Medical coding specialists use a wide variety of equipment and tools that include computers, microfilm or microfiche viewers, scanners, special purpose telephones, categorization or classification software, Computer Assisted Coding (CAC) software, database query software, Electronic Medical/Health Records (EMR or EHR) software and medical practice management software.
Electronic Medical/Health Records (EMR or EHR) Systems
Many U.S. health care providers and professionals, including medical coding specialists, still prefer paper-based medical charts and records systems despite the growing use of Electronic Medical/Health Records (EMR or EHR) software systems. According to the U.S. Department of Health and Human Services (HHS), as of 2010, only 25 percent of physicians and 15 percent of acute care hospitals have implemented EMR/EHR systems.
Electronic Medical Records core functions include:
- Compilation of patients’ diagnoses, allergies and lab results
- Compilation of patients’ new and past clinician treatment test results
- Compilation of all medications, tests and other patient services
- Identification of drug interactions
- Administration of patient scheduling
Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) part of The American Recovery and Reinvestment Act of 2009 (ARRA). It serves to create uniform EMR/EHR standards that allow Health Information Technology (HIT) systems to communicate with each other nationwide.
HITECH offers incentives to insurance companies and health care providers, up to $18,000. This federal government-imposed medical records keeping system, in turn, has created a greater need for those in the medical coding specialist profession to help convert traditional paper-based record keeping systems to an EMR/EHR system.
The HITECH part of ARRA, however, also imposes penalties on physicians and other health care providers who don’t implement EMR systems by 2015. They will be subject to reduced Medicare and other government medical program reimbursements. The American Medical Association (AMA) is the monitoring body for member compliance with ARRA.
HHS’s Office of the National Coordinator of Health Information Technology (ONCHIT) has been authorized to make available qualified EHR/EMR systems to health care providers for a nominal fee. At ONCHIT’s website, health care professionals can find over 500 ARRA-certified EHR technology products via their Certified Health IT Product List. EHR product providers include 3M Health Information Systems, General Electric Healthcare IT, INVISION EHR and Meditech.
EHR systems can either be standalone software-based or network-based through a service. Many medical coding specialists prefer network-based EHR services because of lower upfront costs and the delivery of frequently updated information regarding changes in insurance company and federal government medical program reimbursement rules. Also, network-based systems can better integrate with other existing health care office management and reimbursement software systems.
HHS has also opened Regional Extension Centers (REC) throughout the United States. These Centers provide technical assistance to physicians and clinicians adopting EHR systems. They can also help select certified EHR products appropriate for individual medical practices and health care facilities.
Microfilm or Microfiche Viewers
Physician offices and hospitals have traditionally stored their paper health records on microfilm or microfiche. Medical coding specialists and other health care professionals need microfilm or microfiche viewers to access these records when converting them into an electronic format. While many health care providers are complying with the conversion process, some don’t yet trust electronic record systems and maintain a hybrid medical record keeping system that’s part electronic and part microfilm and/or paper.
Scanners
Scanners are used for the conversion process of paper medical records. Scanned paper records are put in an electronic format and can be sent to a remote coder vendor service where the records are encrypted for security purposes and accessed remotely by medical coding specialists who either work at a home office or at a hospital or physician office setting.
Computer Assisted Coding (CAC) Software
Medical coding specialists either manually enter code into an EHR/EMR system or use Computer Assisted Coding (CAC) software. CAC software is a tool that converts disease or injury descriptions into numeric or alphanumeric codes. CAC “reads” electronic records much like a spell-check program reads any word processed document. For example, CAC determines what are proper CPT and ICD-9-CM procedural and diagnostic codes based on official medical coding guidelines and rules.
Natural Language Processing (NLP) is a type of CAC software used to read any type of Electronic Health Record. Another type of CAC may use a macro or template system to capture medical records data.
Another primary function of CAC coding software is the detection of possible medical insurance billing fraud through the analysis of EHR entry patterns. According to the Centers for Medicare and Medicaid Services (CMS), the most frequent fraudulent activities include the incorrect reporting of patient diagnoses and procedures to maximize insurance reimbursement payments.
While CAC software can be handy, no software is bulletproof. Coding specialists should still be well versed in medical codes to perform the double-checking needed for final code assignments.
Popular CAC software products include QuadraMed Quantim Encoding and the 3M Coding and Reimbursement System.
Special Purpose Telephones
Telemedicine is a type of professional health care service provided by medical practitioners and delivered remotely by phone. Specific Current Procedural Terminology (CPT) medical codes are used for insurance reimbursement purposes at both ends of the telemedicine service. Software used with special purpose telephones by medical coding specialists for facilitating telemedicine include iPath and Zephyr Open. Telemedicine software made for smartphones include CommCare, Epihandy and Frontline SMS.
Categorization or Classification Software
Categorization software allows users to search across complete volumes of core medical references including CPT Professional Edition, ICD-9-CM volumes 1-3, as well as HCPCS Level II. It also includes Diagnosis Related Groups (DRG) codes and their associated major diagnostic categories, as well as Dorland’s Illustrated Medical Dictionary.
Popular categorization software products include CodeManager, a categorization software product licensed through the American Medical Association, and Clinical Classifications Software (CCS) for ICD-10, developed at the HHS’s Agency for Healthcare Research and Quality. CCS is used to identify medical cases according to disease groupings, as well as to analyze trends in mortality according to diagnosis groupings.
Database Query Software
The Healthcare Cost and Utilization Project (HCUP) is a family of government health care program databases accessed by medical coding specialists and other health information technology professionals. Databases include The Nationwide Inpatient Sample (NIS), The Kids Inpatient Database (KID) and The Nationwide Emergency Department Sample (NEDS). NIS includes inpatient data sampled from over 1,000 hospitals nationwide. KID is a sampling of pediatric inpatient data nationwide. NEDS includes national estimates of hospital emergency department visits.
Database query software like Microsoft Access also serves to maintain medical database functions, allowing a user to delete and move medical data from table to table or within a data table.
Medical Practice Management Software
Medical Practice Management software is used by coding specialists typically in a hospital setting to manage everyday patient records, schedule appointments and bill insurance providers. Popular management software includes Care2X, OPEN EMR and TAPAS. QuadraMed MPI Suite includes Smart ID for patient identity management and SmartMerge for duplicate records management.
About our expert. Jan Jacobs has worked in medical offices since the early 1980's. Ms. Jacobs has worked for M.D.'s and D.O.'s in primary care and specialty care. She is employed as a senior medical biller and has been at her current job for nearly 10 years, where she uses three different billing systems.
