By Zack Higbie, CEO, Helix Advisory

As the healthcare revenue cycle continues to evolve, propelled by artificial intelligence (AI) and more specifically through large language models (LLMs) and natural language processing (NLP), coding professionals are faced with a challenge. To thrive in this AI-augmented world, coders need a skill stack that blends technical chops with Revenue Cycle Management (RCM) acumen.

Here’s the professional blueprint:

Step 1. AI and LLM Literacy:

– Learn the basics: How does an LLM tokenize a progress note? Why does a confidence score of 0.85 matter when suggesting I10 vs. I11.9?
– Get firsthand knowledge of tools like Python scripts to query APIs or Tableau to visualize denial trends—skills that bridge coding and data science.

Step 2. Data-Driven Decision Making:

– Master KPIs like case mix index (CMI), CC/MCC capture rates, and denial rates by DRG.
– Use AI outputs to spot trends—e.g., “Why are 20% of our CHF cases downcoding to DRG 292?”—and propose fixes like targeted CDI training.

Step 3. Tech Collaboration:

– Partner with IT to refine Robotic Process Automation (RPA) workflows—e.g., automating things like 835 remittance parsing to flag underpayments, auto-generation of appeal letters for items with high confidence scores or low value accounts through relevant documentation capture
– Work with clinicians to close documentation gaps AI can’t resolve (e.g., unspecified laterality in ortho cases).

Step 4. Regulatory Deep Dive:

– Stay ahead of CMS updates (e.g., yearly IPPS changes) and payer-specific quirks (e.g., crackdowns on modifier 25).
– Train AI tools to flag compliance risks—like unbundling errors—before they hit DRG validation or line-item desk audits.

The Bottom Line: Coders as Revenue Cycle Architects
AI and automation are not here to steal jobs; they are here to amplify coders’ impact. The future of RCM lies in symbiosis: AI manages the grunt work, while coders wield their expertise to safeguard compliance and maximize reimbursement.

Upskilling is not optional—it is the key to turning coders into strategic linchpins who do not just process claims but shape clinical and financial outcomes through better data.


About the author:
Zack Higbie is a 15-year veteran in healthcare finance, having led all facets of revenue cycle operations, managed care, IT, and analytics for service vendors, acute and ambulatory health systems, and consulting groups. He currently leverages that background as CEO of Helix Advisory, an RCM technology and services company addressing revenue-killing problems with AI-based solutions. To get in touch, please reach out to info@helixadv.com or https://helixadv.com/contact/.

 

 

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