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Advances in medical technology
Advances in medical technology
Technology in modern medicine
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What is CAC? CAC is computer-assisted-coding, which is software that recommends codes to users to confirm the results before processing the codes to billing. Computer-assisted-coding is meant to help coders ensure quality of their coding. Many healthcare professionals were concerned that the use of computer-assisted-coding would eliminate the need for professional coders, but were soon put at ease to see that this was simply not the case, as professional coders are still needed to review productivity and accuracy.
How does CAC Work? Computer-assisted-coding uses a natural language processor (NLP) to electronically read and interpret text-based clinical documentation from patient charts to identify key words, analyze their context, and suggest
appropriate codes for professional coders to review. What are the benefits of implementing CAC? Computer-assisted-coding has been proven to increase productivity by eliminating lag time within the coding process, as well as accelerating manual tasks or removing them altogether. CAC also improves accuracy, which can be seen by a decrease in the rate of denials, as well as a reduction in auditing discrepancies. Another benefit of CAC is improved consistency. Consistency is essential to the coding process, and results in the most accurate results for clinical and financial analysis. Computer-assisted-coding is undeniably valuable to the world of medical coding for several reasons. Technology, such as CAC and natural language processing, provide numerous advantages for professional coders.
The American Health Information Management Association provides guidelines of elements to be included in a health care organization’s policies of a coding compliance plan. (“Coding Compliance: Practical Strategies for Success,” ahima.org, 1998).
Hebda, T. & Czar, P. (2013). Handbook of Informatics for Nurses & Healthcare Professionals. (5th Edition). Upper Saddle River. : N.J: Pearson Education
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
Another useful tip: understand that sometimes a code from another section must be used to fully describe the procedure. This is called, component or combination coding. For example, when the radiologist injects, or places material necessary to perform a procedure, a CPT code from the surgery section must be used.
CA – Certificate Authority - is an entity that issues digital certificates. A digital certificate certifies the ownership of a public key by the named subject of the certificate.
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
Medical coding is the conversion of diagnosis and healthcare procedures and services into the universally accepted ICD-10 (International Classification of Diseases, CM and PCS) or CPT (Current Procedural Terminology) alphanumeric codes. These diagnoses and procedure codes are abstracted from the medical record documentation provided by a physician. The coding professionals ensure each ICD-10 code is assigned appropriately and correctly. The ICD-10 alphanumeric codes are imperative to the billing process, and allow the facility and physician to create claims that are paid either by the patient or insurance carriers. An inpatient coder is a medical coder that assigns codes to diagnosis and healthcare procedures and services in inpatient facilities.
The Office of the National Coordinator for Health Information Technology (ONC) and CMS have adapted SNOMED CT as a medical terminology for Meaningful Use Stage 2, Electronic Health Record (HER) system, and health information exchange (HIE). SNOMED CT offers the clinical detail and terminological sophistication necessary for more effective use of clinical data to support timely, effective, and high-quality care. For example, SNOMED CT is an efficient documentation system that is highly recommended towards patient’s history and clinical procedures. When the ICD-10 CM was implemented, it impacted everyone who used it for diagnosis or inpatient procedure codes. In addition, SNOMED CT is not the only terminology that is used for healthcare needs, but RxNorm and LOINC are also
The CPC exam is an exam for medical coders to help them obtain a certification of expertise in medical coding. The CPC exam contains 150 multiple choice questions and you are given five hours and 40 minutes to complete. The CPC exam costs $380to take and but only $300 for members of the AAPC. The cost includes an additional opportunity to re take the exam if you didn’t passed the first one. The CPC exam tests a coder’s grasp of the entire coding process, from medical terminology to code sets and beyond. The CPC exam consists of questions regarding the correct application of CPT, HCPCS Level II procedure and supply codes and ICD-10 CM diagnosis codes used for coding and billing professional medical services to insurance companies.The exam covers
This is a digital rendition of a patient’s paper chart. They are actual time, patient-centered records that make data accessible right away and securely to approved users. Although an EHR has the medical and treatment histories of patients, this system is created to move beyond regular information composed in a provider’s office and can be comprehensive of an expansive view of a patient’s care. (Health IT. Gov, 2018).
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
(2014). Reducing medication errors by educating nurses on bar code technology. Med-Surg Matters, 23(5), 1-10. http://web.b.ebscohost.com.bakeru.idm.oclc.org/ehost/detail/detail?vid=116&sid=7d1a7ff0-47e6-4393-abaf-dba8f3afa50d%40sessionmgr120&hid=106&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#AN=109799108&db=c8h
Computer technology is one the most innovative advancements in modern-day education. Technology has made its way into the world of teaching practice and principle by expanding the way we approach instruction in the classroom. We are no longer confined to pencil and paper, but have the ability to project and present knowledge in an enhanced way to capture the minds of a generation of students whose society is built around ever expanding world of computer technology.