Guest Post: Natural language processing and clinical documentation, part 2

by Crystal R. Stalter, CPC, CCS-P, CDIP

Effect on coders

Once the patient is discharged, it is the coding team’s time to shine. If the hospitals’ providers and clinicians have an electronic health record (EHR) that uses natural language processing (NLP) technology, coding’s job becomes much easier. From the physicians/providers to the CDI specialists, NLP helps ensure documentation is robust, with conditions that have been queried when necessary and fully specified—producing a fully documented encounter by the time the chart crosses the coder’s desk.

All that is left is for coding to assign the appropriate diagnosis codes to their highest specificity, ensuring capture of CC/MCC conditions and appropriate DRG assignment. The end result is a faster progression from discharge to claim submission. Of course things aren’t always this simple, but they could be—and perhaps should be.

In the outpatient setting, there are fewer steps between the face-to-face encounter and bill submission, but the documentation needs remain the same. Providers can’t always have CDI specialists reminding them in real time to include elements in their documentation—but NLP could fill this role, if we learn how to harness its power for each and every encounter.

When the physician or midlevel provider documents to the fullest specificity, the coding team can assign the most appropriate diagnosis code, ensuring much less time that balance is registered in accounts receivable as “not paid.” In addition, medical necessity denials are not a concern, and conditions that qualify as a Hierarchical Condition Category are submitted with the most appropriate diagnosis code.

Of course, I am not able to observe all these processes firsthand as a patient, but my experience on the “other side” gives me insight into the life cycle of my encounter and claim. I can see the diagnoses that were submitted when I review my insurance claim, and that clues me into what occurred (or didn’t occur) with the documentation of my encounter.

Summary

There is no question that fully specified documentation is the key to quality care, compliance, and reimbursement. Technology has come a long way in supporting efficient completion of documentation. We can reach providers at the time of the patient encounter, giving them tools and insight for fully specifying patient conditions. In turn, the CDI specialists and coders are more efficient in their roles, thanks to software engines that do the heavy lifting and provide them with complete documentation from which fully specified diagnosis and procedure codes can be assigned.

At the beginning and the end of this cycle is the patient. Giving providers time to spend with their patients and ensuring full and complete documentation is the focus of my job every day. As a patient, I am appreciative of my doctors’ time; as a CDI manager, I am grateful for the insight and perspective granted by technology that helps us help the doctors, hospitals, and staff.

Editor’s note: To read part 1 of this article, click here. Stalter is the CDI manager for M*Modal in Pittsburgh. Contact her at crystal.stalter@mmodal.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article originally appeared in JustCoding.