How AI and machine learning can streamline surgical documentation and streamline reimbursement

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Medical coding requirements have grown increasingly complex. As a result, specific words can have both significant legal and financial ramifications. By using artificial intelligence and machine-learning technologies, ASCs can improve their postoperative documentation.

During a recent session in The Business & Operations of ASCs conference hosted by Becker's ASC Review,  Lucian Newman III, MD, chief medical information officer of Nuance Communications, and Tanya Fengel, MSN, RN, manager of compliance and education of the Center for Health ASC, discussed current documentation challenges for ASCs and how AI and machine learning can help ensure standardized language, completeness and accuracy, more accurate reimbursement and greater efficiency.

Four key insights: 

1. ASCs face constrained cash flow, resource limitations, and burnout challenges, with poor documentation threatening revenue loss. "Obviously, cash flow and budget, resource constraints and burnout all impact how your center runs," Dr. Newman said. "In addition, we hear the same old thing about documentation: If it's not written, it's not done. That may sound unfair, but it's just the truth we live in." Missing notes can delay billing; EHR systems lack appropriate prompts, and poor CPT coding and transcriptions result in delays, higher costs, and incomplete documentation. All of this results in a potential 2 percent net surgical revenue risk for ASCs

2. Nuance's AI/machine learning solution has a template design that aligns surgeons to discrete fields while still providing room for personalization. "When you commit to discrete fields, they can be measured, monitored and improved," Dr. Newman said. "The system 'learns' particular styles and wording, so surgeons all get a more personalized approach, which they appreciate." Notes take about a minute to complete, resulting in a complete and accurate document that can be immediately sent to medical records for coding.

3. Streamlining communication between surgeons and coders means greater accuracy and reimbursement. Surgeons tend to dictate notes in a freeform way, not necessarily using the key words that coders are looking for. "This point-of-care tool allows surgeons to use the language that their coding professionals need," Dr. Newman said. For example, the precise word choices used to describe an excision of a pilonidal cyst can make a big difference. Using the word "simple" has an ambulatory payment classification of $482 and a relative value unit of 2.66 while using the word "complicated" boosts the APC to $948 and the RVU to 7.35. "Doctors and surgeons are not coders, they're just doing their jobs," he added.

4. AI/machine learning point-of-care tools benefit both physicians and ASCs. According to Ms. Fengel, the Center for Health ASC has decreased the amount of time surgeons spend on their notes, speeding up billing and making information easily accessible for next-day post-op visits. "It's been a big satisfier on the physician side," she said. "On the center side, we save anywhere from $1,100 to $1,500 a month on transcription costs. In addition, one of our business professionals estimates that she saves 60 to 70 percent of her time because she no longer needs to follow up on transcriptions that needed fixing. She has been able to redirect more than half of her job to other areas. It really helps both the surgeon and the surgery center."

Nuance's AI/machine learning point-of-care solution makes it easier than ever for ASC surgeons to use the right words to standardize and streamline their post-op notes, creating a more reliable and accurate legal document while maximizing their reimbursement.


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