Full coding – case-related
The new ID Clinical Context Coding (CCC) analyzes digital and digitalized free-text for hidden services. Hospitals can thereby invoice not only promptly, but completely.
Currently, in the ongoing coding process and for the final case check by a coding staff member, a lot of resources are required to identify diagnoses, procedures, laboratory values, and medicines in the files and to transfer the data to the health insurance carrier within the context of §301. ID clinical context coding helps to reduce the work involved. It complements the coding carried out by doctors through ID DIACOS® 8 because the software prepares medical free-texts semantically and searches the text for any information that is relevant for invoicing. This information is compiled in a list and suggested to the coding specialists as an amendment.
This means that ID clinical context coding reduces personnel input and administrative effort for the final case check and supports inspections for the medical service of the health insurance carriers.
The software uses the ID LOGIK® terminology server to analyze all the documents digitally recorded during daily hospital routines. Doctors’ letters, nursing documentation, OP reports, pathology results, laboratory values, and discharge letters, etc., prove to be a rich source for reading out free texts and for generating coding recommendations for the services rendered. The program is error tolerant and can even process abbreviations and typing errors.
Functions
- Comparison of clinical documents with previously completed coding
- Comprehensive service overview for medical controls
- Finding fee-related services
- Semantic preparation of digitalized patient files
- Selecting instances for diagnoses and procedures to be documented
