Lions and Tigers and AI, Oh My – How Will AI Improve Coding and Billing in Your Practice

As Dorothy stepped onto the yellow brick road with Toto, realizing they weren’t in Kansas anymore, so are we as a people in the healthcare landscape, as we embrace Artificial Intelligence. Over the next few years, AI will be a major part of the healthcare landscape and a dynamic process of integration into the various sectors under the healthcare umbrella. Already, there are close to 150 million Americans enrolled in government programs such as Medicare, Medicaid, and the Child Health Insurance Program (CHiP). CMS alone houses one of the most vigorous data portfolios in the federal government. They store millions of patient and provider claims, beneficiary enrollments, and medical records. There has been almost $30 billion raised by various healthcare start-ups to promote AI over the last three years and a recent report by McKinsey & Company forecasts that generative AI will produce significant reductions in overall healthcare costs in the United States upwards of $150 billion annually by 2026. Overall projections point to AI’s contribution to the global economy market, which should come close to $16 Trillion by 2030.

We know that many practices and facilities struggle with the day-to-day of most administrative practices in healthcare due to outdated and inefficient EMRs and process flows. Recently, Chime-Cerner conducted a survey that reflected a disappointing 54 percent of referrals resulted in an appointment, which ended up costing close to $971,000 per physician annually.  Additionally, the same survey yielded roughly 40 percent of respondents stating referral issues cost an average of almost 10 percent of patient revenue annually. The overall impact of moving to an AI environment in healthcare is an overwhelming cost saving to providers, practices, facilities, payer spaces, and ultimately patients, with better health risk outcomes.

Coding and AI:

We know that accuracy in coding plays a vital role in healthcare and CMS requires a 95% accuracy rating in submitted claims. So, it is mission-critical to ensure that certified coders and any AI programs are monitored and audited regularly. The manual coding process is often littered with coding errors due to a lack of education, no understanding of variances in payer rules and/ or billing processes, and timely filing of claims for reimbursement. Often, claims are submitted with numerous errors which leads to incorrect billing codes and various compliance issues. When AI algorithms are present, coding accuracy for non-complex coding has shown marked improvements. An AI-driven system allows for analyzation medical records, the extrapolation of pertinent data, and the designation of correct billing codes with a high level of precision. The utilization of machine learning algorithms allows these systems to continuously learn and adapt to evolving coding standards, ensuring precision and reducing the risk of costly mistakes.

• Automated coding: AI algorithms can interpret medical records and assign CPT®, ICD10, HCPCS, MODIFIERS, and other billing codes.
• Pattern Recognition: AI can process and learn from variations in documentation and distinguish patterns to improve coding accuracy.
• Error Reduction: AI can significantly reduce human error in the day-to-day tasks of simple coding and mitigate the risk of erroneous billing codes, as well as reduce denial rates.
• Accuracy versus Errors: AI can improve coding accuracy to help reduce the chances of a payer audit for basic daily coding and allow for faster and more accurate reimbursement.

• Auditing: Coders can review the work of AI to ensure accuracy and compliance in areas that require subjectivity.
• Clinical documentation improvement (CDI): Coders help professionals improve their documentation. Good documentation helps AI improve its coding.

Billing and AI:

Billing is labor-intensive for the back office, involving claims processing, invoicing, and payment reconciliation. AI is greatly improving these processes and is paving the way for a streamlined and better billing process. When a healthcare entity implements automation of Billing tasks, they will see a dramatic reduction in manual processes, which will improve overall ROI. This enhances efficiency and mitigates errors and potential denials, thus avoiding delays in payer reimbursement and potential appeals.

The utilization of AI for both Coding and Billing allows a Billing company like us, ZENMED Solutions, to vastly improve a healthcare entity’s bottom line. We are experts in the implementation of AI and ZENMED Solutions has created an RCM Tool called BLISS – “Barometric Live Intuitive Solution(S).” BLISS is intuitive and is able in real time to Track, Categorize, Strategize, Correct & Learn (TCSCL) the specifics of any practice and help improve all aspects of Revenue Cycle Management (RCM). We specialize in automating back-office tasks in the healthcare industry. The Team at ZENMED Solutions Inc., also realizes that practices struggle with submitting Clean Claims, which speaks directly to practices Coding and Billing departments. Our Teams can assist with all these as needed.

Some of these processes BLISS can assist with include the following:

• Correct Procedure code(s)/CPT
• Correct Diagnosis code(s)/ CD 10CM /ICD 10PCS
• Correct HCPCS codes
• Correct Modifier(s)
• Keeping abreast of Payer Reimbursement policies and LCD/NCDs for CMS
• Date of denial/rejection if a denial is received, as the payer only allows a certain amount of time to appeal
• Description of Denial / Rejection Code(s)- coding error, patient registration error, precertification
• Remittance identification number
• Charge capture, a crucial step in the revenue cycle.
• Automating and tracking claims submissions

AI and Revenue Cycle Management 2025 and Beyond:

There are endless possibilities in this landscape and AI is advancing by leaps and bounds with a laser focus on renovating healthcare overall. With AI in practice and utilizing a tool like BLISS, the billing and coding processes, and RCM flow will allow for simpler and faster processes and routing of information. BLISS will study and process extensive volumes of data rapidly, extracting documentation that humans can miss. Deploying an AI program in coding and billing will allow certified coders to focus on more complex cases that require a human factor to resolve and leave the routine tasks to AI. As a certified coder, with a billing background, I am not concerned that humans in this industry will become obsolete but will be able to enhance their skills and focus better on guidance to providers and elevated areas within a healthcare setting. By embracing technology, it will allow me to use my core and critical thinking skills to focus on novel ways to improve my role in this ever-changing landscape.

With that, I say good luck on your journey along the yellow brick road!

“Knowledge is Power”

“The More You Know”

Artificial Intelligence at CMS: https://ai.cms.gov/

CMS AI Playbook: https://ai.cms.gov/assets/CMS_AI_Playbook.pdf

HHS Trustworthy AI Playbook: https://www.hhs.gov/sites/default/files/hhs-trustworthy-ai-playbook.pdf

National Artificial Intelligence Act of 2020: https://www.congress.gov/116/crpt/hrpt617/CRPT-116hrpt617.pdf #page=1210

ICD10 MONITOR – Revolutionizing Healthcare: How AI is Shaping the Future of Care in 2025: https://medlearnmedia41148.emlnk1.com/lt.php?x=3DZy~GE5IXKd6s39_NPLVORy3KIgut~ujhtlXHjGJXbLDXV5zEy.1OFr2HUmmN~vjeUwbHPHMnGb7pN7yK

How AI is Impacting Healthcare in 2024: https://futurehealthcaretoday.com/how-ai-is-impacting-healthcare-in-2024/

Revolutionizing Healthcare: The Transformative Power of AI: https://www.aapa.org/news-central/2024/05/revolutionizing-healthcare-the-transformative-power-of-ai/

Here’s a summary of the document:

The document discusses the transformative impact of artificial intelligence (AI) and automation on medical billing, emphasizing their role in reducing revenue leaks and enhancing efficiency for healthcare providers.

• Introduction to AI in Medical Billing: The document introduces the concept of AI and automation in medical billing, highlighting their potential to reduce manual errors, speed up claim processing, and increase revenue retention.12
• Current Industry Trends: It discusses the growing adoption of AI in healthcare billing and the role of automation tools in preventing revenue leaks, supported by expert insights and industry trends.34
• Utility of Automation: The document provides an overview of how automation reduces billing errors, enhances claim accuracy, and shortens payment cycles, thereby improving the overall billing process.56
• AI’s Role in Medical Coding: AI is transforming medical coding by making it easier and faster to process information, allowing coders to focus on complex cases and transition to more specialized roles.78
• New Roles for Coders: As AI handles routine coding tasks, medical coders can move into specialized roles such as auditing, clinical documentation improvement, education, and obtaining specialized certifications.910
• Enhancing Coding Accuracy: AI-powered systems improve coding accuracy by analyzing medical records, extracting relevant information, and assigning appropriate billing codes with high precision, reducing costly mistakes.1112
• Streamlining Billing Procedures: Intelligent automation powered by AI streamlines billing procedures by automating repetitive tasks, reducing manual effort, and accelerating the billing cycle, thus minimizing errors and delays in reimbursement.1314
• Optimizing Revenue Cycle Management: AI optimizes revenue cycle management by expediting claims processing, identifying errors before submission, and using predictive analytics to forecast payment trends, leading to improved financial outcomes.1516
• The Human-AI Collaboration: The document emphasizes the importance of human expertise in conjunction with AI, as human judgment, empathy, and critical thinking are essential for making complex decisions and maintaining a patient-centered approach.1718