The American Hospital Association is challenging a Blue Cross Blue Shield Association analysis that estimated rising hospital coding intensity added $942 million in costs and linked the trend to AI-enabled billing tools.
The AHA argued in an Oct. 5 blog post that rising coding intensity reflects older, more complex patients, not improper billing. The organization said that the right way to judge whether a patient was coded correctly “is not whether reimbursement increased,” but whether the medical record supports the diagnosis.
What the Blue Cross report found
BCBSA’s September white paper analyzed Blue System inpatient claims from 2023 through 2025. It found that the share of inpatient cases billed as complex rose from about 37% to 40%, which BCBSA estimated added about $942 million in costs over two years.
The report linked the increase to secondary diagnoses such as anemia and low sodium, which it said can often be identified from a single lab result. In major bowel procedures, hospitals with the fastest coding growth classified 75.6% of cases as complex, compared with 65% at other hospitals. Those hospitals still had lower ICU use and lower transfusion rates.
BCBSA said the rise “coincides with hospitals adopting new AI-assisted billing software,” though the report did not measure AI use at individual hospitals.
The AHA’s response
The AHA said the BCBSA analysis does not review medical records, does not identify which claims involved AI tools, and does not account for changes in patient morbidity or the shift of lower-acuity care to outpatient settings.
The association also questioned how much coding intensity matters to premiums. A March 2026 BCBSA issue brief found per-member commercial inpatient costs rose about 9% among participating Blue plans from 2023 to 2024, and attributed about 20% of that increase, or about 1.8 percentage points, to coding intensity. Inpatient facility care makes up about 17% of employer-sponsored health spending, according to the Health Care Cost Institute. Using those figures, the AHA calculated that inpatient coding intensity added about 0.3 percentage points to total commercial spending growth. Employer premiums, by comparison, have been rising about 5% to 7% a year, according to the AHA.
The AHA added that BCBSA itself has named prescription drugs as a major driver of premium increases.
The post also pointed to diagnosis capture among Blue plans in Medicare Advantage:
- An HHS Office of Inspector General audit of Blue Cross and Blue Shield of Alabama’s Medicare Advantage contract found unsupported diagnoses in 247 of 271 sampled enrollee-years.
- The Justice Department alleged that Anthem, now Elevance Health, kept diagnoses in its Medicare Advantage payment submissions after its own chart reviews failed to support them.
“Accurate diagnosis capture is not a coding problem; it is a patient care imperative,” the AHA wrote.
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