize inappropriate application of official clinical coding rules and guidelines and verify the application of coding guidelines contained in NCCI edits and national coverage determinations. Attention to the accuracy of correct diagnosis and procedure code assignment is not eliminated through the use of computer-assisted coding tools. Clinical coding editor may expand the traditional role in clinical documentation improvement (CDI) Working with providers on key information dictated in encounter notes, operative reports, and other health record documents, the clinical coding editor will enhance the accuracy of codes assigned through computer-assisted coding