Full-population claims testing, AI anomaly detection and coding compliance audits
Current month performance metrics and compliance indicators
Upload a claims dataset for full-population statistical and compliance analysis
Structured audit programmes across major coding categories
Evaluation and Management level accuracy audit — tests documentation support for the billed E&M level against CMS guidelines.
Surgical procedure coding audit — validates CPT selection, global periods, assistant surgeon billing and unbundling compliance.
ICD-10-CM/PCS diagnosis code accuracy audit — validates principal diagnosis selection, HCC coding and specificity compliance.
Diagnosis-Related Group validation for inpatient claims — validates DRG assignment, CC/MCC capture rates and MS-DRG optimization compliance.
| DRG | Description | Volume | CC/MCC Capture | Benchmark | Status |
|---|---|---|---|---|---|
| 470 | Major joint replacement or reattachment of lower extremity | 312 |
58%
|
72% | Below |
| 291 | Heart failure and shock w MCC | 187 |
81%
|
78% | On Target |
| 194 | Simple pneumonia and pleurisy w CC | 154 |
62%
|
68% | Below |
| 871 | Septicemia or severe sepsis w MV >96 hours | 98 |
91%
|
88% | On Target |
| 392 | Esophagitis, gastroenteritis and misc digestive disorders w MCC | 76 |
44%
|
61% | High Gap |
Ambulatory Payment Classification validation for outpatient claims — validates APC grouping, composite APCs and packaged services compliance.
Current month denial tracking by category with trend analysis
| Category | Count | Amount | Trend | Recommended Action |
|---|---|---|---|---|
| Prior Authorization | 124 | $284,320 | ↑ 12% | Review auth workflows |
| Coding / Billing Error | 89 | $156,780 | ↓ 8% | Coding education |
| Medical Necessity | 67 | $198,450 | → 0% | Clinical documentation improvement |
| Duplicate Claim | 23 | $42,100 | ↓ 15% | Claims scrubbing |
| Timely Filing | 18 | $31,200 | ↓ 22% | Submission workflow review |
| Total | 321 | $712,850 | — | — |