Healthcare · Revenue cycle

The scrubber missed it. The system didn't.

Your coders still own the judgment calls. The system handles the prep, the rules, and the loop that gets sharper every denial.

Stage 01 Encounter received

An encounter closes in your EHR.

Pulled from your EHR or practice management system the moment the visit is closed out. Nothing waits in a batch queue.

EHR / Practice management
Live
  • 22 min ago Encounter #ENC-2832 Office visit, established Coded
  • 11 min ago Encounter #ENC-2839 Procedure, in-office Coded
  • just now Encounter #ENC-2841 Office visit, new patient New
Detected on encounter close Moving to documentation parse →
Stage 02 Documentation parsed

Clinical notes become structured data.

Chief complaint, history, exam findings, assessment, plan, procedures performed. Extracted into a clean shape the coding step can reason against.

encounter_ENC-2841_note.pdf 94 KB

Encounter #ENC-2841

[Provider] · New patient, 45 min

Chief complaint

Right knee pain, 6 weeks, worse with stairs.

Exam

Mild effusion, tender medial joint line, ROM limited.

Assessment & plan

Suspected medial meniscus injury. In-office joint injection performed. Imaging ordered.

parsed #ENC-2841 1.8s 
{
  "visit_type": "office_new_patient",
  "duration_min": 45,
  "chief_complaint": "knee_pain_chronic",
  "exam_findings": ["effusion", "joint_line_tenderness"],
  "procedures": ["intra_articular_injection"],
  "orders": ["mri_knee"],
  "complexity": "moderate",
  "model": "sonnet"
}
Stage 03 Codes assigned

CPT and ICD codes assigned with reasoning.

This is the real judgment step. Codes are chosen from documentation, each one tied to the line in the note that supports it, with a confidence score. Run on the strongest model because miscoding is expensive.

Encounter #ENC-2841

Office visit, new patient · In-office procedure

97% Avg confidence
99204 · Office visit, new patient, moderate complexity
20610 · Arthrocentesis, major joint, in-office
M23.21 · Derangement of medial meniscus, right knee
Modifier 25 · Significant E/M same day as procedure
Every code linked to a line in the note. Reasoning logged.
Run on a strong reasoning model. Each code retains the supporting documentation reference for audit.
Stage 04 Scrubber checks

Payer-specific edits run before submission.

Rules captured from your billing team at kickoff. Each payer has its own quirks. Rules catch most things; the model only weighs in on the edge cases the rules don't resolve.

Patient eligibility on date of service

Active coverage confirmed with [Payer]

Clear

CPT and ICD pairing

M23.21 supports 20610 under [Payer] policy

Clear

Modifier 25 documentation

Separate E/M elements present in note, payer-specific rule satisfied

Clear

Prior authorization (MRI order)

[Payer] requires prior auth for outpatient MRI on this plan. Flag raised before submission.

Hold

Place of service code

POS 11 (office) matches encounter location

Clear
Stage 05 Coder sign-off · human review

A coder signs off on anything risky.

High-dollar claims, low-confidence codes, and any rule the scrubber couldn't resolve route to your coder before submission. Nothing gets blind auto-submitted. The full code-by-code reasoning is sitting in front of them.

Claim #CLM-4821 · awaiting coder review

Encounter #ENC-2841 · held by scrubber

Review
Reason held Prior auth missing
Estimated billed $684.00
Avg confidence 97%

Audit trail · every code, every decision

  • 99204 New patient, moderate complexity. Time and decision-making documented. 98%
  • 20610 Arthrocentesis, major joint. Procedure note references aspiration and injection. 96%
  • M23.21 Derangement of medial meniscus, right knee. Supported by exam and history. 95%
  • Mod 25 E/M is separately identifiable from same-day procedure per [Payer] policy. 97%
  • MRI order [Payer] requires prior auth on this plan. Submit blocked until coder confirms or auth obtained. Flag

What the coder does

  • Confirm or override each code with one click. Override notes are stored.
  • Resolve the prior auth flag (request auth, or detach the MRI order from this claim).
  • Release for submission, or send back for more documentation from the provider.
Stage 06 Submitted & tracked

Sent to the clearinghouse, tracked to adjudication.

Cleared claims submit straight from sign-off. Status pulls back from the clearinghouse on a schedule. Nothing sits unmonitored.

Clearinghouse status
Polling every 15 min
  • Claim #CLM-4814 [Payer A] · submitted 2h ago Paid · ERA posted Paid
  • Claim #CLM-4816 [Payer B] · submitted 6h ago Accepted by payer Accepted
  • Claim #CLM-4819 [Payer A] · submitted 18h ago In adjudication Tracking
  • Claim #CLM-4821 [Payer C] · released by coder Submitted just now Accepted
EDI 837 out, 277 / 835 back. ERAs auto-posted on receipt. Denials feed the loop →
Stage 07 Denial learning loop

Every denial makes the next claim cleaner.

Denial reasons from each payer are parsed and proposed as new scrubber rules. Your billing team reviews and accepts. The pre-submit gauntlet gets sharper every month. The longer it runs on your payer mix, the harder it is for a competitor to catch up.

Denials → new scrubber rules
Proposed this week
Denial received
Claim #CLM-4702 · [Payer C] CO-197: Precertification absent for advanced imaging on this plan tier. Seen 6 times in 30 days, same payer
Claim #CLM-4738 · [Payer B] CO-16: Diagnosis code does not support medical necessity for 96372 under this LCD. Seen 3 times in 30 days, same payer
Rule proposed for scrubber
Rule RC-218 · pending review If [Payer C] plan tier in (Gold, Platinum) and CPT in advanced-imaging set, require precert on file before submit. Awaiting billing team approval
Rule RC-219 · pending review If CPT 96372 and [Payer B], verify supporting Dx against LCD list. Hold if mismatch. Awaiting billing team approval
Rules never auto-apply. Your team approves each one. 14 rules added this quarter
Outcome Where it lands

Same coders. The backlog disappears.

Your coders stop typing and start reviewing. The system does the prep. Every denial that comes back tightens the rules that catch the next one.

3-5 days Under 24 hours Time to clean-claim submission
12-18 min 2-4 min Coder time per claim
78% 94% First-pass acceptance rate
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