RPA use case in medical coding

 Erika Regulsky RCM, RPA
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Robotic process automation (RPA) enabled medical coding use cases

Medical coding is one of the complex processes in healthcare revenue cycle management. Being a post-registration process it defines whether the rendered services receive payment from the insurance companies. However, the major mistakes happen in the coding process resulting in 40% of all claim denials. Robotic process automation (RPA) for medical coding is an ICD10 data-driven process that assures the removal of any and all coding errors before the submission of claims. 

RPA-enabled medical coding is a technology specifically for hospitals and health systems that are looking to create a coding workflow to self-sustainability while providing a high degree of clinical coding accuracy and an audit-defensible module. This medical coding RPA bots use case is from a strong aspect of RCM operation-centered capabilities that the RPA bots can automatically perform chart analysis from EHRs, quality of clinical documents, and optimization of the overall medical coding process. The RPA bots improve productivity and efficiency through intuitive navigation of various applications and customizable coding audit capabilities. As a matter of fact, most of our RPA bots are programmed with the consultation of medical coders and the various styles of operation strategies used in medical coding departments in various healthcare organizations. Let’s discover the various use cases that RPA medical coding has to offer. 

RPA-enabled medical coding technology has access to almost all clinical coding data structures that enables its high quality and efficiency in recording and documenting  CPT, HCPCS, HEDIS, etc. Some of the data-oriented use cases are beneficial for healthcare organizations to restructure their coding departments. A few of the notable use cases are:

Federal and commercial coding guidelines

Some of the coding issues are due to not checking the federal and commercial health plans coding guidelines and manual human staff taking many hours figuring out the appropriate guidelines for coding a specific code. Robotic process automation (RPA) medical coding bots support ACA Commercial and Medicare Advantage plan guidelines. For Medicare, this includes both RxHCC for Part D and CMS-HCC for Part C. The RPA bots maintain the latest updates on guidelines from Medicare in the RAF scoring models, including complete ICD-9 and ICD-10 code data. RPA-enabled coding technology is designed with several capabilities like this to ensure proper guidelines are verified before applying the code to the claims.

Coding data analysis

Coding data analysis

Performing coding data analysis in the charts, surgical reports, and medical history records is important for a fully functional coding process. Coding staff is able to slowly analyze the coding data before they start coding for a particular date of service which takes 2+ hours depending upon the complexity of the rendered services in the present and past for the patient as insurance companies detect any pre-existing conditions, limitations and coverage determinations. Some of the robotic process automation (RPA) coding advantages include:

  1. The RPA bot’s robust pattern-driven optical character recognition (OCR) analyzes content from charts and medical records and suggests any documentation corrections are needed before entering the codes
  2. RPA bots are powered by a fully configurable 2-stage engine, an ICD10 engine that looks for all types of condition presences ranging from abbreviations to combinations, and a Natural language processing (NLP) engine as a second stage protocol paving way for better detection accuracy. Overall, the RPA bots use up to six different OCR engines depending upon the complexity of the coding in order to produce 60% fewer errors.

Scalability and interoperability

The burden of coding for multi-specialty healthcare organizations is complicated and coding staff that is capable of only coding for one particular specialty cannot adapt to a new specialty. They also need months of training and trial and error to get the coding process flowing again. When it comes to RPA-enabled coding it is scalable to any number of specialties as it already refers to the ICD10 database for coding. Your hospital or health system can implement it either for one particular coding process or for multiple depending upon the workflow. Robotic process automation (RPA) bots are also interoperable and can access multiple applications such as EHRs, EMRs, payer portals, NCCI edits, etc. The read and write function enables capturing data and writing it in the designated application of your choice coinciding with both scalability and interoperability.

Reducing operations time and expenses

Coding manually using certified medical coders is a time-consuming process, regardless of their expertise as human beings it takes a lot of time and effort to know the in and out of the specialty they’re coding for. Approximately it takes around 3-4 certified coding teams for a healthcare organization with a patient volume of 60 a week, if it is going to be inpatient coding it takes a lot more coding staff. This is very expensive and the healthcare organizations have to pay around $150k per month just for the coding department. On the other hand, implementing robotic process automation (RPA) for medical coding will drastically reduce time as referring multiple documents and guidelines to code can be done by the RPA bots within 5 mins enabling you to save more time and allowing your coding staff to concentrate on high-value tasks. The investment in RPA is one-time and the monthly maintenance and licensing costs are lesser over time resulting in a much faster ROI than coding staff. 

Medical coding is an important part of healthcare RCM. Neglecting it would cause improper payments, upcoming issues, external audits, etc. Hospitals and health systems looking to change their coding process for the better should consider adopting Robotic process automation (RPA) enabled medical coding technology. After reading our use case we understand more questions might arise concerning your current coding workflow and operations. BillingParadise and our team of RPA experts working along with 15+ years of certified medical coders have devised major RPA implementations for hospitals and clinical groups. As RPA is becoming more experimental to suit each and every practice’s needs we offer a free consultation to discuss and explore the areas of automating your RCM processes. The best time to know. More about RPA in healthcare RCM is now! Contact our RPA experts for a free consultation!

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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