Q: what is CAC?

A: AHIMA has defined Computer-Assisted Coding (CAC) as “… use of computer software that automatically generates a set of medical codes for review, validation and use, based upon clinical documentation provided by healthcare practitioners.”

This broad definition currently includes two technology options. The first is natural language processing (NLP) and the second is structured input/decision tree models.

Both models require human supervision: NLP solutions automatically generate and offer codes for review by qualified coders whereas structured input systems may be used by caregivers, clerks or coders to walk towards an appropriate code.

PLATOCODE CAC is a NLP-type tool to assist coders to work more quickly and accurately than ever. The distinction matters because when reviewing coder productivity improvements, you need to know whether the "improvement" actually reflects coding being transferred to somebody else using a structured entry system or whether the coder really is performing the same work more quickly and accurately.

Q: Can your CAC do inpatient charts?

A: The PLATOCODE company invented Computer-Assisted Coding (CAC) in 1992 and our engine has been processing inpatient charts since then- yes, that's 20 years. In 1998 we added ICD-10 for inpatient charts.

Some people consider that Inpatient coding is the most difficult for CAC. Actually, inpatient is the easiest modality because it usually only involves ICD-9 or ICD-10, not CPT. CPT is much more difficult for most coding engines.

Inpatient charts do tend to be larger which requires more concentration and work by a human coder, but processing a larger chart just takes the computer a little longer. It's still only ICD codes and the computer doesn't need a break after it processes a big chart.

The other issue is that a CAC engine is only as good as the electronic chart presented to it. Handwritten or image-scanned charts may not be able to be processed by a CAC engine.

This is why the PLATOCODE company has emphasized the use of CAC for Ambulatory care and Diagnostic Radiology: those areas often have a more complete electronic record so the CAC engine can maximize its benefit and deliver the biggest ROI.

In 2012, many healthcare providers have an increasingly electronic chart and there are new technologies that may allow processing even of handwritten material, so the value for inpatient CAC is rising all the time.

Q: Is CAC really done by computer?

A: The PLATOCODE Computer-Assisted Coding (CAC) process is entirely performed by computer. Electronic charts are sent to the PLATOCODE server which "reads" the records and returns a set of codes a few moments later. These codes are then reviewed/audited by your own human coders. Under this process, all your coders act as senior coders who review code sets produced by somebody (or something) else rather than doing it all themselves. It's much quicker and less tiring, especially for bulky inpatient charts.

Q: Who signs off the coding?

A: Your own coding team still codes and signs off your charts. But rather than trawling records looking for relevant diagnoses and procedures, the coder reviews the CAC output and accepts or rejects the results. This new role is less tiring, quicker and more accurate.

Q: How does CAC access my records?

A: The PLATOCODE system does not delve into your systems to extract records. Usually we rely on HL7 feeds used by facilities to send data between systems, or existing interfaces offered by vendors to allow integration with their products. This means that the transfer process is completely transparent and controlled by your facility.

Q: Will you send my records offshore?

A: No.

Q: Who else gets to see the records?

A: Your own coding team gets to see the records. No PLATOCODE personnel will get to see the records except as part of a quality improvement process requested by you. Apart from that, the entire PLATOCODE CAC process is conducted by machine.

Q: What about HIPAA compliance?

A: The PLATOCODE company provides a standard privacy policy and technical security statement for your HIPAA documentation. In addition, because patient records are not retained by the PLATOCODE CAC server and are not viewed by human staff, the system is not a "designated dataset" which simplifies HIPAA compliance considerably.

Q: Do I need an expensive new server?

A: It is unlikely that you will need a new server. We will work with your IT Department to decide whether you need an onsite database which should not need its own server. Definitive information on this topic is available on the Technical pages of this site.

Q: What does it cost?

A: We charge a per-chart fee for the PLATOCODE Computer-Assisted Coding (CAC) process. This is a recurring service expense rather than a capital cost. We also charge a setup fee to cover the costs of implementation and training, but this can be substantially discounted or waived for facilities with higher volumes or that use standard IT systems and commit to use our system for two years. Please Contact us to discuss pricing opportunities for your facility.

Q: How much training will my coders need?

A: The PLATOCODE CAC system integrates with your existing coding process rather than imposing a whole new system. We allow a day's training during most implementations, aiming for a "train the trainer" scenario. However, our experience is that experienced coders may not need very much training at all.

Q: How reliable is your service?

A: We have a two-hour maintenance window at around midnight PST once per month. Apart from that the service is extremely reliable.

Q: Is it secure?

A: Yes. All PLATOCODE data transmission is covered by 128-bit SSL protection, just like a banking website. In addition, all clinical data in the PLATOCODE system is encrypted using extremely strong Blowfish 448 or AES encryption. Finally, clinical records are erased by us at the first opportunity unless you instruct us to keep them.