The AI2 SDK Solution
The Access Integrity Software Development Kit (AI2 SDK) provides automatic coding suggestions to medical practices with full assurance that they’ve used fully compliant coding. The AI2 SDK mitigates audit risk by coding based solely on what is truly noted in the documentation. While it can’t prevent a user from submitting an incorrect or noncompliant code, it will warn them against doing so, leaving risky decision making to the person doing the coding.
What does this mean to me?
Medical coding decisions rely on the way a provider documents the encounter and on the subjective analysis of the coding professional as they read the EHR. There is, in a sense, a game of “Telephone” that begins at the time of the encounter. The provider, who often documents encounters in the evening or during off hours, not immediately, so must rely on memory for documentation. Then the coder must interpret that documentation and translate them into a list of codes for submission to the insurance companies and Medicare or Medicaid.
The insurance industry will only pay precisely what the coding and supporting documentation warrants. In 2015 alone, the medical industry spent $4.55 trillion on insurance claims. Insurance companies must be extremely careful in how they reimburse claims. There are two major danger areas in payments to providers, claims and fraud.
First, Insurers review, and may deny claims, citing their reasons and give the practice an opportunity to resubmit the claim properly. Currently about 30% of claims are rejected on initial submission. The time delay due to resubmission and reimbursement has a significant impact on the cash flow of the provider’s organization and is an enormous drain on their resources. The Access Integrity Solution is shown to significantly reduce rejected claims because all codes are supported by the EHR Patient Encounter directly, this proves out the claims at the time of submission.
Second challenge is the identification of medical fraud. Many insurers don’t have the time or resources to identify medical fraud directly and instead depend on medical auditors to do it for them.
As a general rule, medical audits are executed by Recovery Audit Contractors (RACs), a program created through the Medical Modernization Act of 2003 to identify and recover improper medical payments. Claims suspected of fraud are collected and sent to one the RACs for review and action. The RACs are empowered to conduct an audit on demand using all of the records from a selected date range. Based on a sample of those, they extrapolate what the total fraud damages across the time period and fine the practice based on that.
The combination of delayed payments due to claim rejections and the threat of the RAC audit process can be devastating to a medical practice of any size.
What Is AI2 SDK and How Does it Work?
The AI2 SDK was designed for use within medical applications. It is a set of RESTful APIs that call out to robust ICD-10, CPT, HCPCS, ICD-9, and Evaluation & Management concept extractors to deliver pertinent coding suggestions to users based on the context of the medical record documentation. All of this is done in a kernel framework that allows application developers to utilize the power of the engine and expand their offerings.
How is the Access Integrity SDK implemented? Here are some sample use cases:
- The Access Integrity SDK integrates with the EHR at the patient encounter level of the software. This deep native integration assures that the user is coding with compliance for ICD-10, CPT, HCPCS, and E&M Codes.
- Medical Specialty integration allows specific practice type focus, g. radiology or oncology. One implementation uses a mobile-based app that presents the user with a representation of the human body. The user taps a body part and is then taken to a list of radiological tests. The user chooses the appropriate test and shown a list of possible modifiers, like the use of contrast in the test. The user selects the correct one and is automatically delivered ICD-10 and CPT codes that can be sent to the referring physician immediately.
- Many providers dictate their documentation, even during the patient encounter. With the AI2 SDK in the workflow, as the dictation by EHR section is done the codes are automatically attached. The provider can select the diagnosis without having to go outside the EHR. With this integration, efficient and accurate documentation and coding is completed during the patient encounter.
The Centers for Medicare & Medicaid Services (CMS) mandated that medical practices convert to digital systems so that medical encounters are stored electronically, and this gave rise to Electronic Health Record companies (EHRs). With those EHRs, Access Integrity can quickly, cleanly, and automatically capture the information, parse it, analyze it for context, and return code suggestions to speed the coding process.
While there are several applications that claim to streamline to coding process, Access Integrity is the only one that uses text analytics and semantic analysis to deliver coding suggestions. Using the semantic context of the medical record achieves coding compliance, and, in the case of an audit, that the selected codes are represented by words in the text of the documentation that support their selection. This is a significant step forward in coding accuracy and productivity. The final assignment of the suggested codes is still the responsibility of the coding staff, utilizing their training and their ability to understand the provider’s documentation. However, with Access Integrity, coders can process more records and the rates of correct coding are much higher due to the application of text analytics and semantic analysis.