Community Health Centers and other safety-net providers are under increasing pressure. Shrinking Medicaid budgets, tighter compliance requirements, and the growing complexity of coding can make even routine billing a challenge. Many clinics are turning to AI coding tools to save time and improve consistency—but without careful oversight, these tools can introduce errors, misapplied codes, or compliance risks that put both revenue and patient care at stake.
That’s why it’s essential to understand not just whether your AI is fast, but whether it’s actually following official coding guidelines. From confirming up-to-date references to auditing complex scenarios, there are key steps every clinic should take to ensure AI supports accurate, compliant coding.
- Confirm Guideline Integration
Ensure the AI references current ICD-10-CM, CPT, HCPCS, and CMS rules. Outdated sources can lead to incorrect or noncompliant coding.
- Audit Regularly
Compare AI-assigned codes to those reviewed by certified coders. Audits reveal errors, omissions, and trends that need correction.
- Test Complex Scenarios
Edge cases—comorbidities, multiple procedures, or unusual presentations—are where mistakes happen. Make sure the AI handles these correctly.
- Verify Guideline Adherence
Check not just the code, but that it follows sequencing rules, specificity requirements, and correct modifiers. For example, is chronic disease properly sequenced for risk adjustment?
- Require Transparency
AI should explain why it chose each code, referencing guideline rules. Transparency builds trust and makes auditing easier.
- Maintain Human Oversight
AI is a tool, not a replacement for coders. Certified coders should review high-risk or complex encounters to ensure compliance and accuracy.
AI can streamline coding, but validation is critical. Ensure it uses current guidelines, passes audits, handles complex cases, provides transparency, and works alongside human expertise.
At BCA, we help healthcare organizations evaluate and optimize AI coding tools. Through audits, education, and consulting, we ensure your AI supports accurate, compliant coding—protecting revenue, quality reporting, and patient care.