A transparent, deterministic walkthrough of how clinical documentation is ingested, parsed, cross-referenced against audit rules, and delivered to human reviewers.
Unstructured EHR physician notes, discharge summaries, nursing assessments, operative notes, and pre-bill diagnosis/procedure code lists are ingested via standard interfaces.
Specialized clinical language models extract anatomical terms, symptoms, acuity indicators, surgical maneuvers, diagnostic test results, and provider MDM statements.
Crucial semantic differentiation: classifies every clinical entity as active, historical, familial, uncertain rule-out, or explicitly negated.
Assigned billing codes (ICD-10-CM, CPT) are aligned against extracted clinical concepts to establish whether documentation evidence exists for every coded item.
Deterministic audit rules evaluate clinical coding guidelines, LCD/NCD coverage policies, NCCI bundling edits, and provider organization compliance standards.
For every flagged discrepancy, the engine anchors exact sentence spans in the EHR note, generating bidirectional proof links and statistical confidence metrics.
Encounters are placed on a multi-factor risk spectrum (Low, Moderate, High, Critical) based on evidence strength, rule severity, and potential denial impact.
High-risk findings are queued in the human reviewer interface. Certified medical coders inspect the highlighted evidence and choose to Accept, Dismiss, or Escalate.
All reviewer decisions are logged in an immutable cryptographic audit record. When all blocking findings are resolved, the encounter is marked Claim Ready.
Run an interactive simulation of the complete 9-stage pipeline using synthetic patient documentation.
Launch Simulation Demo