Health Leaders Explore AI, Other Options to Spur Adoption of Single Path Coding

Like most health systems nationwide, MaineHealth found itself faced with a shortage of medical coders. That’s when healthcare leaders began to ask this question: Why do two different coders (one inpatient and one outpatient) need to review and code the same operative report?

In the spirit of streamlining efficiency and reducing redundancies, MaineHealth started to explore the idea of single path coding in which the same medical coder would submit all necessary codes for a single encounter on both the CMS-1500 and UB-04 claims.

“Our [emergency room] coders already code hospital and professional services, but we started looking at how we could develop this single path model in the ambulatory surgical area because coders who could code ambulatory surgery cases are difficult to find,” says Wendy Piker, RHIA, CCS, CPC, CRC, director of coding at MaineHealth, a nonprofit integrated health system serving 1.1 million residents in Maine and New Hampshire. “While there are some differences in the coding, there are also a lot of similarities. If the same coder coded the hospital and physician surgical services, it would help us gain efficiency within our coding department.”

“In the long term, our goal with single path is to reduce staffing through attrition and also gain compliance with our coding,” she adds. “We want to make sure the professional CPT [Current Procedural Terminology] code that goes out on the CMS-1500 form matches the CPT code on the UB form for many of our surgical cases.”

Understanding Current and Future States of Single Path Coding

Single path coding tends to work best with ambulatory surgery and observation cases because CPT coders don’t need to learn ICD-10-PCS, says Vanessa Youmans, MA, CCS, CPC, chief operating officer at YES HIM Consulting in Largo, FL. Training inpatient coders to learn all CPT coding (or training CPT coders to learn all of ICD-10-PCS) isn’t beneficial or cost-effective for most organizations, she adds. Neither is hiring coders with deep knowledge of inpatient and outpatient coding who are often impossible to find.

However, as artificial intelligence (AI)-driven solutions continue to evolve, Youmans says healthcare organizations may not be as pigeonholed when it comes to single path coding. For example, if technology companies could crosswalk procedural coding system (PCS) codes to CPT codes, that could help offset the deep knowledge that’s required of both coding systems.

“But we’re not there yet,” she says. “I’ve been sitting in a lot of calls with clients talking to AI vendors, many of which are doing great things with diagnosis and CPT codes, but for some reason, PCS seems to be much harder to automate.”

AI tools may be a necessary step toward more widespread adoption of single path coding, says Gail Smith, MA, RHIA, CCS-P, owner of Gail I. Smith Consulting, LLC in Estero, FL. “If we had tools that could decipher all of the billing idiosyncrasies and integrate coding guidelines, then it might open up a world of possibilities.”

Youmans agrees, adding that AI may be able to eventually help organizations operationalize single path coding more easily by automating the application of inpatient- and professional-specific coding rules (e.g., reportable diagnoses, separately reportable procedures, and modifiers) and the addition of facility chargemaster-driven healthcare common procedure coding system codes (HCPCS) and CPT codes on professional claims.

For now, in the absence of automation, Smith says one approach is to narrow the scope so single path coders only focus on the organization’s top 10 outpatient procedures. This would make it easier for coders to develop deep subject matter expertise of billing rules and nuances for hospital outpatient and professional services.

Another approach is to focus on ambulatory surgery cases but with a specialty-specific focus. That’s what MaineHealth is doing.

“Right now, all our ambulatory surgery coders are training on hospital and physician coding, but they’re not learning all of CPT,” says Piker. “Three separate coding teams each learn five specialties. This allows them to become experts in the surgical cases they code, and it makes them more efficient overall.”

Smith is a proponent of coder specialization because she says it will help organizations as they implement AI solutions. That’s true regardless of whether they ultimately move to a single path coding model. “AI is a tool that needs to be in the hands of people with deep subject matter expertise,” she adds.

Overcoming Technology Barriers

At MaineHealth, it will be at least a few years before single path coding is live. That’s because the health system must first be able to unite the inpatient and outpatient coding functions within their electronic health record (EHR).

“In our [EHR], it’s almost like coding out of two separate systems. A lot of other [EHRs] are like this, too,” Piker says. “The hospital side for coding is different than the physician side with different encoder software.”

To unite the hospital and professional coding workflows, MaineHealth is implementing computer-assisted coding (CAC) first in its inpatient setting and then in its ambulatory surgery center. CAC will pull up the hospital and physician encounters, suggest codes for validation, and then drop those codes back into the appropriate places in the EHR for billing.

The University of Pennsylvania Health System in Philadelphia is taking a similar approach. “We are transitioning to single path coding in conjunction with our implementation of CAC that will help facilitate the single path process,” says Tami Montroy, MS, RHIA, CCS, director of central fee abstraction for the health system.

The health system currently uses single path coding for its emergency department cases but is expanding the program to include cardiology procedures and same-day surgeries. “Single path coding can be a very positive process for health information departments, if it’s done properly and in the appropriate areas,” Montroy says.

Experts agree there are many questions to consider as healthcare organizations consider single path coding.

“I encourage facilities to really look into how much it will truly cost to implement single path coding before jumping into it,” says Youmans. “It’s not an easy thing to do.”

Lisa A. Eramo, MA, is a freelance healthcare writer based in Cranston, RI.