How Medical Coders Can Improve the Revenue Cycle for Primary Care Practices

Traditionally, medical coding professionals have worked in a variety of settings, including healthcare facilities, government agencies, health plans, and with primary care providers. The focus on employing certified medical coders for revenue cycle roles for primary care providers has grown due to increased audits by regulatory agencies, denial of claims for services, increase in value-based care contracts, and risk adjustment payment models.  

Medical coding professionals assist in alleviating the administrative burden for healthcare providers by comprehending the nuances of annual code updates. Consequently, providers are freed from the complexities of coding and billing, enabling them to focus on patient care. This efficiency enables claims for provider services to be processed faster and more accurately, leading to quicker reimbursement.  

In recent years, we have seen how coding errors can lead to claim denials, underpayments, audits, and compliance issues, negatively affecting primary care practices' financial performance and reputation. To assist with many of these coding and reimbursement challenges, artificial intelligence (AI) is quickly making a presence in the healthcare environment, including primary care practices. There are many applications of AI being developed and implemented in clinical care, and coding and billing are no exception. AI offers efficiency, improved coding accuracy, accelerated revenue integrity and charge capture capabilities, and promises to reduce lag times for claim submission. 

How Does AI in Coding Work? 

AI solutions use different data mining tools, such as machine learning, natural language processing, and neural networks, to name a few. These tools are the backbone of AI platforms, where a process known as “deep learning” takes place to ingest and recognize documentation among millions of electronic notes. This process, also known as “training the platform or engine,” is a key step in developing autonomous coding for physician and facility medical services.  

Once the platform autonomously assigns codes, it can navigate coding rules and guidelines and custom business rules to deliver code assignments with a high level of accuracy in near to full real-time. Some solutions boast an 80 percent or higher throughput rate of claims going direct to bill without the need for human review or intervention. In addition, AI can recognize gaps in documentation, making the identification of potential missed charges a more efficient process for coders and revenue cycle staff.  

What Can AI Deliver to the Primary Care Practice? 

Physicians often handle some aspects of the coding process, beginning with documentation of the patient encounter. As AI platforms integrate into the practice revenue cycle process, they have the potential to free physicians from time spent reviewing and correcting documentation, coding errors, and improving the claim denials process.  

Coders also become more effective as their roles change from complete review of all encounter notes to reviewing exceptions identified by the software. Coders can transition into audit activities related to monitoring accuracy of the software, as well as clinical documentation improvement activities aimed at providing feedback to physicians on the quality of their documentation. This also allows coders to focus on the denials process and produce more robust appeals to payers.  

To improve the primary care revenue cycle, the medical coding professional will have a positive effect on the practice by performing and developing processes and procedures for the following: 

• Stay updated on the latest coding guidelines, rules, and regulations. Coding standards change frequently, and medical coders must know the current requirements and updates for different payers and specialties. Medical coders should attend regular training sessions and webinars to receive these critical updates and obtain the required continuing education units to keep their certifications active. 
• Use technology to streamline and automate coding processes. Technology can help medical coders reduce manual work, improve accuracy, and increase productivity. For example, coding software can help coders assign codes faster, check for errors, and generate reports. Electronic health records can facilitate coding by providing accessible patient information and documentation access. As an emerging technology, AI shows promise in helping providers translate electronic notes into diagnosis and procedure codes in an automated manner. The coder’s role grows increasingly technical and vital in enhancing the AI platform’s overall health and reducing lag times and claim denials. 
• Perform regular audits and reviews to identify and correct coding errors. Audits can help medical coders monitor the quality and consistency of their coding and identify improvement areas. Coders should conduct internal audits regularly and external audits by independent third-party experts. They should promptly review payer feedback to resolve issues or discrepancies and identify and correct any coding errors affecting the quality or cost of care, such as undercoding, overcoding, or mismatched codes. 
• Educate and communicate with providers and other staff members on coding requirements for evaluating and managing procedure codes and any changes or updates in the coding rules related to local and national coding edits. 
• Analyze and report on coding trends and patterns of providers, such as utilization, outcomes, performance, gaps, and opportunities for improvement. 

By undertaking these crucial tasks, medical coding professionals help primary care providers optimize their revenue cycle and enhance patient care quality, thereby improving patient satisfaction by allowing providers to focus more on patient care and management, rather than billing and coding.  

Martha Tokos, MHI, CPC, CRC, CPMA, CCS-P, CDIP, CCDS-O, is executive vice president of coding and CDI  operations at risk adjustment and documentation improvement service provider Secondwave Delivery Systems in Las Vegas, NV.  

Sandra Hernandez, MSMIS, RHIA, CPHI, CCS, CHC, is assistant vice president of coding at United Musculoskeletal Partners in Atlanta, GA.