Main image courtesy of Prism Career Institute. 

When you visit any type of healthcare practitioner, there is a process of documenting your treatment plan, procedures, and any tests that the provider orders through medical coding. These codes are then used to bill insurance or other third parties so the provider is paid, but sometimes issues arise. In this article we’re going to delve deeper into: 

• What medical billing and coding are
• If AI can help with billing and coding
• The benefits of implementing AI billing and coding processes

AI is making its presence felt in a variety of industries, and healthcare is no different. Already there are all kinds of health professionals who take advantage of ambient medical scribes to transcribe patient encounters and create notes. Including AI in this manner not only saves time and money, but it reduces the chances of clinician burnout. So what if AI in billing and coding could do the same?

What are medical billing and coding?

Medical billing and coding are essential to the healthcare system

You’ll find medical billers and coders at all kinds of healthcare facilities, from large hospitals, to smaller private practices, and even at some insurance companies. Typically they are two separate jobs, but they are related and essential to ensure continuous cash flow for healthcare systems by getting providers paid on time.

• Medical coding. After each encounter with a patient, a doctor generates a note of the visit to summarize medical information, diagnoses, and treatment plans—and whether or not follow ups or additional tests need to be done. All of this needs to be coded into a standardized system such as the CPT, ICD-10, and HCPCS Level II. It’s essential that the correct codes are used because this will have an impact on billing both the insurance company and the patient.

• Medical billing. In order to ensure the provider is paid for their services, the codes that have been added to each of the patient’s services, treatments, and tests will be used by medical billers to create a claim. The claim is then sent to the insurance provider (or other party such as the government) for payment based on those codes. Medical billers are then responsible for keeping track of claims to ensure prompt payment. Whatever amount the insurance company does not pay is then the responsibility of the patient.

What are the benefits of accurate billing and coding?

Medical coding is a standardized way to ensure what providers do during a patient encounter is documented so they can receive payment. All of this rests on the correct use of medical codes, which is why medical coding and billing specialists have an important job. Accurate medical coding ensures:

• Healthcare facilities receive timely reimbursement. Clinicians of all kinds provide services for a fee, and need to be reimbursed for them as quickly as possible. Proper codes that accurately reflect what the clinician ordered and has laid out as a treatment plan for the patient ensures the insurance company and other parties approve the claim promptly. When this system operates smoothly, providers, their staff, and the facility’s bills are all paid on time, and the cash flow required to run a practice isn’t held up.

• Denials are limited. Denials not only delay payments to healthcare providers, but they cause extra administrative work for medical billing and coding specialists. Once the denial is received, it will either need to be adjusted or corrected and sent back again for approval. The billing specialist will need to follow up and track the claim to ensure it gets paid.

• Financial health of the facility. Healthcare practices need money to ensure they can run properly and provide the level of care their patients expect. When claims are coded properly there’s less of a chance that they’ll be denied, and payments can be posted on time. On time payments from insurance companies and patients ensures a smoothly running facility that is on stable financial footing.

• Proper budgeting. Accurate coding means prompt payments, which not only allows the healthcare facility to be in good financial standing, but it can help with budgeting for the future. Knowing your revenue sources are consistent and reliable gives facilities the confidence to potentially expand or make upgrades to their systems.

Issues with billing and coding 

It is crucial that the codes used for the services provided are accurate, so that insurance and other providers pay what they are required to. When codes are inaccurate or there is a mistake, it can lead to a denial of a claim, which can put financial strain on the healthcare facility. Medical codes are important because they are what the insurance company uses to determine how much they will pay, and what will be left to the patient.

Ideally this is a smooth process and providers get paid for the services provided, but unfortunately, claim denials and resubmissions are common enough to cause delays in payments. Not only does incorrect coding negatively influence the financial health of the healthcare facility, but it puts extra work on the billing team who will have to resubmit the claim and continue to track it and follow up until it is paid. 

Can AI do billing and coding?

Is there a way AI can help with billing and coding?

The process of going from patient encounter through coding, and onto billing can be slow, even when the codes are correct. And then you have the wait time from when the claim is sent by billing, to approval and payment by insurance, third parties, or the patient themselves. AI can definitely streamline this process, because it has the capability to use enormous amounts of data to learn how to more accurately code. Using natural language processing and machine learning, AI applications can be fed large amounts of digital documentation in order to “learn” the likelihood of what code goes with what procedure/treatment correctly. 

Over time the AI learns what is correct and what is not, as well as those items that are flagged for human follow up due to their complex nature. Recognizing these patterns, eventually AI learns what codes are accurate, what codes can be further optimized, and can make suggestions for those that need to be replaced. The more records it has access to, the more the AI can learn and improve, and it can offer substantial benefits to those healthcare facilities that start to use it for their coding and billing processes.

The benefits of including AI in medical billing and coding

• Revenue increases thanks to better code attribution. AI applications can learn constantly and can work non-stop to learn the patterns behind what medical codes are correct, and which can be improved upon or replaced entirely. When better codes are automatically generated after scanning a clinician’s note or the patient’s EHR, there is less of a chance the claim will be rejected and that the facility will get an on time payment. Revenue increases when claims contain accurate codes, and the entire process of coding, billing, and payment moves along smoothly.

• More accurate and complete claims. Because AI can process information faster and digest it, it creates more accurate codes than a human. When something is manually coded, there’s always room for human error or omission, but not with an AI application. Claims are no longer under-coded, or do not accurately reflect the severity of the code needed when an AI system has learned how to best correct such instances.

• Saves time and ensures less burnout. AI continuously learns, it learns to better assign codes to specific procedures and treatments. Human coders no longer need to go through the tedious process of coding everything in a chart or note, but instead can rely on AI to quickly do this. When AI augments human coders, they instead can be elevated to a supervisory role that looks at flagged or complex items that need a human’s discernment. 

• Easily integrated into EHR systems. Another bonus of using an AI application for billing and coding is that it’s easy to integrate into EHR systems. Having access to the medical documentation in the system allows AI to be proficient in all types of coding possibilities, so it can learn the patterns for successful codes as well as those that should be altered.

• Forms patterns for successful claims. On the billing side, AI can learn what types of claims and their codes tend to be successful, and what those are that are more likely to get denied. Learning these types of patterns can help billers submit more accurately coded claims that have the highest chance possible of acceptance. 

Challenges of AI billing and coding

There are numerous advantages of using AI for billing and coding, along with human supervision. These AI tools are meant to help billing and coding specialists so that they can ensure proper coding and increase the chances that the claims are approved and payment is received. However, there are some challenges to implementing an AI system that healthcare facilities should also be aware of. 

• Compliance. HIPAA compliance is essential, so the AI application will need to also be HIPAA compliant. While this shouldn’t be a problem with an AI system for medical billing and coding, if a practice is shopping around, it needs to ensure it meets this standard.

• Linking with other systems. Most healthcare facilities do not operate in a vacuum, and beyond the EHR system, they need to interact with other parties’ systems—notably those of an insurance carrier. In order to send and process claims efficiently, the AI in the healthcare facility will need to be able to link up and accept the data from outside systems. 

• Continuous training. In order to be the most accurate it can be, any AI application will need access to all types of medical documentation so that it can keep training. New data will need to be available, as well as the results of any audits or updates to medical coding standards. 

To sum up AI billing and coding 

There are some major benefits to implementing the help of an AI application in billing and coding for healthcare facilities large and small and in all types of fields. And while there may be a learning curve to start out, that will quickly be replaced with:

• Improved coding accuracy
• Reduced human error
• Decreased operating costs and increased revenue
• Claims approved more quickly
• Reliable flow of money

Will your practice engage AI billing and coding?

If you’re ready to get a better handle on medical billing and coding to reduce claims and ensure proper reimbursement, then it may be time to look into AI for help. Artificial intelligence has all kinds of benefits for healthcare facilities, from ambient medical scribes, to automating the patient journey, and even streamlining billing and coding, which is why more clinicians are signing up to take advantage of it!