In today’s value-based digital healthcare ecosystem, top-quality coding and auditing capabilities are key to a successful revenue cycle management framework. This is especially significant considering the shift in care volumes. Recent studies have shown that 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 rigours 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. In fact, when building dedicated departments, their integration often poses several challenges instead.
Besides adequate resources, healthcare providers need a clear understanding of the hurdles in the way and the levers that can help overcome the challenges and achieve their goals.
The Hurdles: What’s Hurting Coding and Auditing?
Coding and auditing are two inextricable halves of a continuous process in a value-based healthcare system. So, when it comes to building the best possible coding and auditing frameworks, it is important to simultaneously consider challenges pertaining to both.
In a digital healthcare ecosystem, medical coders form the bridge between health systems and payers. However, the transition to ICD-10 and its more comprehensive code sets has introduced a layer of complexity to the process and increased the demand for experienced medical coders as a result.
Additionally, with constantly evolving reimbursement models and coding guidelines, the risk of inaccurate or outdated medical codes increases. This, in turn, can lead to severe risks and penalties that hospitals simply cannot afford. Similarly, the lack of insights – stemming from insufficient information in electronic health records and incomplete documentation of medical histories is another major hurdle when creating a comprehensive coding workflow. Finally, the lack of coding uniformity across organizational processes and a diverse set of variables in medical procedures/situations further contribute to a faltering coding framework.
At the other end of the spectrum, the auditing process suffers from a transparency problem. As a result, auditors often fall into the insufficient data trap and miss out on identifying potential revenue leaks. Additionally, audits can sometimes creep beyond their scope – venturing into areas that are not relevant – which in turn costs time and money.
Audits are also known to often be limited to censuring and collecting reimbursements, rather than defining actual remedial action. While reclaiming lost revenue is vital, a strong audit system must focus on picking up on errors to improve medical coding accuracy and overall patient care.
People, Process, Technology – The EZDI Approach to a Better Department
For a high-level coding and auditing department to function, the right tools are needed for the job. This involves leveraging actionable reporting capabilities to simplify the coding process and provide the necessary visibility to improve coder performances. It is also important to create a transparent database of services being utilized.
This is where EZDI’s NLP-powered Computer-Assisted Coding (CAC) software can help. By tracking coder performance in real-time, the solution provides accurate productivity metrics. Its comprehensive documentation capabilities effectively capture which codes are being used by coders, physicians, and facilities and subsequently identify segments of the patient population that are being served.
For auditors, this means a complete audit trail with pinpoint data insights. The EZDI easy-to-audit module offers intelligent worklists that are automatically queued and tracked. Moreover, predictive audit suggestions based on pre-established rules and actionable reporting to track accuracy rates across departments in real-time contribute to a holistic audit practice that perfectly complements the coding team to enable a high-performance department.
With these systems in place, hospitals can establish an effective feedback loop: auditors can use the comprehensive insights gathered through the CAC solution to provide focused feedback into accurately identified coding practices and areas that need improvement. This feedback can then be implemented by coders and logged into the system for reference, thus improving overall departmental quality by a significant margin.
By leveraging AI and ML integration, EZDI’s automation solutions ensure better, faster, and cheaper revenue cycle management and accuracy 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
EZDI’s CAC and Audit software are indispensable tools for organizations that want to ensure their coding and auditing departments are well equipped to not only overcome hurdles, but achieve their goals at the highest levels possible.