Carolina Neurosurgery’s software is an IQMax (Charlotte, N.C.) platform that presents and captures data from physicians at the point of care, with another layer provided by 3M (St. Paul, Minn.) that incorporates Natural Language Processing (NLP) and content to suggest codes based on the documented encounter.
Before implementation, the vendors analyzed the normal codes and patterns that Carolina Neurosurgery clinicians generally used and extracted them out of the practice’s electronic health record (from the Horsham, Penn.-based NextGen). Now, when clinicians round at the hospital, they can see a list of patients via a feed from the hospital, so clinicians can proceed to enter charge and diagnosis codes as they see their patients. This information is sent to a file on the network that is then sent to the billing coders.
“The whole purpose of doing charge capture is to streamline and efficient way to communicate with the coders and be able to have one application that all the providers use, so you have consistency,” says Pam Saunders, director of information systems and managed care, Carolina Neurosurgery and Spine Associates.
Saunders says this new system beats the old manual workflow that required the physician to turn in a paper form to the coding department. This way allows providers to get all the information to the billing department immediately while rounding, so that part is out of sight. Saunders adds that the solution has a great tool for coding edits that lets clinicians interact with their edits. The software engages the physician with messaging about an error, so it can be fixed before being translated by the coder.
