How AI-powered systems can help physician groups improve coding – and earn more
Coding doctor visits can be very confusing – and is constantly changing.
The rules and guidelines change every year and it is difficult for providers to keep up. Most groups have coding staff with limited training, which means some changes go unnoticed.
The downside of coding is compliance – and the ever-increasing risk of compliance audits that can have serious financial consequences for supplier groups if violations are found.
Increasing sales
“In healthcare, you only get paid for what you document and for the codes you submit,” says Dr. Bruce Cohen, a surgeon and former CEO of OrthoCarolina in Charlotte, North Carolina. “Proper coding of encounters combined with the right documentation can really increase revenue.
“Often, providers operate under legacy rules and procedures and miss significant revenue opportunities by coding office visits,” he continued. “This is especially evident in primary care, as the majority of practice revenue comes from office visits.”
AI-based programs that provide proper coding guidance and leveling in real time can be invaluable to a practice, Cohen said.
“This does not mean eliminating coders’ tasks; it increases visibility and accuracy of each cost item based on evaluation and management (E/M) coding,” he explained. “It also brings a level of documentation compliance that is not present in today’s practice environments. As annual coding requirements are instituted, an AI-based system will integrate and implement these changes in real time.”
Switch to an AI system
OrthoCarolina went with the Calm waters AI coding system from vendor MontecitoPLUS to aid in its coding efforts.
“Calm Waters AI is used by physicians, physician assistants, medical coders, and certain others who review physician documentation and assign CPT and ICD-10 codes for appropriate billing for services provided,” Cohen explains. “Coding is a complex and often confusing process due to both the sheer volume of different codes and the number of regulations and guidelines that change from year to year and within each year.
“For E/M services, part of the physician’s daily workflow is to assess each patient encountered and provide documentation of the patient’s symptoms, history and diagnosis, along with treatment recommendations,” he continued . “Based on the diagnosis – including the acuity and complexity of the problems diagnosed – the complexity of the data required to make the diagnosis, and the level of risk for complications and morbidity/mortality in the patient, the doctor assigns a level of medical decision-making. (MDM) to the meeting.”
The types of MDM – low complexity, medium complexity, and high complexity – determine the coding and billing decisions for providers’ services.
Integrate AI into the Epic EHR
“After the provider has documented the types of history, exams, and MDM, the group’s coders can assign E/M codes based on this information,” Cohen said. “Give-and-take between coders and healthcare providers often prevents this from being a seamless and time-efficient process. Coders may disagree with the physician’s assigned MDM level, or they may ask the physician for more documentation to justify a particular MDM. level and associated billing.
“Because Calm Waters AI is integrated into our Epic EHR, it is seamlessly part of physicians’ workflow,” he continued. “The system relies on artificial intelligence to review physicians’ documentation for each encounter and suggests the appropriate level and coding.”
Doctors can then review the system’s recommendations and decide within seconds whether to accept or override them. The system helps them identify potential coding compliance and documentation issues while the data is still on the physician’s desktop, before it reaches the coding and billing stage and errors become more difficult and time-consuming to correct.
“In this way, the system helps increase accuracy and compliance, reducing the risk of denials, delays and audits by payers,” Cohen said. “In addition, the system saves documentation time for suppliers and makes coders’ tasks easier and faster.”
What they expect from the system
Cohen said it is too early in the implementation to report firm results, but believes the AI-powered system will provide a significant return on investment by allowing OrthoCarolina to receive reimbursement for a greater portion of the time doctors spend caring for patients and by improving accuracy. of E/M coding.
Cohen has a few words of advice for colleagues implementing or using AI-based systems for encryption.
“The first is to reassure your coding staff that this should not be seen as threatening from a job security perspective,” he said. “It should reaffirm the importance of their jobs and give them the opportunity to expand their reach without exceeding their current capacity.
“Most groups examine the accuracy of their coding through audits or spot checks; in contrast, we can use these AI-based systems at every encounter, which would be unfeasible with current staffing levels,” he added.
Embrace technology
The second piece of advice he has is to adopt the use of technology as quickly as possible.
“In healthcare, we will continue to put downward pressure on reimbursement and increasing demands on documentation and medical decision-making,” he said. “Why not use AI-based systems to optimize our compensation for these encounters?
“The providers are doing the work and having to do more and more for the same reimbursement code; why shouldn’t they be fairly compensated for that encounter?” he concluded. “I would strongly encourage healthcare administrators and providers to look to technology to assist us in the areas of practice management and documentation.”