Improper Coding: It’s Not Just your Revenue that’s at Stake

Inavalue-basedhealthcareenvironment,theimportanceofaccuratemedical codingcannotbeoverstated.Propercodingensurespatientrecordsare accurate,careteammembershavenecessarydataanddocumentation availableinreal-time,andtherevenuecycleishealthyandstrong.Incorrect codingwillalmostalwaysresultinclaimdenialsandreducedreimbursements frompayers.However,ascodingprotocolshavebecomemorecomplex, healthcareorganizationshavestruggledtomaintaintheefficacyofthe medicalcodingprocess.

WiththeintroductionoftheICD-11codingclassification,codingand documentationprocessesareexpectedtoincreaseincomplexity. Furthermore,CMScodechangesbringanadditionallevelofcomplication.Asa result,hospitalsarefightinganuphillbattletoimprovetheircoding frameworkandmaintainconsistentrevenuestreams.Accordingtothe2019 report“MedicareFee-for-ServiceSupplementalImproperPaymentData”by theCentersforMedicare&MedicaidServices(CMS),80%ofimproper paymentsaretheresultofincorrectcoding.

Whilerevenuelossisthemostprominentanddirectconsequenceofincorrect coding,theconsequencesofincorrectcodingextendfarbeyonddisrupting revenuecycles.

The Repercussions of Improper Coding: Beyond Revenue Loss

Qualityofcareisthemostimportantaspectofthevalue-basedcaremodel. Thegoalofaccuratecoding,amongotherthings,istoensurethathigherqualitycareisdelivered.Inaccurateorimpropercodingworkscountertothis goalandmayresultinirreversibledamage.Assigningincorrectdiagnosis codes,forexample,resultsinincorrectproceduresthatcouldbedamagingto thepatient.

Thespecificsofeachdiagnosisinfluencethecodes.Asaresult,it'soneofthe mostcommonmistakesduringthecodingprocess.Sucherrorscancause chaosandconfusion,leadingtothebreakdownoflong-standingrelationships betweenpatientsandhospitalstaff.

Incorrectcodingcanalsoresultinfraudandmedicalabusecharges.Medical abuseoccurswhenmedicalcodes,intentionallyorunintentionally, misrepresenttreatment,resultinginmonetarygainsforhospitals.Such circumstancesareconsideredfraudandarepunishableundertheFederal CivilFalseClaimsAct(FCA).ViolationsoftheFCAcanresultinfinesofupto threetimestheamountofthefalseclaim.Furthermore,ahistoryofsuch transgressionsmayresultinalossofreputation.

Getting Ahead of it with AI- and NLP-based CAC

Thefinancialandreputationalconsequencesofimproperbillingareterrifying, andtheyoftentakealongtimeandmuchefforttorecoverfrom.Buthospitals arenotentirelyhelplessintheaftermathoftheseincidents.Withthe introductionofcutting-edgetechnology,hospitalsareconstantlystrivingto improvetheirprocessesandavoidrevenuelossduetomedicalbillingand codingerrors.

Thisiswhereartificialintelligence(AI)-poweredcomputer-assistedcoding (CAC)softwarecomesintoplay.Thesesystemsemploythelinguistic algorithmsofnaturallanguageprocessing(NLP)toextractclinicalindicators fromunstructureddata,includingnotesandprescriptions.Thisdatacanthen beusedtoassignappropriateclinicalcodes.

CACpoweredbyAIandclinicalNLPautomatestheclinicalcodingprocess, allowingorganizationstoreducedenialsandimprovecarequality. Additionally,thespeedwithwhichthesetoolsoperateincreasesthecoding team’soverallproductivity.Asaresult,hospitalscaneliminateinaccuraciesin theircodeanddosoquickly.Inaddition,theCACtooldetectsthepatternand likelihoodofclaimsdenials.Thiscandirectthebillingteam'sattentionto specificareastomaximizepaymentreturns.

CACSoftwarepoweredbyAIcanenhancehospitalcodingprogramsand improverevenuestreams,whichallowshospitalstomaintainasolidcoding framework.CAC-AIalsoeasesresourcepressures,whichcouldallowthe organizationtopushforwardwithinnovationstopositionthemas forerunnersinthemodernizationofhealthcare.

Forhospitals,codingtoolssuchasAGSHealth’sCACSoftwarethatleverages clinicalNLPwillprovidereliefagainstthestrugglesofimpropercoding.AGS offersacomprehensiveserviceplatformthatenableshospitalstoextract criticalinsightsfromunstructureddataandorganizethatdataintoa structuredformatforclinicalanalysis.Thissoftwareasaservicereducesthe cost,time,errormargins,andeffortrequiredforprocessingandclinical coding,allowinghospitalstoreceivequickandaccuratehealthcareexpertise innear-real-time.

TolearnmoreaboutAGSHealth’sAI-based,mid-revenuecyclemanagement solutions,visitAGSHealth.comorrequestalivedemo.

Source of content: https://www.agshealth.com/blog/improper-coding-its-not-just-your-revenue-thats-at-stake/