Main image courtesy of Collaborative Imaging. 

If you’ve ever been to a doctor’s office, clinic, the ER, or outpatient facility, you have had medical billers and coders help process your insurance claim. These healthcare specialist play an important part of the patient journey, which is why we thought it would be helpful to learn how AI fits in with this process, so this article will cover:

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• What medical billing and coding are
• How AI can help streamline this process
• Whether or not medical billing and coding will be replaced by AI

AI scribes can assist clinicians during patient encounters by transcribing notes and creating accurate summaries of what transpires. But did you know they can also help automate the patient journey in a variety of ways—such as producing the medical codes that correspond with the provider’s diagnosis. But what do medical billing and coders do anyway?

What is medical billing and coding?

This is an essential part of all healthcare facilities

Although they work behind the scenes of healthcare facilities, medical billers and coders are essential members of the team. Coders and billers are two separate functions, but often healthcare clinics have the same person do both jobs, unless it’s a large hospital where they may be broken up into separate positions. These specialists work together to ensure that providers are paid properly for the services rendered to patients. It is crucial that these two positions record accurate codes and bill insurance companies and third parties (such as the government) correctly, as the financial health of the facility depends on it. 

• Medical coding. This position is responsible for reviewing the medical documentation produced from the patient encounter and translating it into universal billable codes, such as the CPT (current procedural terminology), ICD-10, and HCPCS. There are codes for diagnoses, prescriptions, tests, medical devices, etc.—anything that the clinician indicates on the note from the encounter. Once the codes have been accurately recorded in the system, they are then sent on to medical billers.

• Medical billing. These specialists take the codes and use them to bill insurance companies by submitting a claim. This means they must understand medical codes so that they can translate them into a billing claim so that the healthcare facility can receive reimbursement from the insurance company or government. They will post payments and send notice of the remaining balance after the claim is paid to the patient for payment. Medical billers must also follow up with companies and patients to ensure the providers are paid, and if not, must turn the outstanding bill over to collection agencies. 

Medical coders and billers need to be trained accordingly, which is why the best ones hold the title Certified Professional Coder or a Certified Professional Biller. The coursework, hands-on experience, and exams ensure that these specialists are trained to accurately code and bill medical documentation. 

This is a very detail-oriented process, and the codes must be accurate so that insurance and the patient pay the correct amount. These codes also become a part of the patient’s health record, which can have an impact on any future conditions or treatment plans. Claims can be denied by insurance companies if the wrong code is chosen, forcing medical billers to check the codes for accuracy and resubmit the claim, slowing down the payment process. 

The benefits of precise billing and coding

Ensuring that the right codes are used means that all parties are billed properly

Medical billing and coding is an important part of the healthcare industry, after all, it ensures that providers are paid what they deserve and allows them to properly budget. There are a lot of benefits to having a medical coder that can accurately turn medical documents and notes into codes for billing, and that keeps up with any changes and updates.

1. Proper reimbursements

When the codes are entered correctly, they are sent to the biller who will turn them into an insurance claim. When the insurance specialist sees that these codes accurately represent what diagnosis or treatment the patient needs, they will provide payment promptly. Quick payment for the provider’s services means that the healthcare practice’s money flow isn’t held up or interrupted. 

2. Reduced claim denials

Claim denials can happen if something is incorrectly coded, causing the insurance company to send it back to the healthcare facility. This not only creates more work for the medical biller, but it holds up payment to the facility. Insurance companies are less likely to deny a claim when it has been accurately coded.

3. Financial stability

Correct coding ensures payment, which gives a healthcare facility some financial stability. You do not want to be worried about payments getting processed, or held up in denials, since this can have a serious impact on the financial health of your practice. 

4. Patient protection

The codes are generated from the diagnoses, tests, and treatments noted by the provider, and all of that is on a patient's electronic health record. It’s essential that this information be accurate since it can have an impact on their future care.

5. Budget for the future

Good coding means that both the insurance company and patient are paying exactly what they owe, which means you are able to budget for the future with greater confidence. Your practice will have a better understanding of revenue flow, so you can make the best business decisions possible, such as whether or not to hire more staff or make a technology upgrade.

Unfortunately there are a lot of instances when the codes are incorrect, which can lead to some impacts on both the practice and the patient.

• Inaccurate codes can lead to delayed reimbursement, which puts a great financial strain on the healthcare facility. 
• Having to resubmit an insurance claim creates more administrative work, and it keeps staff from concentrating on other insurance claims. The claim’s codes will need to be rechecked, resubmitted, and then the biller will need to ensure proper follow up until the claim is approved.
• If the codes being used are denied by an insurance company because they were outdated, it can lead to issues of non-compliance, which may incur penalties or a fine. 

How AI can help medical billing and coding

There is definitely room for improvement in medical billing and coding

We know that AI has been making big strides in the healthcare field, especially when it comes to saving providers’ time, improving the accuracy of medical documentation, and streamlining the patient journey. Ambient AI scribes are assisting clinicians every day, and they’re taking the tedious clerical task of creating notes off their shoulders. But in addition to these accomplishments, AI can also assist with medical coding and billing, but how?

AI systems use advanced algorithms to process enormous amounts of information in order to generate accurate medical codes. It must engage in machine learning, which means it is exposed to a large amount of data for training purposes, so that it starts to understand patterns. Using past data allows it to learn how to detect these patterns, and determine how precise the codes actually are. This is why it’s essential that all kinds of medical codes are used, so the machine learns the likelihood of what code should be assigned where.

Once the AI has done this, it can make more accurate predictions, and continuously learn how to better choose the medical code for a particular procedure, treatment, or diagnosis. Using AI in this way has a few advantages:

• Process information faster. AI applications can process information much faster than a human. This is how it learns how to choose what code to place with what procedure/treatment in the first place—by processing large amounts of past data coding. Humans can only go through and accurately choose codes at a certain pace.

• The amount of data it can digest is larger. An AI system can cover a vast amount of claims in a certain period of time, assigning codes based on what it has learned from previous patterns.

• More accurate. Perhaps the biggest advantage that AI applications bring to medical coding and billing is that it can increase the accuracy of the codes. When codes are consistently more accurate, it leads to a decrease in the amount of claims that are denied, a better patient experience, and a more stable financial situation for the healthcare facility. 

Will medical billing and coding be replaced by AI?

AI is not going to completely replace humans from medical billing and coding. There are still some concerns when it comes to the accuracy of the codes that the AI chooses, the biggest in regards to bias. If the data that the machine learns on is biased, it could potentially lead to issues with the AI system producing incorrect codes based on the patterns it developed from the biased data. 

It’s also essential that the AI system is regularly updated with new data to learn from so it can get even better at detecting patterns. Updates to the software also ensure that changes to the medical codes themselves are always accounted for.

Just like clinicians must review their notes and medical documentation for accuracy after using an AI scribe, it is also essential to have a human medical coder and biller periodically review the codes that the AI is choosing for accuracy. Monitoring its progress ensures that the facility is not losing accuracy, and that the AI system is correctly choosing codes. This is important to keep in check especially for complex medical situations. AI cannot replace humans in this capacity, instead it can assist them by taking care of the daily tasks of coding, while a human is available to monitor and adapt the codes as necessary. 

Improving workflow and saving money

Another one of the big benefits of using AI for coding and billing is that it can streamline the workflow process. Without AI, coders need to manually enter each code required for a patient, and sometimes that may be across multiple files or systems. When the AI is tasked with putting codes in, a human doesn’t have to manually do it, and instead can focus on verifying the codes are correct, making the whole process much smoother. This is especially important when the amount of claims being filed seems to keep increasing, and coders and billers cannot afford to make inaccurate coding choices.

Humans working with an AI system is a great way to tackle large amounts of claims, and to ensure they are coded correctly. The healthcare system still requires humans to be at the center of the patient experience, and AI applications that can improve the medical billing and coding process are simply a great tool that can help healthcare workers excel at their job.

Can an AI system help with your medical billing and coding?

An AI application could improve the accuracy of a healthcare facility’s coding and billing process, just like an AI medical scribe allows clinicians to focus on their patients. If you’re ready to see what AI can do for you, contact Playback Health!