In today’s value-based digital healthcare ecosystem, top-quality coding and auditing capabilities are critical to a successful revenue cycle management framework. These capabilities are especially significant considering the shift in care volumes. Recent studies show outpatient revenue has been catching up to inpatient numbers , highlighting the growth and underlying opportunity in this sector.
With this in mind, the imperative for medical institutions to establish high-performance coding and auditing departments cannot be overstated. In keeping with the demands of an evolving healthcare system, coding and auditing practices are witnessing a rapid uptake of technology and professional services to stay ahead of the curve. However, as much as Artificial Intelligence (AI), Machine Learning (ML), and Natural Language Processing (NLP) are gaining popularity within the industry, these changes do not come easily. When building dedicated departments, their integration often poses several challenges instead.
Besides adequate resources, healthcare providers need to understand how to overcome the challenges and achieve their goals.
What’s Hurting Coding and Auditing?
Coding and auditing are two inextricable halves of a continuous process in a value-based healthcare system. When building best-in-class coding and auditing frameworks, it is essential to consider the challenges of both.
Medical coders form the bridge between health systems and payers in a digital healthcare ecosystem. However, the transition to more comprehensive code sets with ICD-10 and the forthcoming adoption of ICD-11 has introduced a layer of complexity to the process and increased the demand for experienced medical coders.
Additionally, with constantly evolving reimbursement models and coding guidelines, the risk of incorrect or outdated medical codes increases. Those errors can expose hospitals to severe risks and penalties. Similarly, insufficient information in electronic health records and incomplete documentation of medical histories create major hurdles when creating a comprehensive coding workflow. Finally, the lack of coding uniformity across organizational processes and diverse variables in medical procedures and situations further contribute to a faltering coding framework.
Auditing lacks transparency. As a result, auditors have insufficient data and overlook potential revenue leaks. Additionally, audits can experience scope creep, which costs time and money.
Audits are often limited to censuring and collecting reimbursements rather than defining actual remedial actions. While reclaiming lost revenue is vital, a robust audit system must focus on identifying errors to improve medical coding accuracy and overall patient care.
People, Process, Technology – The AGS Health Approach to a Better Department
The right tools are essential for a high-level coding and auditing department to function. High-performing departments require reporting that simplifies the coding process and provides visibility to improve coder performances. It is also vital to create a transparent database of services.
AGS Health’s NLP-powered Computer-Assisted Coding (CAC) software tracks coder performance in real-time. The platform provides accurate productivity metrics. Its comprehensive documentation capabilities capture the codes used by coders, physicians, and facilities, and subsequently identify patient population segments.
For auditors, this means a complete audit trail with pinpoint data insights. The AGS easy-to-audit module offers intelligent worklists that are automatically queued and tracked. Predictive audit suggestions are based on pre-established rules and actionable reporting. This tracks accuracy rates across departments in real-time. It also contributes to complete audit practice and complements the coding team - enabling a high-performance department.
With these systems in place, hospitals can establish an effective feedback loop. Auditors can use the comprehensive CAC insights to provide feedback on accurately identified coding practices and areas that need improvement. Coders can then implement this feedback and log it into the system for reference, significantly improving overall departmental quality.
By leveraging AI and ML integration, AGS’s automation solutions ensure better, faster, and cheaper revenue cycle management with greater accuracy and with the following improvement opportunities:
- Improved Case Mix Index
- Greater reduction in scoring denials
- Increased risk score capture
- Higher coder productivity
- Lower number of A/R Days
- Real-time analytics on KPIs
AGS’s CAC and audit software are indispensable tools for organizations that want to ensure their coding and auditing departments are well equipped to overcome hurdles and achieve goals at the highest levels possible. Our team works collaborative with customers to deliver optimal results.
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