Key Takeaway: Autonomous medical coding solutions are most often leveraged to improve medical coding quality and efficiency, but the technology's benefits for revenue integrity should not be overlooked. By ensuring consistent charge capture, boosting CPT and HCPCS coding accuracy, and simplifying compliance with payer policies, autonomous coding solutions like Nym’s engine enhance revenue integrity and ultimately improve financial performance for healthcare organizations.
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The Importance of Revenue Integrity in Healthcare Revenue Cycle Management
Enhancing Revenue Integrity with Autonomous Medical Coding
Ensures Consistent Charge Capture
Simplifies Compliance with Payer Policies
Final Thoughts: A Strategic Move for Financial and Operational Performance
Revenue integrity is a crucial component of healthcare revenue cycle management that ensures accurate, compliant, and optimized revenue generation from clinical services. At a high level, the core components of revenue integrity are as follows:
Audit and Monitoring: Conducts regular audits of charging and billing processes to help identify discrepancies and potential gaps in workflows, ensuring compliance and accurate revenue capture
Revenue Reconciliation: Uses data analytics to track key performance metrics, identify denials trends, and charge reconciliation
Policy Development: Establishes policies and procedures that guide billing, and clinical documentation practices to align with regulatory and payer requirements
Denial Prevention and Management: Proactively addresses issues that lead to denials by analyzing root causes and implementing corrective edits
Education and Training: Educates clinical departments on new guidelines, payer requirements, and documentation best practices
By successfully managing these components, revenue integrity teams directly improve the financial and operational performance of healthcare organizations.
Autonomous medical coding solutions, which fully automate the coding process, are most often leveraged to improve medical coding quality, increase efficiency, and reduce costs. While these benefits are essential, the impact of autonomous coding on revenue integrity should not be overlooked.
We spoke with Nym’s internal revenue cycle, coding, and integration experts, who put together an overview of three key ways that Nym’s autonomous medical coding engine enhances revenue integrity.
One of the most significant challenges in maintaining revenue integrity is ensuring consistent and accurate charge capture. Hard codes (e.g. Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes) are directly tied to the charges that healthcare providers bill to payers, and any missed or incorrect charge can lead to significant revenue loss or compliance issues. Traditionally, this process relies heavily on manual input and EMR automated processes, which is prone to errors such as missing charges or duplicating services.
Nym’s autonomous medical coding engine reduces these risks by deciphering the clinical documentation and capturing all charges. Orders not being mapped to a charge or system malfunctions such as a broken EMR button failing to drop a charge are concerns of the past. Additionally, the engine prevents excessive charges by coding purely based on clinical documentation —if it’s not documented, it’s not charged.
Revenue integrity depends not only on capturing charges but also on applying the correct codes. CPT and HCPCS codes are the backbone of healthcare billing, as they represent what services and/or procedures a facility or provider has provided to a patient. Additionally, they dictate how much a provider will be reimbursed for services rendered. Errors in assigning these hard codes can lead to claim rejections, delays in payment, or compliance issues that require time-consuming and costly corrections.
Nym’s autonomous medical coding engine enhances the accuracy of hard coding by ensuring that all CPT and HCPCS codes applied to charges are valid (e.g. outdated CPT codes would never be assigned by the engine). If a charge has an invalid CPT code associated with it, the engine identifies the discrepancy and sends back the valid CPT code. This automated validation process reduces the risk of rejected claims and minimizes the need for manual intervention to resolve charging discrepancies.
Navigating the complex world of payer policies and guidelines is a significant challenge for revenue integrity teams. Every payer has specific coding and documentation requirements that are not updated on any set schedule, and failure to comply with these guidelines can result in denied claims or delayed payments. In a traditional revenue cycle workflow, this necessitates back-end billing corrections, increasing administrative overhead and prolonging the payment cycles.
Nym’s autonomous medical coding engine offers a solution to this challenge. It is configured to align with specific payer guidelines, taking into account different payer policies around things like modifier application or covered procedures, for example. Additionally, Nym’s engine is quickly updated when new policies are enforced by managed care payers. This increases clean claim rates and reduces the lift for revenue integrity teams typically responsible for monitoring and adding charge rules and/or edits.
Autonomous medical coding solutions can have a profound impact on revenue integrity by ensuring consistent charge capture, boosting CPT and HCPCS coding quality, and simplifying compliance with payer guidelines. These benefits ultimately help healthcare organizations avoid costly errors, reduce revenue leakage, and improve financial performance, ensuring long-term revenue integrity in an ever-evolving healthcare landscape.
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