The ongoing clinical labor shortage and expanding administrative duties are consuming greater portions of physicians’ time—time that should be spent on patient interactions—and contributing to rising rates of clinician burnout and low satisfaction.
In many healthcare settings, those duties include self-coding patient charts, which requires physicians to keep up with increasingly complex and rapidly evolving coding guidelines. What’s more, tasking physicians with self-coding can cause back-end delays in billing and reimbursement and higher rates of coding-related denials.
To alleviate these burdens and centralize coding processes, organizations like St. Joseph’s Health are turning to professional coding automation. This technology offers the added benefits of streamlining revenue cycle performance and enhancing compliance.
Understanding the Impact of Underpayments
Underpayments occur when payers do not fully reimburse providers for the services delivered, based on the terms of their managed care contracts. This can happen through outright denials or more subtly, through reduced payments that providers may mistakenly accept as complete.
These issues can significantly impact the financial health of healthcare organizations, as the American Medical Association (AMA) estimates the accuracy rate of payments by insurance companies at only 77%. This means more than one in five claims are not appropriately reimbursed according to managed care contracts. Research indicates that this discrepancy translates into a net revenue loss of 1% to 3% for providers - a significant figure for healthcare organizations where each percentage point of loss can equate to substantial amounts of forfeited revenue.
Seeking to Unburden Physicians
A leading health system based in Paterson, New Jersey, St. Joseph’s Health provides world-class care through a combination of medical expertise, innovative technology, and compassion. Its more than 6,000 skilled providers, including about 1,000 physicians, provide nationally recognized care through a network of hospitals, physician practices, urgent care centers, and outpatient centers.
Recognizing the detrimental impact self-coding can have on both physicians and the health system’s financial well-being, St. Joseph’s Health turned to coding automation as an alternative approach to processing professional fee coding across its more than 150 facilities.
“We were allowing providers to do their own billing and coding because they're at the ship's helm, but in fact, we had a lot of issues. I also don't want our providers spending time Googling CPT codes. I want them seeing patients,” says Beth Kushner, DO, CCDS, CPCO, Chief Medical Informatics Officer with St. Joseph’s Health.
Kushner, an ER physician, sponsored the pro-fee coding automation program to help drive adoption and change management. “I wanted to use computer-assisted coding to take away that burden and allow the provider to have more time at the bedside with the patient,” she notes.
With the coding automation initiative, the health system sought to enhance coding efficiency and accuracy and:
- Optimize physician availability: Reduce or eliminate administrative burdens on physicians to mitigate burnout and enable them to spend less time in front of screens and more time with patients.
- Streamline revenue cycle management: Improve coding productivity to prevent billing and reimbursement delays at the back end of the revenue cycle.
- Improve clean claim rates: Increase first-pass adjudication rates to ensure appropriate and maximum reimbursement for physicians' services.
Autonomous coding technologies were initially attractive; however, the evaluation team found that available solutions lacked model transparency. With physicians' compensation at stake, they needed a solution that provided a clear rationale for coding decisions. This ultimately led the health system to choose a blend of computer-assisted professional coding (CAPC) and outsourced coding services from AGS Health. This approach would enable the organization to immediately transition coding duties from its clinical resources to a dedicated team of coders while also achieving technology-enhanced productivity, efficiency, and accuracy.
"I really like the fact that AGS Health’s approach leverages a combination of technology and human input,” says Kushner. “Medicine is one of the rare fields that you just can't [fully] automate. There is not a single patient that has ever followed any textbook that has ever existed … Healthcare is unique. It’s robust and different [with] weird regulations and different payers. It’s a totally different beast than other industries."
A 5-Phase Implementation Approach
AGS Health’s solution engineering team collaborated with key stakeholders at St. Joseph’s Health to evaluate infrastructure and interoperability, identify potential barriers, and align the coding automation initiative with the organization’s existing roadmap for coding centralization. Two key priorities emerged from this process: technology integration and education through change management.
These priorities were addressed with a five-phase implementation plan that gradually introduced coding automation across all facilities by specialty. This approach supported education and change management efforts, bolstering stakeholder confidence and acceptance while allowing for feedback-driven improvements to maximize adoption.
Because St. Joseph’s Health is also a teaching institution it was also vital to ensure proper attestation and accurate attribution, particularly for Part B teaching hospital coding. While the technical aspect of final signatures by the attending physician was straightforward, human intervention was essential for flagging missing attestations to ensure accurate billing of resident work.
Rapid ROI and Unexpected Outcomes
Within four months of going live with CAPC, coder productivity increased from an average of 6-7 charts per hour to 10 charts – a 40-60% improvement. The need for five additional full-time coding resources was also eliminated, saving St. Joseph’s Health nearly $200,000 annually.
Today, St. Joseph’s Health and AGS Health are using CAPC to process more than 320,000 charts annually with a 78% E/M coding accuracy. This has normalized E/M distributions for outpatient coding, which has been verified through internal audits. Physicians are now confident in the CAPC algorithm and can easily identify why codes were assigned specific levels. Other outcomes include:
- A decrease in pediatrics coding denial rates from 34% to 8%.
- A decrease in primary care denials from 26% to 9%.
- An increase in monthly collections on the current month’s billing in pediatrics from 36% to 87%.
- An increase in clean claim rates from 55% to 66%, or up to 90% if registration and eligibility issues were not a factor.
One unexpected benefit of CAPC has been an improvement in capturing CPT Category II codes, which are vital for tracking quality metrics. Previously underutilized due to a lack of awareness among physicians, the CAPC system increased the capture of these codes. This enhancement has made it easier to evaluate the quality of care using claims data, supporting the organization’s value-based metrics without requiring manual data extraction.
The Right Partnership
Kushner credits the partnership with AGS Health and the balance between CAPC and human intervention with the rapid success of St. Joseph Health’s pro-fee coding automation initiative.
AGS Health has "proven repeatedly that this is a partnership," she says, pointing to "the ability to enhance the CAPC program while knowing that, in the end, there is still a human to verify, to do the eyeball check. That is an undervalued thing in healthcare, and it's so incredibly important for what we do."
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