Electronic Health Records Assignment: Coding, Systems, and Procedures

This assignment delves into the realm of Electronic Health Records (EHR), examining the processes and systems involved in medical coding. It focuses on the application of Computer-Assisted Coding (CAC) and its benefits, such as increased efficiency, accuracy, and cost reduction, while also acknowledging its limitations and potential issues like the 'Garbage In, Garbage Out' concept. The assignment highlights the importance of accurate coding using ICD-10 codes and discusses the use of DSM-IV-TR for substance abuse centers and CPT/HCPS codes for ambulatory records. It explores the techniques used by CAC systems, including natural language processing and structured input, and emphasizes the significance of proper documentation for accurate diagnosis and procedure coding. The assignment uses real-world examples to illustrate the coding process and the importance of correct code selection for various medical scenarios.

Running head: Electronic Health Records 1
Electronic Health Records
Course name
Institutional Affiliation

Electronic Health Records 2
Electronic Health Records
Medical institutions have a lot of health records on different patients. These records hold
the diagnosis and trends of a patient’s health and the treatment options provided by the doctor.
With the advent improvement in technology, the medical field has embraced the computer
assisted coding (CAC) that generates medical codes from medical documentation (Mag, 2010).
The utilization of the CAC technique does not entirely eliminate the medical coding
professionals. The primary benefit of using CAC is that it increases accuracy especially where
the tasks required are repetitive or mundane. The human eye performs rather poorly in such
circumstances. The coders are needed even if the CAC is implemented since the medical field
continuously experiences change. The use of CAC in the medical institutions allow more coding
to be done over a shorter period of time and less staff are employed hence they cut more costs.
The medical field uses the ICD-10 code that updates the medical codes as well as
describing the diagnoses and procedures in a detailed manner. The CAC does not manage to
solve all the problems brought about by the ICD-10 transition. When the physicians provide the
wrong information to the CAC systems, a huge problem ensues based on the Garbage In,
Garbage Out concept. Some of the examples of the problems encountered are: -
(i) The software used may have difficulty differentiating E-codes and V-codes
(ii) The codes are listed in numerical order. It is much more difficult to review and re-
order in categories.
(iii) Some of the code sections were highlighted as “x” instead of the 5th digit which
differentiates the obstetric codes from others.
To confirm the patient’s principal diagnosis for coding for a chart one needs to review the
discharge summary documents. Such a document shows all the procedures a patient went
through before a final conclusion on the diagnosis was made. This document provides the correct
information. The degree to which the codes accurately reflect the patient’s diagnosis and
procedure is validity. For a person who works at a substance abuse center, the appropriate
systems to use to code for the diagnosis is DSM-IV-TR. I need to code an ambulatory record but
the procedure code is not in the CPT manual. Use the HCPS level 2 codes to code for it (CMS,
2015).
In a nutshell, it is easy for one to code using the CAC systems as the systems present a
myriad of advantages. It is much easier to perform data queries, it tends to decrease the coding
costs, provides a coding evidence trail. The use of CAC systems provides consistency,
productivity, and efficiency. The system uses the free text to record documentation using two
techniques. The natural language processing technique reads narrative text and voice documents.
It electronically records the key words while analyzing their context or use in different sections
of the documentation. Another technique employed is the structured input. It allows the
physician to generate records while picking out specific diagnostic phrases to which a code is
generated.

Electronic Health Records 3
References
CMS. (2015). ICD-10 Compliance. Official CMS Industry Resources for ICD-10 Transition, 1-
32.
Mag, H. (2010, January 29). Computer-Assisted coding: The secret weapon. Retrieved from The
health Management Technology: https://www.healthmgttech.com/computer-assisted-
coding-the-secret-weapon.php