Compliance considerations for autonomous coding

Autonomous coding and artificial intelligence (AI) are quite the buzzwords these days, creating lots of excitement in the healthcare industry. This is the perfect timing to fill the coder shortage gap and can prove to be very beneficial when adopted compliantly. With all the chatter around ChatGPT and other models, it’s important to consider what compliance mechanisms are in place with your technology partners and within your internal organization. It’s safe to say that the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG) and commercial payers are also aware of the autonomous coding efforts and will be doing their due diligence to ensure there are no shifts in coding quality and reimbursement.

Where do we start with autonomous coding? Make sure you understand what processes your technology partner has in place to support compliant coding. AI can only take you so far in the world of coding, so it’s important to understand a little more about what’s under the hood. We know healthcare is ever-changing; including the regulations and guidelines that we must follow for billing. 

How does your technology partner handle coding regulation changes, what source of truth do they use for guidelines and engine behavior, and how are more risk adverse coding situations handled? Are National Correct Coding Initiative (NCCI) and the Outpatient Code Editor (OCE) edits addressed during the automation process? Can you control what your organization believes is higher risk, as this may change per organization? 

My advice is to get to know your technology partner subject matter experts to ensure that both parties are in lock step when it comes to coding compliance. It’s important that you have guardrails in place and can manage scenarios you don’t want to automate or things you want to do a second-level review on. Consider a quality review process for items that are being reviewed both in the vendor’s software and internally that are approved by your compliance department. As autonomous coding continues to grow, I expect payers to have a higher focus on this area, which may increase post payment claim audits or reviews.  

Compliance doesn’t have to be a scary word if you are prepared! Understand your technology and how to best navigate it. Incorporate targeted areas that are automated into your internal audit plan so you can build confidence and catch any concerning behavior early. Know your organization’s risks and mitigate those in your automation processes. Ensure you have a regular cadence for checking for regulatory changes to ensure there are no unexpected changes in your coding behavior. Remember, outliers tend to be a high focus point for payers, so knowing those as soon as possible will allow for a quicker plan of action if needed.   

Amanda Hudson is a business manager at Solventum.