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Identification of Relevant Content for ICD-10 Coding in Electronic Health Records

IP.com Disclosure Number: IPCOM000245413D
Publication Date: 2016-Mar-08
Document File: 5 page(s) / 272K

Publishing Venue

The IP.com Prior Art Database

Abstract

The effectiveness of computer-assisted coding (CAC) workflow is dependent on accurate identification of relevant content for automatically identified ICD-10 codes. Some auto-coding methods generate relevant content as part of code identification while other methods leverage circumstantial textual cues that would not be readily recognized as relevant by medical codes. It is therefore important to identify relevant content for codes identified by these latter methods retrospectively. This paper describes several techniques for achieving this goal.

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Identification of Relevant Content for ICD-10 Coding in Electronic Health Records

Abstract

The effectiveness of computer-assisted coding (CAC) workflow is dependent on accurate identification of relevant content for automatically identified ICD-10 codes. Some auto-coding methods generate relevant content as part of code identification while other methods leverage circumstantial textual cues that would not be readily recognized as relevant by medical codes. It is therefore important to identify relevant content for codes identified by these latter methods retrospectively. This paper describes several techniques for achieving this goal.

Introduction

Medical coding is a process used to classify medical care. The codes created are frequently used in the United States to reimburse a healthcare organization by a suitable payment organization for services provided to a patient. This process generally involves transforming narrative descriptions transcription or dictation of diseases, injuries, and/or other healthcare procedures into standardized alphanumeric designations, called medical codes. These codes are sufficiently detailed to accurately capture the patient's past and current history (e.g. what is wrong with the patient and procedures performed during the encounter). Once the codes are determined, they are generally submitted in a payment request to the payment organization that reviews the codes and makes a payment.

The International Classification of Diseases, 10th Edition, Procedure Coding System (ICD- 10-PCS) is an American system of medical classification used for inpatient procedure codes. The U.S. Department of Health and Human Services has mandated use of ICD-10 PCS for reporting inpatient procedures. The compliance date for implementation of ICD-10- CM/PCS, currently scheduled for October 1, 2015 or later, holds for all Health Insurance Portability and Accountability Act (HIPAA)- covered entities.

As procedures are performed on a patient, in the hospital, detailed narrative accounts are produced (often by dictation and transcription or direct entry into Electronic Health Records). These accounts are part of the patient's permanent medical record. During the patient's stay, or after discharge, the narratives can be read either by computer programs called "auto- coders" or by trained medical record technicians called "medical coders." When medical coders perform these tasks, they are often assisted by other computer programs called "encoders." The overall process transforms the narration into one or several procedure codes, which abstract the procedures performed during the patient's stay according to the rules of the target coding system, published guidelines, and generally accepted professional coding practice.

When using an ICD-10 coding platform, a medical coder generally may choose 1) a "code- centric" view, where a list of codes suggested by auto-coders is displayed, or 2) a "document- centric" view, which displays t...