UC-426
Risk Adjustment Coding Evidence Integrity
Reads submitted diagnosis codes back against the chart evidence, flags unsupported entries, and packs each case for a certified coder.
TBDBuild Duration
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The Challenge
Unsupported diagnosis codes get repaid with penalties while genuinely documented conditions go unsubmitted. Charts, claims and submission files are reconciled by sampling a few hundred records a year.
How It Works
- Reads encounter charts, claims lines, submitted diagnosis files and the coding guidelines.
- Matches every submitted code to chart evidence and scores support strength and gaps.
- Puts the ranked delete and query list to the certified coder before the window closes.
What It Removes
- Sampling audits that never touch most of the file
- Manual chart reads to confirm one diagnosis code
- Rebuilding submission deletions by hand each cycle
Input Data RequirementsEncounter charts and progress notes, claims and encounter data, submitted diagnosis files, coding guidelines, prior audit findings
Output FormatPer-code support register with chart citations, ranked delete and query list, provider education report, audit defence pack per submission window
“We audit a sample and hope the rest looks like it, and the rest never looks like it”