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Computer Assisted Physician Documentation (CAPD)

Streamlining the transition from ICD-9 to ICD-10

Computer-Assisted Physician Documentation (CAPD™) is a revolutionary technology being developed by two global leaders in clinical documentation and medical coding.  CAPD leverages Nuance Healthcare's Clinical Language Understanding (CLU) technology and 3M's extensive knowledge base of Clinical Document Improvement (CDI) guidelines and coding standards to help physicians improve documentation.  It monitors physicians' documentation continuously and, when necessary, prompts for additional information to help improve documentation.

How Nuance makes a difference

  • Helps improve clinical documentation for patient care, ensuring appropriate reimbursement and quality reporting 
  • Supports physicians to improve clinical documentation today within the context of ICD-9
  • Facilitates and streamlines transition to ICD-10 for physicians and staff
  • Reduces volume of disruptive queries for additional information to physicians
  • Supports and sustains internal efforts to improve clinical documentation for all payers
  • Reduces the time CDI specialists spend generating and following up on manual queries

CAPD helps physicians create ICD-9-compliant clinical documentation today and streamline the transition to ICD-10 in the future. The ability to understand the content of a dictated note in "real time" combined with CDI guidelines allows CAPD to identify gaps and ambiguities in the note and give the physician pertinent and focused suggestions to improve clinical documentation.

CAPD is an automated, interactive system that will help physicians improve clinical documentation to ensure accuracy and completeness, reducing the need for coders and CDI specialists to query physicians for more information or clarification.  Finally, CAPD enables physicians to use narrative — their preferred mode of documentation — instead of structured data entry, while still addressing organizational needs for unambiguous and structured patient data.

Ultimately, CAPD can help improve physician documentation processes to ensure appropriate reimbursement and more accurate quality reporting.

CAPD can:

  • Allow facilities to document patient acuity accurately by identifying accurate severity and risk of mortality
  • Reduce interruptions to physicians by reducing the number of (and associated physician time needed to address) manual documentation queries from CDI and HIM coding staffs. This may help hospital executives as they focus their priorities on physician recruitment and retention
  • Reduce risks of financial losses from audit exposure (for example, RAC) due to more accurate and compliant physician documentation
  • Support and sustain internal efforts to improve clinical documentation for all payers, not just those who are DRG based.  This will help organizations as they transition to value-based purchasing and quality reporting (a key priority for healthcare executives)
  • Reduce the time CDI specialists spend generating and following up on manual queries. This will allow them to expand their services to include non-DRG payers, enhance physician education and work more closely with HIM and Quality teams.

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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)

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