Towards computer-assisted coding: A case study of ‘charge by documentation’ software at an endoscopy clinic

•We compare billing codes from a manual approach and with computerized support.•More ICD-9 codes were generated with computerized support.•Fewer codes had missing supporting documentation with computerized support.•The ‘charge by documentation’ approach is recommended for predictable workflows.

ObjectivesAn imminent transition to the ICD-10 diagnostic code set has increased interest in automating portions of the reimbursement process for clinical procedures. In this paper, we compare two distinct sets of billing codes generated at an endoscopy clinic using a traditional manual methods and computer-assisted coding using a ‘charge by documentation’ approach.MethodsThis is a retrospective, cross sectional research design analyzing data collected from all patients treated at one outpatient endoscopy clinic from July 2010 through June 2011. The collected data were the medical record number, data of service, diagnosis, procedure, CPT codes, ICD-9-CM codes, and CPT modifiers. The paired data were categorized as either an exact match or discrepant.Results98% of the 2923 procedures were either colonoscopies or upper GI endoscopies, which have predictable workflow deviations that reliably map to changes in procedural and diagnostic codes. The codes from the two methods were an exact match for 31% of the cases. The automated approach generated 1–8 additional codes for 62% of the cases, and the manual approach generated codes without accompanying supporting documentation in the progress note for 24% of the cases.ConclusionsWe conclude that the automated approach was superior to the manual approach. We recommend the ‘charge by documentation’ approach for settings where the workflow is relatively predictable, including pre-identified frequently occurring branches to the workflow that affect the selection of procedural and diagnostic codes.