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Re-envisioning the Role of Medical Coding in a Value-Driven Healthcare Landscape


While medical coding may not be at the forefront of innovation priorities for some healthcare systems, there is real opportunity for care delivery improvement and systemic cost savings. Instead of perceiving coding solely as a necessary mechanism for fee-for-service reimbursement, progressive healthcare leaders are viewing coding as a catalyst for advancement in population health, value-based care and research.

Diagnosis (ICD-10) and procedure (CPT) code sets offer substantive data insights to support the patient journey and experience. Clearly, tracking patients’ activities over time is an imperative for clinical decision-making, and clinically specific codes can be an accurate and efficient tool for care providers to summarize relevant and critical information in each patient’s chart.

Codes as numeric signals offer a wealth of information that can enable predictive insights into future health incidents, while satisfying reimbursement requirements with higher quality and reliability.

For progressive health systems that want to leverage tech to improve population health, there are two realizations that are important to consider.

First, health systems must reimagine the benefits of coding and its potential to extract the complexities of patient experiences, enable proactive care and support predictive outcomes.

Secondly, health systems should embrace technology-driven strategies that extend beyond the basics of coding for medical necessity to improve clinical specificity, which can be thought of as a higher order of clinical detail to make better connections for patient care and diagnosis.

Artificial Intelligence as a Driver to Value-Driven Coding

Artificial intelligence (AI) is playing a pivotal role in helping realize the potential of coding in value-based care. AI coding tools offer intuitive workflows that identify gaps at the point of care and autonomously suggest codes from clinical notes within electronic health records (EHR), thereby reducing manual intervention.

These AI tools continuously enhance their accuracy by learning from past inputs and corrections, thereby streamlining chart pulls, optimizing the prior authorization process, reducing claims denials, and ensuring data comprehensiveness to advance value-based care.

AI-supported coding also significantly reduces burden on the healthcare system, especially with clinicians, enabling them to operate at the top of their license and provide more time to focus on patient engagement, quality, and more extensive patient care.

The Future of Coding for Value-Based Care

Leading medical authorities in the United States, like the American Medical Association (AMA), are highlighting coding as an integral factor to drive value-based care models.

In an AMA article, Dr. Ezequiel Silva, III, MD, stated that, “as payment models call for more risk sharing and accountability from physicians, the CPT code set takes on increased value of its own.” Coding provides foundational infrastructure to realize the vision and value offered by novel delivery models in healthcare.

Improvements in quality, outcomes and cost savings are unlocked with the information that ICD-10 and CPT codes hold.

Today, healthcare organizations are in a unique position to reimagine the role of coding to support critical initiatives like risk scoring for value-based contracts, patient recruitment for clinical research, and contributing data insights to advance public health initiatives.

© Andrey Popov - stock.adobe.com

© Andrey Popov - stock.adobe.com

As health technology continues to progress, provider organizations must reevaluate tech-based population health strategies and embrace AI-driven coding platforms that are evolving the landscape. These innovations offer new methods to glean more substantive clinical insights, improve healthcare delivery, and become a catalyst for long-term advancement for providers, patients, and the system at large.

Hamid Tabatabaie is president and CEO of CodaMetrix.

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