Request for Proposal: Computer Automated Coding for Medical Group

This report addresses the implementation of a Computerized Automated Coding (CAC) program for a large medical group practice. It focuses on creating a Request for Proposal (RFP) to target potential vendors, emphasizing the software's accuracy, including documentation of accuracy statistics from providers who have already implemented CAC systems, and providing recommendations for corrective actions. The report outlines the software's function in generating medical codes based on clinical documentation, highlighting its advantages in reducing human error and enhancing the role of coding professionals. Key recommendations include reviewing documentation for diagnostic and therapeutic services, considering treatment interventions for emergency department coding, and ensuring comprehensive medical records for observation and ambulatory surgery. The conclusion emphasizes the system's benefits due to reduced human intervention and a less error-prone approach, making it a valuable resource for healthcare providers considering CAC implementation. Desklib provides access to similar assignments and study tools for students.

Running head: COMPUTER AUTOMATED CODING
COMPUTER AUTOMATED CODING
Name of the Student
Name of the University
Author Note

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Table of Contents
Introduction................................................................................................................................3
Software.....................................................................................................................................3
Recommendation........................................................................................................................3
Conclusion..................................................................................................................................4
References..................................................................................................................................5

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Introduction
The main proposal which is taken into consideration is for a large medical group
which is considering to take into consideration the implementation of a computerized
automated coding (CAC) program. The main purpose of the aspect is to take into
consideration a request for proposal (RFP) which is directed for the target potential vendor
for a response.
Software
The main focus point of the software is the use of computer software that generates a
set of code which is related to medical aspect which can be reviewed, validated and use
which is based on the aspect of clinical documentation which are provided by the heath care
practitioners. It can be stated here that the concept which is related to the CAC can be
misunderstood as a concept of auto coding (Jones, Beecroft & Patterson, 2014). In the last
few years the practices which are very little in limited selection of code for example
radiology, laboratory and physical clinical practice – a CAC solution could be used which
would be directly reducing the error which are human oriented to validate the code
assignment. The aspect of the CAC would be directly reducing human intervention into the
internal working of the system. The main advantage which can be related to the concept is
that the CAC would be transforming the role and would be enhancing the sector which is
related to the human coding professionals (Weinberg et al., 2015).
Recommendation
Recommendation 1: Taking into consideration the patients which only receive
diagnostic service, the coder must review the documentation relating to the condition,
diagnosis, problem and other reason for the visit. These aspect would be shown in the
medical record for the outpatient service which is provided.

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Recommendation 2: Taking into consideration the patients which would be receiving
therapeutic service during their visit, it should be taken into consideration that the medical
record should be corrected taking into consideration the problem or other reason which are
related to the visit.
Recommendation 3: The emergency department coder should take into consideration
the aspects which are related to the treatment interventions, nursing notes, physician orders,
diagnostic interventions and progress note with principle diagnosis.
Recommendation 4: Taking into consideration the aspect which is related to
observation record must contain the physical and history, progress notes which are
handwritten, clinical observation and final progress notes or summary that majorly include
the diagnosis and any procedures which are treatment rendered or performed (Rains, Skurka
& White, 2017).
Recommendation 5: Taking into consideration ambulatory surgery it should be taken
into consideration that the medical record of the diagnosis for which the surgery would be
performed. If the diagnosis of the postoperative is known to be different from the diagnosis of
the preoperative diagnosis the coder must directly review the physical and history of the
examination, operative/procedure report, pre-operative report, progress notes, anesthesia
record, encounter summary and face sheet.
Conclusion
The system can be stated to be very much beneficial due to the factor that it would be
involving less human intervention as a result of which it would be less error prone approach
related to the normal functionality.

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References
Jones, K. A., Beecroft, N. J., & Patterson, E. S. (2014). Towards computer-assisted coding: A
case study of ‘charge by documentation’software at an endoscopy clinic. Health
Policy and Technology, 3(3), 208-214.
Rains, S. K., Skurka, M. A., & White, M. (2017). Coding, Compliance, and Classification
Systems. Health Information Management: Principles and Organization for Health
Information Services.
Rastegar-Mojarad, M., Sohn, S., Wang, L., Shen, F., Bleeker, T. C., Cliby, W. A., & Liu, H.
(2017). Need of informatics in designing interoperable clinical registries.
International journal of medical informatics, 108, 78-84.
Weinberg, J., Peterson, S., Marc, D., & Sandefer, R. (2015). Aligning Computer-Assisted
Coding and Information Governance Efforts. Journal of AHIMA, 86(10), 36-40.