By Nancy Hirschl, BS, CCS, AHIMA-Approved ICD-10 Trainer
Vice President, HIM Services, Streamline Health, Inc.
For healthcare providers, limiting regulatory and financial risk associated with coding and billing is a core component of organizational compliance. Risks to the mid-revenue cycle can appear in the forms of undercoding, where appropriate revenue is not captured and money is “left on the table” or overcoding, where revenue is inappropriately determined and the provider is overpaid. Both of these risks may arise from incorrect coding and/or insufficient physician documentation. Because reimbursement is based on coded data and the associated documentation, even the best coders may struggle to achieve and maintain 100% accuracy. Keep reading to learn why human error is inevitable in the revenue mid-cycle and how a new type of technology can significantly reduce this risk:
Although technology seems to dominate the health care industry, the billing cycle remains a very human-centric endeavor. The possibility for error enters the equation right from the beginning—when the physician documents the patient’s condition and treatment plan. When the coder reviews this information, the possibility for error increases again. An inexperienced coder may undercode or overcode the case if they’re unsure of how to best proceed. Given the complex interdependencies inherent in coding, even experienced coders aren’t immune to making mistakes.
“Undercoding can leave money on the table.”
Many organizations already use automated coding software to help coders perform better and lower risk. Yet these aren’t perfect systems and problems may still arise. Natural language input—the data from the physician—can be misinterpreted. Likewise, a coder who has been burned too many times by computer-assisted coding errors may simply ignore future suggestions from the program, offsetting any benefits it might offer.
In the end, this amounts to a juggling act for revenue cycle managers and compliance officers. How much risk can they afford to take? How much money can they afford to let slip through the cracks?
The solution: Auditing before billing
In many organizations, code audits happen long after the bills have gone out for payment. At that point, it can be difficult to recoup missed opportunities for revenue. Or, the organization might find itself dealing with Medicare-identified overpayment issues. Post-billing audits are most effective when they can be conducted frequently and thoroughly. Audits of random bills once a year are far from perfect. And while quarterly audits of every bill would be more effective, there’s still the issue of timeliness. No matter how frequently they are conducted, post-billing audits still have inherent risk—money from overcoded bills could have already been paid!
The only way to prevent that risk is to audit all coding before the bills go out. And that’s exactly what Streamline Health’s Looking Glass® eValuator™ solution does. As coders are working, Looking Glass eValuator acts as an Artificial Intelligence (AI) assistant, auditing 100% of coded charts before they can go through to billing. The tool informs the coder of possibility of coding error as well as the financial impact associated with that potential error. Looking Glass eValuator even provides helpful guidance and suggestions and reduces risk and reward across the organization and actually helps coders become more effective at their jobs.
Human effort will continue to be key to managing the revenue cycle, but with automated solutions like Looking Glass eValuator, those efforts will be better spent and the resulting risk will be minimized accordingly.