Spring 2024 Issue

HIM Challenges: Triaging Your Automation Needs in Five Steps
By Suhas Nair
For The Record
Vol. 36 No. 2 P. 26

HIM is rapidly going digital as advances in automation and artificial intelligence (AI) drive adoption and efficiencies up and costs down—making AI-powered and automated coding and documentation tools attractive options for closing the resource gaps created by ongoing staffing shortages and increasing patient and audit volumes.

However, the promise of a significant return on investment doesn’t negate the challenge confronting HIM managers tasked with determining how best to allocate their technology budgets for optimal impact on productivity, accuracy, and revenues.

Midcycle Pain Points
Falling at the midpoint of the revenue cycle, clinical documentation, coding, and auditing are important aspects of a high-performing revenue cycle. Errors, oversights, or delays at any step cause a ripple effect that can reduce or impede reimbursements and expose a health care organization to audits and, potentially, penalties for fraud and/or noncompliant billing.

To avoid these outcomes, HIM leaders must overcome several obstacles inhibiting accurate and comprehensive documentation and coding that are necessary for appropriate and timely reimbursement and to minimize the risk of denied or delayed claims. What’s more, a rapid escalation of third-party audit volumes has heightened the urgency around resolving these pain points, the most pressing of which include the following:

• An ongoing labor shortage. The American Medical Association reports a coder shortage of 30%, and the Bureau of Labor Statistics estimates an increase in medical coding jobs by 15% from 2014 to 2024. This exacerbation of the chronic labor shortage contributes to coding errors and backlogs, which in turn lead to an increase in accounts receivables, write-offs, denials, and over- and underpayments. Understaffed coding teams also frequently suffer from a lack of oversight, raising compliance risk and potentially leading to audits and financial penalties.

• Growing patient volumes. Patient volumes increased across the board in December 2023 compared with December 2022, according to Strata’s National Patient and Procedure Volume Tracker, with inpatient admissions reaching their highest monthly level over the three-year reporting period. Outpatient annual visits were also up, rising 14% in 2023 compared with the 2019 pre-COVID baseline. Higher patient volumes translate into higher documentation, coding, and billing volumes.

• Heightened compliance scrutiny. CMS shows no signs of backing down from its commitment to identifying and eliminating fraud, including an increased investment in automation tools to accelerate hospital reviews. By using automation to group complaints based on file types and hospital systems, CMS in 2023 increased the number of comprehensive reviews conducted from 30 to 40 per month to more than 200. Between January and April 2023, it issued more than 730 warning notices and 269 requests for corrective action plans and imposed civil money penalties on four hospitals
for noncompliance.

• Ongoing budget cuts. Hospital and health system operating margins are still razor thin and Fitch Ratings expects they will remain that way in 2024, predicting nonprofit hospitals in particular will trend below 3%. This will result in continued cost-cutting measures that are likely to affect HIM operations and technology budgets.

• Siloed technology. An uptick in mergers and acquisitions and new system implementations is contributing to the already serious issue of siloed HIM technology tools, which prevent documentation specialists and coders from collaborating on physician queries and quality improvement efforts. The situation is magnified when clinical documentation improvement (CDI) initiatives—and therefore workflow tools—fall under revenue cycle rather than HIM.

Five-Step HIM Technology Triage
AI and automation are often held out as one-stop solutions to combat these prevailing revenue cycle management and HIM headwinds. But availing HIM departments of these advanced workflow tools is not as simple as deploying whichever platform fits the budget. Nor is full automation feasible for many HIM teams.

To find the right fit, HIM technology decision-makers should apply a triage mentality to the selection process, assessing five areas to determine the solution or mix of solutions that best align with short- and long-term needs, budgets, capabilities, and resources.

1. Assess the Current State
What are the facility’s technology vital signs? Encoders and other basic coding technologies are ubiquitous among provider organizations, and computer-assisted coding (CAC) solutions are rapidly closing in. More health care organizations are also deploying computer-assisted professional coding (CAPC) tools to support outpatient coding. Even the latest entrant on the coding technology market—autonomous coding—is enjoying a rapid uptake, with 60% of health care organizations having adopted or planning to adopt the technology.

But not all existing CAC systems can easily expand to accommodate new AI-driven automation tools, nor do they necessarily play nicely with the less common CDI tools. In fact, many CDI tools are siloed from CAC solutions, whether because interfaces have not been built or because they are incompatible. Thus, when evaluating IT needs, HIM leadership needs to understand what tools already exist, their level of scalability, and if or how they can interface with other tools (eg, CAC, CAPC, CDI).

2. Review the Problem List
What’s the problem list? Just as with patient triage, knowing the problems technology can resolve will help inform technological investment decision-making. Are coding and CDI teams short-staffed and/or overwhelmed, causing backlogs that are impeding the revenue cycle? Are there revenue leakage or billing compliance issues that can be traced back to coding and documentation?

Look at time-to-bill and denial rates, under- and overcoding, case mix index, length-of-stay, and third-party audits, as well as process issues such as physician query response rates. This information can help determine where new technology—including integrated workflow tools to enable cross-department collaboration—can have the greatest impact.

3. Stabilize the Situation
What is needed immediately to stabilize the situation? Prioritize the problem list so that the most urgent issues are addressed first. Is the hospital hemorrhaging revenues because coding or documentation errors are preventing reimbursement at the highest appropriate level? Are coding backlogs affecting time-to-bill and therefore slowing the revenue cycle? Is lack of collaboration between coding and CDI teams forcing physicians to waste time dealing with duplicate queries? Is expanding the case mix index needed to generate new revenues? Once the most urgent problems are identified, a determination can be made about which tool(s) to prioritize to stabilize them.

4. Evaluate Internal Capabilities
Does your team have the bandwidth and proficiency to support the solution under consideration? Particularly with advanced technologies, more than budget allocations are required to acquire, implement, train on, and use new technology.

For example, a common misconception about autonomous coding—which leverages machine learning, natural language processing, clinical language understanding, computational linguistics, knowledge graphs, large language models, and advanced algorithms to analyze, interpret, and classify large volumes of patient data—is that it can code 100% of a facility’s cases without human coder intervention. The reality is that it’s limited to areas with a lot of repetition. It also does not automate the abstraction of additional parameters. As such, autonomous coding typically requires additional technology tools and vendors to fill the gaps as well as coding support tools like CAC, CDI, and encoders to manage the coding of low-confidence charts.

It’s important to understand the resources—aside from budgetary—required to support the solution and manage the multiple vendors needed to ensure the entire system works to achieve desired end goals. If those resources are not available and cannot be brought in, certain tools will be out of reach.

5. Call in Specialists if Needed
Based on the findings of the evaluation of internal capabilities, consider whether it would be beneficial to bring in an outsourcing partner to support coding and documentation teams before, during, and after implementation. Is help needed to eliminate existing backlogs or prevent new ones while internal teams are getting up to speed with new technologies? Is outside help needed to fill the autonomous coding gaps?

A Triage Approach to Success
Thanks to advances in automation and AI-powered tools, it’s now possible to deploy some degree of automation to nearly every aspect of HIM. But not every organization wants, needs, or can support every possible workflow tool.

When it comes to determining the best use of an HIM technology budget to achieve short- and long-term goals, engaging in a five-step triage approach to analyzing the HIM department’s current state, pain points, priorities, and resource needs sets the stage for immediate and future success.

— Suhas Nair is executive director of product management at AGS Health.

 

References
1. Casellas B. The future of RCM: our top 2024 prediction. Becker’s Hospital Review website. https://www.beckershospitalreview.com/strategy/the-future-of-rcm-our-top-2024-predictions.html. Published November 16, 2023.

2. Lubell J. Addressing another health care shortage: medical coders. American Medical Association website. https://www.ama-assn.org/about/leadership/addressing-another-health-care-shortage-medical-coders. Published April 19, 2023.

3. 3M. Navigating the coding shortage. https://multimedia.3m.com/mws/media/1440560O/nareceivablee-coder-shortage-infographic.pdf. Published 2017.

4. Strata Decision Technology. StrataSphere® ResearchReport: National Patient and Procedure Volume Tracker™. https://info.stratadecision.com/hubfs/Website/NPPVT/
NPPVT%202024_January_Final.pdf?__hstc=251652889.0e9105ad6ce949c3be1a854
b10c5e802.1709231175871.1709231175871.1709231175871.1&__hssc=251652889.
2.1709231175871&__hsfp=1652900091. Published December 31, 2023.

5. Hospital price transparency enforcement updates. Centers for Medicare & Medicaid Services website. https://www.cms.gov/newsroom/fact-sheets/hospital-price-transparency-enforcement-updates. Published April 26, 2023.

6. Key hospital and provider trends in 2024. Healthcare Dive website. https://www.healthcaredive.com/news/key-healthcare-hospital-provider-trends/703141/. Published January 10, 2024.

7. Why autonomous coding is having a moment in healthcare – exclusive survey report. AGS Health website. https://www.agshealth.com/reports/why-autonomous-coding-is-having-a-moment-in-healthcare-exclusive-survey-report/