Workflow — Inpatient & Outpatient Coding

CPT / ICD-10 / MS-DRG coding without the offshore floor.

H&P, operative report, discharge summary, progress notes, ED notes → principal diagnosis, secondary diagnoses, procedure codes, MS-DRG assignment, CDI provider-feedback queries. Coded encounter into the 837 claim file. Replaces AAPC / AHIMA-certified coder labor — ~50% of US hospital coding is offshored to India and the Philippines — at a fraction of the per-encounter cost.

Take the AI Assessment Get a Per-Encounter ROI Model

$3M–$8M

Annual coding spend at a typical 300-bed hospital

~50%

Of US hospital coding offshored

60–85%

Routine coding off the offshore line after AI cutover

What This Replaces

The Offshore Coding Floor on Every Encounter

The work the AAPC / AHIMA-certified coder does on every encounter — and the cost of leaving it there.

The labor

CPT / ICD-10 coding today moves through AAPC / AHIMA-certified coders — onshore at $25–$45 per hour fully loaded plus heavy offshoring to India and the Philippines at $9–$18 per hour at Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, AGS Health. A typical 300-bed hospital spends $3M–$8M per year on coding alone. Approximately 50% of US hospital coding is offshored — that line is the cell where AI workflows undercut the labor cost.

The cycle time

Standard coding cycle runs hours-to-days from encounter completion to coded claim, with longer cycles when the documentation requires CDI (Clinical Documentation Improvement) provider query — which itself runs days-to-weeks from query to physician response. Coding backlogs translate directly to AR (accounts receivable) days, and DNFB (discharged-not-final-billed) days are a CFO-watched metric. Every day in DNFB is a day the cash conversion cycle stretches.

The Workflow

Input · Analysis · Output

What goes into encounter coding, what we do to it, and what shows up in the billing system.

Input

Encounter documentation from the EHR

H&P (history & physical)
Operative report and procedure notes
Discharge summary
Progress notes and consult notes
ED notes and triage data
Pathology and radiology reports
Anesthesia records and OR records

Analysis

Code, sequence, MS-DRG

Principal diagnosis identification per UHDDS
Secondary diagnosis sequencing per coding guidelines
CPT / HCPCS procedure-code assignment
MS-DRG assignment for inpatient encounters
CDI provider-query identification for documentation gaps
NCCI edit and modifier appropriateness check
Confidence score per code; exceptions to certified-coder queue

Output

Coded encounter into the 837 file

837 claim file (institutional and professional)
Epic Resolute / Cerner Revenue Cycle / athena Collector
CDI feedback queue for providers
CDI metrics dashboard
Coded-encounter audit trail per encounter
Coding-quality QA sample feed
AR / DNFB-day tracking

Side by Side

CPT / ICD-10 Coding Today vs. With Last Rev

The numbers that matter: cycle time, per-encounter cost, accuracy, and CDI / DNFB impact.

Dimension	Offshore + Onshore Certified Coders	Last Rev CPT / ICD-10 Coding
Cycle time, encounter to coded claim	Hours-to-days at the coder desk	Minutes per encounter
Per-encounter unit cost	$9–$18/hr offshore, $25–$45/hr onshore translated per-encounter	Per-encounter, benchmarked at 25–45% of certified-coder unit cost
Coding consistency	Variable — coder judgment, drift across rotations	Same UHDDS / coding-guidelines logic applied identically per encounter
CDI provider-query identification	Coder catches gaps, manual query drafting	Per-encounter gap detection with provider-query draft
NCCI / modifier check	Manual NCCI lookup, drift on edge cases	NCCI edits applied per claim with the basis cited
EHR / billing integration	Encoder + manual data entry into Epic Resolute / Cerner / athena	Direct via documented Epic / Cerner / athena APIs
Audit log per code	Coder notes, no per-code lineage	Source documentation + UHDDS / coding-guideline citation + confidence per code

How It Works

From Encounter Documentation to Coded Claim

Five steps. Every one logged. Every one reversible if your confidence threshold isn't met.

Submission Lands

H&P, operative report, discharge summary, progress notes, ED notes, pathology and radiology reports, anesthesia and OR records from Epic, Cerner / Oracle Health, athenahealth — paired with admission / discharge / transfer (ADT) data and prior-encounter coding history.

Extraction & Classification

Principal diagnosis identification per UHDDS. Secondary diagnosis sequencing per AHA Coding Clinic guidelines. CPT / HCPCS procedure-code assignment. MS-DRG assignment for inpatient encounters. CDI provider-query identification for documentation gaps. NCCI edit and modifier-appropriateness check.

Validation Against Coding Bar

Findings validated against AHA Coding Clinic guidelines, AMA CPT Assistant, and the hospital's HIM / coding-quality playbook. Anything below your confidence threshold per code is routed to the AAPC / AHIMA-certified-coder review queue — final code assignment remains with the regulated entity.

Push to Billing System

Coded encounter into Epic Resolute, Cerner Revenue Cycle, or athenahealth Collector via the documented integration. 837 claim file (institutional or professional) generated. CDI feedback queue updated for provider follow-up. AR / DNFB-day tracking updated.

Audit Log Persisted

Every diagnosis identification, procedure-code assignment, MS-DRG decision, and CDI-query trigger logged with the source documentation, model version, prompt, and confidence score. Payer-audit-ready, OIG-ready, and yours.

Compliance & Defensibility

Built to Meet the Quality Bar Hospital Coding Already Runs On

AHA Coding Clinic and AMA CPT Assistant fidelity

AHA Coding Clinic ICD-10-CM/PCS guidelines and AMA CPT Assistant guidance applied per encounter. Per-version-year guidance preserved in the audit log. Updates to coding guidance flow into the validation engine within days of effective dates.

AAPC / AHIMA standards alignment

Coding follows AAPC and AHIMA standards-of-practice. We don't replace certified coders where the regulated workflow requires their sign-off; we accelerate the routine coding work and surface CDI / NCCI / modifier issues so the coder makes the call on a richer file.

Payer-audit defensibility

When payers post-payment audit (RAC, MAC, commercial-payer audits), the audit log produces what was coded, which UHDDS / Coding Clinic / NCCI rule applied, and what the source documentation basis was. Cleaner chain of custody than the offshore-coder reconstruction post-audit.

PHI / HIPAA / HITRUST posture

Encounter documentation contains PHI under HIPAA. Deployable in your VPC or our SOC 2 / HITRUST / HIPAA-aware environment. Encryption in transit and at rest; retention policies tied to your HIPAA recordkeeping rules and CMS billing-record requirements.

Common Questions

What Hospitals and Health Systems Ask About CPT / ICD-10 Coding

Those are the systems where coded encounters and 837 claim files live, plus computer-assisted coding (CAC) tools that augment certified-coder work. The competitor on this page is the certified-coder labor — typically AAPC / AHIMA-certified coders at $25–$45 per hour onshore plus offshore at Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, or AGS Health at $9–$18 per hour. We undercut that labor cost, integrate directly into your EHR / billing system, and deliver coded encounters with CDI / NCCI / modifier evidence.

Most hospitals and health systems keep the offshore arrangement in place during pilot and early production — we route exceptions, complex multi-comorbidity cases, and any encounter that genuinely requires senior-coder judgment to the team you already have. Volume to the offshore coding floor drops 60–85% on routine coding once cutover completes. Onshore certified coders shift to higher-leverage work like CDI specialty review, audit response, or coding-quality QA.

Our pilot success threshold is principal-diagnosis, secondary-diagnosis, procedure-code, and MS-DRG accuracy at parity with or above your incumbent coder process, measured on the same shadow-data sample of historical encounters. Anything below your defined confidence threshold per code is routed to the AAPC / AHIMA-certified-coder review queue — your call which queue, ours or yours.

CDI provider-query identification surfaces documentation gaps with the missing element cited. Query drafts are generated for the coder review and physician response. Per-encounter gap detection at coding time means CDI feedback flows back to providers continuously rather than in retrospective batches — DNFB days drop and case-mix-index optimization improves.

MS-DRG assignment runs against the CMS MS-DRG grouper rules for the encounter year. Per-DRG documentation requirements (e.g., MCC vs CC requirements) are checked during coding so DRG-validation findings surface at coding time rather than post-payment. The audit log records the MS-DRG basis cited per encounter.

Yes — through the documented integration surface each platform supports. Epic via App Orchard / FHIR APIs; Cerner / Oracle Health via FHIR APIs; athenahealth via REST APIs; 3M / Optum / Solventum encoders via documented integration patterns where available. Your IT, clinical, and HIM teams review and approve service accounts. We do not require platform-side custom development.

Coding pilots typically run 6–8 weeks: 1–2 weeks of integration and per-service-line / per-payer rule mapping with the HIM / coding team, 4 weeks of shadow-mode running on real encounters with no billing-system writes, 1–2 weeks of supervised cutover on a constrained scope (one service line, one campus). Production rollout is staged after the pilot meets your accuracy and HIM-management sign-off.

We benchmark against your current per-encounter fully-loaded cost — typically derived from $9–$18 per hour offshore or $25–$45 per hour onshore certified-coder rates translated into per-encounter economics. Our target is 25–45% of that per-encounter cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs (DNFB days), not hourly billable rates.

Two Ways to Start

Take the AI assessment for a structured read on CPT / ICD-10 coding feasibility. Or talk to us if you already know coding is your largest revenue-cycle line item.

Self-serve · 8 minutes

Take the AI Assessment

A short structured assessment that maps your annual encounter volume, EHR / billing platform, and current coding arrangement to AI feasibility and ROI.

Talk to a specialist

Get a Per-Encounter ROI Model

Send us your annual encounter volume, your EHR / billing platform, and your current coding arrangement. We'll come back with a per-encounter unit-cost comparison and a 6–8 week pilot plan in 5 business days.

Other Workflows

More Healthcare Admin Workflows We Replace

The same approach, applied to the other document-heavy labor lines on your healthcare-admin budget.

Charge Capture & Reconciliation

Charge tickets, EMR docs, supply utilization → undocumented / late / missed charges identified.

HCC Coding Review

Progress notes, discharge summaries → HCC capture per MEAT criteria. Submission to CMS RAPS/EDS.

Clinical Denial Appeal

Denial letters and medical records → payer-policy-cited appeal letters with evidence chronology.

Prior Authorization

Physician orders + clinical notes → InterQual / MCG match, payer-portal submission, status tracking.