Health Information Management 230: Classification Systems II

Write a on the electronic applications of clinical coding.

Describe the use and function of computer assisted coding systems (CAC).
Discuss the function of encoders.
Compare the similarities and differences in the coding process with paper/manual systems versus electronic systems. Be sure to outline key advantages and drawbacks of each.
Create a flowchart or diagram on the step-by-step coding process both the paper and electronic coding process
Explain the application of the systems development cycle in the implementation of electronic applications, such as encoders and CACs.
Provide an example of how SDLC can be used in the decision-making process to implement an encoder or CAC.

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Sample Answer

Computer-assisted coding (CAC) systems

CAC systems are software applications that help clinical coders to assign the correct codes to medical diagnoses and procedures. CAC systems typically include a database of medical codes, as well as a set of rules and algorithms that help coders to select the correct codes. CAC systems can also provide coders with feedback on their coding choices, and can help to identify potential coding errors.

Encoders

Encoders are specialized software applications that are used to automatically assign medical codes to patient records. Encoders typically use a combination of natural language processing and machine learning algorithms to identify the medical codes that are most likely to be applicable to a given patient record. Encoders can significantly reduce the amount of time that coders need to spend on coding, and can also help to improve the accuracy of coding.

Full Answer Section

Similarities and differences between paper/manual and electronic coding systems

The main similarity between paper/manual and electronic coding systems is that they both involve the process of assigning medical codes to patient records. However, there are also some key differences between the two systems.

One of the main differences is that electronic coding systems are more efficient than paper/manual systems. This is because electronic coding systems can automatically search through large databases of medical codes, and can also provide coders with feedback on their coding choices.

Another difference is that electronic coding systems are more accurate than paper/manual systems. This is because electronic coding systems can use machine learning algorithms to identify potential coding errors.

Flowchart of the coding process

The following flowchart illustrates the step-by-step coding process for both paper/manual and electronic coding systems:

Start

1. Review the patient record.
2. Identify the medical diagnoses and procedures.
3. Look up the appropriate medical codes in the coding manual.
4. Assign the medical codes to the patient record.
5. Review the coding for accuracy.
6. Submit the coded record.

End

Systems development cycle (SDLC)

The systems development cycle (SDLC) is a process that is used to develop and implement information systems. The SDLC consists of the following phases:

  1. Planning
  2. Analysis
  3. Design
  4. Development
  5. Testing
  6. Implementation
  7. Maintenance

The SDLC can be used to implement electronic applications, such as encoders and CACs. In the planning phase, the needs of the organization are assessed, and the scope of the project is defined. In the analysis phase, the current system is evaluated, and the requirements for the new system are identified. In the design phase, the new system is designed. In the development phase, the new system is developed. In the testing phase, the new system is tested to ensure that it meets the requirements. In the implementation phase, the new system is implemented in the organization. In the maintenance phase, the new system is maintained and updated.

Example of how SDLC can be used in the decision-making process to implement an encoder or CAC

The following is an example of how SDLC can be used in the decision-making process to implement an encoder or CAC:

  1. In the planning phase, the organization would assess its needs and determine if an encoder or CAC would be beneficial.
  2. In the analysis phase, the organization would evaluate its current coding system and identify the problems that it is facing.
  3. In the design phase, the organization would design a new coding system that would address the problems that it is facing.
  4. In the development phase, the organization would develop the new coding system.
  5. In the testing phase, the organization would test the new coding system to ensure that it meets its requirements.
  6. In the implementation phase, the organization would implement the new coding system.
  7. In the maintenance phase, the organization would maintain and update the new coding system.

The SDLC can be a valuable tool for organizations that are considering implementing an encoder or CAC. By following the SDLC, organizations can ensure that they are making a sound decision that will meet their needs.

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