Navigation Content

Computer Assisted Physician Documentation

Streamlining the transition from ICD-9 to ICD-10

Computer Assisted Physician Documentation

Computer Assisted Physician Documentation (CAPD) is an automated, interactive system that helps physicians improve clinical documentation at the point of entry. With revolutionary Clinical Language Understanding (CLU) technology and over 20 years of innovation driving Clinical Documentation Improvement (CDI) success, Nuance Healthcare solutions powered by JA Thomas Advanced Practice Clinical Documentation Improvement strategies go beyond just using documentation to support coding. Automated, clinically appropriate guidance and clarifications are presented to physicians at natural points during their workflow. This combined solution helps physicians document the details required for communication of care, reimbursement and quality reporting in their preferred workflow. CAPD helps organizations with their efforts to improve quality of clinical documentation, achieve appropriate reimbursement and support the transition to ICD-10. It monitors physicians' documentation continuously and, when necessary, prompts for additional information to help improve documentation in the context of ICD-9 today and supporting the transition to ICD-10.

 

How Nuance makes a difference

  • Helps physicians improve clinical documentation to ensure diagnoses accurately reflect the clinical condition of the patient, improving communication between caregivers
  • Better documentation ensures accuracy of your records, substantiates claims, mitigates risk and more accurate reimbursement
  • Facilitates and streamlines transition from ICD-9 to ICD-10 for physicians and staff through automated technology
  • Brings the clarification process closer to physician documentation workflow and clinical thought process
  • A clinically focused approach to documentation improvement improves the ability to manage population health and function successfully in an ACO and shared payment models
  • Allows Clinical Documentation Improvement teams to focus on more complicated cases and quality improvement efforts

Computer Assisted Physician Documentation helps physicians include details necessary to support ICD-9 coding today and streamlines the transition from ICD-9 to ICD-10 in the future. The ability to analyze and understand the content of a dictated note in "real time" combined with Clinical Documentation Improvement guidelines allows CAPD to identify gaps and ambiguities in the note and gives the physician pertinent and focused suggestions to improve clinical documentation.

Computer Assisted Physician Documentation is an automated interactive system that will help physicians increase accuracy and completeness in their documentation and ensure reimbursement better reflects the level of care provided. By bringing the clarification process closer to the documentation workflow physicians are able to address missing details while still focused on documenting the patient’s treatment and care. CAPD enables physicians to continue using narrative — their preferred mode of documentation — in addition to structured data entry through advancements in speech recognition and Clinical Language Understanding technology. This optimal combination of speech and understanding technology offers the necessary balance in clinical documentation to communicate the essence of what’s happening with each patient while still addressing organizational needs for discrete data elements and details to support reporting requirements.

Ultimately, Computer Assisted Physician Documentation allows your organization to put smart technology to work to help improve physician documentation processes that ensure appropriate reimbursement, more accurate quality reporting, and support the transition to ICD-10.

Computer Assisted Physician Documentation can:

  • Detect missing or unspecified diagnoses and procedures and unclear associations between relevant findings and generate clarifications to physicians to provide more specific details in their documentation
  • Facilitate a concurrent review process, with appropriate clinical guidance allowing physicians to accurately capture compliant documentation, complexity levels and severity levels in their documentation from the moment the patient enters the healthcare system
  • Subtly train physicians on the level of detail required to support coding in ICD-10
  • Support and sustain internal efforts to improve clinical documentation for all payers, not just those who are DRG based, by automating the most common specificity queries across all sources of speech driven physician documentation

Reduce the time CDI specialists spend generating and following up on the most common specificity queries, allowing them more time to expand their review of complex cases, enhance physician education and work more closely with HIM and Quality teams on additional sources of quality improvement.

 

Relevant Links

American Academy of Professional Coders (AAPC)
ICD-10 FAQ

National Center for Health Statistics (NCHS)
Basic ICD-10-CM information

Centers for Medicare & Medicaid Services (CMS)
2011 ICD-10-PCS and General Equivalence Mappings (GEMs)

ICD-10 Overview

American Health Information Management Association (AHIMA)
ICD-10 Education

Workgroup for Electronic Data Interchange (WEDI)
Strategic National Implementation Process (SNIP)

DOTmed
ICD-10: Health care’s Y2K bug or something more serious?

   Deutschland & Österreich
Computer Assisted Physician Documentation

Choose your country.