Medical coding system with CDI clarification request notification

• US 10,373,711 B2
• Filed: 06/04/2014
• Issued: 08/06/2019
• Est. Priority Date: 06/04/2014
• Status: Active Grant

• Current Assignee: Microsoft Technology Licensing LLC (Microsoft Corporation)
• Original Assignee: Nuance Communications, Inc. (Microsoft Corporation)
• Inventors: D'Souza, Howard, Sarkar, Debjani
• Primary Examiner(s): Long, Fonya M
• Assistant Examiner(s): Lultschik, William G
• Application Number:
  US14/296,274
• Publication Number:
  US 20150356246A1
• Time in Patent Office: 1,889 Days
• Field of Search: None
• CPC Class Codes: G06Q 30/0283 Price estimation or determination
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

Techniques are provided whereby a clarification request may be generated with a clinical documentation improvement (CDI) system for resolution by a clinician, and notification of the clarification request may be transmitted to a medical coding system. At a medical coding system, notification may be received of a clarification request generated at a CDI system for resolution by a clinician. In some embodiments, the medical coding system may be a computer-assisted coding (CAC) system.

Claims

1. A method for use with a Clinical Document Improvement (CDI) system implemented via at least one processor and generating a clarification request for resolution by a clinician, the CDI system configured to communicate with a Computer-Assisted Coding (CAC) system that analyzes at least one medical document, generates one or more medical codes associated with the at least one medical document, and presents, via a user interface, the one or more medical codes and the at least one medical document for which the one or more medical codes were generated to a medical coder, the method comprising:

in response to generating, at the CDI system, the clarification request relating to the at least one medical document relating to a patient encounter between a patient and the clinician, the clarification request requesting that the clinician provide additional information regarding the at least one medical document;

transmitting, from the CDI system to the CAC system, a notification of the clarification request, for presentation to the medical coder via the user interface at the CAC system in association with the at least one medical document for which the clarification request was generated at the CDI system; and

after receiving, at the CDI system, a response of the clinician to the clarification request;

subsequent to transmitting the notification of the clarification request from the CDI system to the CAC system, transmitting, from the CDI system to the CAC system, the response of the clinician to the clarification request.

2. The method of claim 1, wherein the notification of the clarification request includes the notification and one or more documents pertaining to the clarification request.

3. The method of claim 1, further comprising transmitting to the CAC system, from the CDI system, identification of the at least one medical document for which the clarification request was generated.

4. The method of claim 1, further comprising transmitting to the CAC system, from the CDI system, identification of at least one medical billing code for which the clarification request was generated.

5. The method of claim 1, wherein transmitting a notification comprises transmitting the notification via an Applications Programming Interface (API) of the CDI system.

6. A method for use with a Computer-Assisted Coding (CAC) system that analyzes at least one medical document associated with a patient encounter between a patient and a clinician, generates one or more medical codes associated with the at least one medical document, and presents, via a user interface, the one or more medical codes and the at least one medical document for which the one or more medical codes were generated to a medical coder, the CAC system configured to communicate with a Clinical Documentation Improvement (CDI) system implemented via at least one processor and generating a clarification request for resolution by the clinician, the method comprising:

receiving, at the CAC system from the CDI system, a notification of the clarification request generated at the CDI system, the clarification request relating to the at least one medical document relating to the patient encounter and requesting that the clinician provide additional information regarding the at least one medical document;

presenting, to the medical coder and via the user interface at the CAC system, the notification of the clarification request in association with the at least one medical document for which the clarification request was generated at the CDI system; and

subsequent to receiving the notification of the clarification request at the CAC system from the CDI system, receiving, at the CAC system from the CDI system, a response of the clinician to the clarification request.

7. The method of claim 6, further comprising presenting to the medical coder, at the CAC system, a visual indication that the clarification request is associated with the at least one medical document for which the clarification request was generated at the CDI system.

8. The method of claim 6, further comprising presenting to the medical coder, at the CAC system, the notification of the clarification request in association with at least one medical billing code for which the clarification request was generated at the CDI system.

9. The method of claim 6, further comprising presenting to the medical coder, at the CAC system, the clarification request as a peer document with the at least one medical document for the patient encounter for which the clarification request was generated at the CDI system.

10. The method of claim 6, further comprising suppressing generation and/or transmission, at the CAC system, of a duplicate clarification request matching the clarification request generated at the CDI system.

11. The method of claim 6, wherein the notification of the clarification request includes the notification and one or more documents pertaining to the clarification request, and the method further comprises:

analyzing, at the CAC system, the one or more documents pertaining to the clarification request to automatically suggest one or more medical codes for the patient encounter.

12. The method of claim 6, further comprising presenting to the medical coder, at the CAC system, the clinician'"'"'s response as a peer document with the clarification request and the at least one medical document for the patient encounter for which the clarification request was generated at the CDI system.

13. The method of claim 6, further comprising analyzing, at the CAC system, the clinician'"'"'s response to automatically suggest one or more medical codes based on text of the clinician'"'"'s response.

14. The method of claim 6, further comprising generating an alert in response to receiving the notification of the clarification request, wherein the alert is generated while the at least one medical document is being coded by the medical coder.

15. At least one computer-readable storage medium storing computer-executable instructions that, when executed, perform a method for use with a Computer-Assisted Coding (CAC) system that analyzes at least one medical document associated with a patient encounter between a patient and a clinician, generates one or more medical codes associated with the at least one medical document, and presents, via a user interface, the one or more medical codes and the at least one medical document for which the one or more medical codes were generated to a medical coder, the CAC system configured to communicate with a Clinical Documentation Improvement (CDI) system implemented via at least one processor and generating a clarification request for resolution by the clinician, the method comprising:

receiving, at the CAC system from the CDI system, a notification of the clarification request generated at the CDI system, the clarification request relating to the at least one medical document relating to the patient encounter and requesting that the clinician provide additional information regarding the at least one medical document;

presenting, to the medical coder and via the user interface at the CAC system, the notification of the clarification request in association with the at least one medical document for which the clarification request was generated at the CDI system; and

subsequent to receiving the notification of the clarification request at the CAC system from the CDI system, receiving, at the CAC system from the CDI system, a response of the clinician to the clarification request.

16. The at least one computer-readable storage medium of claim 15, wherein the method further comprises presenting to the medical coder, at the CAC system, the notification of the clarification request in association with at least one medical billing code for which the clarification request was generated at the CDI system.

17. The at least one computer-readable storage medium of claim 15, wherein the method further comprises presenting to the medical coder, at the CAC system, the clarification request as a peer document with the at least one medical document for the patient encounter for which the clarification request was generated at the CDI system.

18. The at least one computer-readable storage medium of claim 15, wherein the method further comprises suppressing generation and/or transmission, at the CAC system, of a duplicate clarification request matching the clarification request generated at the CDI system.

19. The at least one computer-readable storage medium of claim 15, wherein the method further comprises:

presenting to the medical coder, at the CAC system, the clinician'"'"'s response as a peer document with the clarification request and the at least one medical document for the patient encounter for which the clarification request was generated at the CDI system.

20. The at least one computer-readable storage medium of claim 15, wherein the method further comprises analyzing, at the CAC system, the clinician'"'"'s response to automatically suggest one or more medical codes based on text of the clinician'"'"'s response.