Long gone are the days of tedious manual-based coding where coders didn’t have the luxury of access to encoders or the Internet. Today’s coder is savvy in the ways of the electronic world-a world in which computers play a large role in the day-to-day coding routine.
And up until now, however, coders have used computers only to assist in assigning codes. But imagine a world in which the computer itself reads the medical record, scans for vocabulary and syntax, and then assigns the code-all on its own. Sound like something out of the future?
Think again. Computer-assisted coding (CAC)-the use of computer software to generate a set of medical codes for review and validation-is actually a practice in place at some facilities. And although the idea of letting a computer assign a code might make some leery, there’s nothing to be afraid of, says Susan Fenton, RHIA, MBA, manager in practice leadership for the American Health Information Management Association in San Antonio. “I think it’s a continued evolution, and instead of being scary, I think it’s incredibly exciting,” she says.
