Upcoding, AI, audits, ICD-11 all keeping medical coders up at night, according to HIM survey

By Brian Murphy

What’s keeping medical coders up at night? Besides a Halloween hangover of too many scary movies and candy?

Topping the list are upcoding pressures, artificial intelligence, audits, value-based care coding, and ICD-11 (yikes—scary).

Thanks to Becker’s Hospital Review for offering up this helpful summary of an Oct. 18 survey of HIM professionals from Black Book Research. Links to both below. To summarize:

• 90% of survey respondents identified upcoding as a major ethical dilemma, and no wonder. Hospital margins are under relentless pressure, and incentives are a powerful motivator. No one wants to be in the headlines of an OIG report, but it is distressing to see that so many feel pressured to code for increased reimbursement over clinical accuracy. 

• Nearly 2/3 of survey respondents (64%) are being kept awake by the industry’s shift to value-based care, i.e., providers reimbursed based on patient outcomes. My answer: Get an outpatient CDI program now. Hundreds of organizations have gotten on board. It should be thousands, but the latest survey numbers show that only 26% of hospitals possess an outpatient CDI program. The ROI is clear (Norwood does this, and well, BTW). In addition, some respondents “acknowledged accusations of manipulating risk scores to enhance reimbursements under value-based care programs. This practice continues to fuel concerns about the integrity of coding processes by 48% of respondents.”

• Nearly 80% of survey respondents are concerned with the impending shift to ICD-11. Queue the cries of “I’ll retire first!” I suspect the big issue here is that the vast size and structure of ICD-11 will apparently mark the end of coding manuals, a major concern for those who still prefer paper (looks at my book collection, and nods). 87% of respondents are concerned about ICD-11 readiness, and yet only 11% have begun any training. I can’t say I blame the latter, considering how many delays we saw with the implementation of ICD-10. ICD-11 was ready for use on Jan. 1, 2022, and is rumored for adoption in the U.S. sometime between 2025-2027. We’ll see.

• There is vast concern with the use of AI in medical coding. 94% of survey respondents raised concerns about the accuracy and nuance of AI-generated codes, and 97% believe critical human oversight may be lost. These overwhelming numbers confirm that autonomous coding is not ready for primetime, despite what you hear from some corners of the industry. Way too much nuance and gray especially around things like PDX selection and documentation context, not to mention copy/paste, AI hallucinations and the like.

• Finally, some 85% of respondents argue that discrepancies identified during coding audits, often leading to denials, stem from the complexity of the current system, raising concerns about the fairness of audits.

References

• Beckers, “What’s Keeping Medical Coders Up at Night”: https://www.beckershospitalreview.com/finance/whats-keeping-medical-coders-up-at-night.html 

• Newswire, “Medical Coding & HIM Industry Faces Mounting Challenges” (Black Book Research press release): https://www.newswire.com/news/medical-coding-him-industry-faces-mounting-challenges-according-to-22444692