Coding & Billing
Clinical, operational, and financial complexity where patient outcomes, revenue, and compliance all intersect.
Inside this journey
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Customer Discovery
Align on desired outcomes (revenue recovery, backlog reduction, accuracy), current coding volumes, stakeholder roles, and measurable success signals.
Discovery Questions
Start Here: Tell Us About Your World
- Roughly how many patient encounters does your organization code per year?
- Which role(s) currently own day-to-day coding operations and final code sign‑off?
- Which EHR and billing systems are primary in your coding and charge capture workflow?
- How is your coder team structured (FTE count, onsite vs remote, senior vs junior mix)? Please describe briefly.
- What are the top three operational priorities for coding/revenue cycle this year?
What's Keeping You Up at 2 AM?
- If you lost 20% of your senior coding capacity overnight, what single risk would surface first?
- How many charts are currently backlogged, and how is that backlog distributed by age?
- Which stages in your workflow most often slow coding (select up to three)?
- When backlog or delays occur, how does that effect your team’s morale and turnover?
- Tell us about a recent day when coding felt unmanageable — what happened and who had to cover?
Where Are You Losing Dollars Without Knowing?
- How confident are you that your current process captures all reimbursable diagnoses and procedures?
- Do you have an estimate of annual revenue leakage from undercoding, denials, or missed bundles?
- Which payer problems create the most financial pain today?
- When you find lost revenue or denied claims, what is the root cause most often identified?
- Describe a recent example where better coding accuracy would have changed the financial outcome—what was the impact?
How Far Are You From Confident Coding?
- If a payer audited a random sample of 500 charts today, do you expect material findings?
- What is your current internal/full-time audit or accuracy benchmark for coding (select closest)?
- Which error types appear most in audits or denials (choose up to three)?
- What tools or processes do you currently use to measure accuracy and trace root causes?
- How much trust do coding leaders and compliance believe they can place in automated code suggestions today?
Who Holds the Keys — People, Process, and Politics
- Who are the essential decision-makers and influencers for piloting new coding technology, and who could block it?
- What procurement, security, or contract constraints typically slow down pilots or integrations here?
- How long does it usually take from pilot approval to go‑live for a new revenue cycle tool?
- Who would be the day-to-day owner of a pilot (name/role), and who must we train to make it successful?
- Which stakeholder group will judge the pilot as a success first — finance, coding ops, compliance, or IT?
What Would Less Chaos Actually Look Like?
- Imagine your backlog is reduced by 80% and accuracy improved—what would that change in your daily operations and outcomes?
- Which three KPIs would you use to prove success for a pilot or rollout?
- What minimum improvement on those KPIs would you need to see before recommending expansion?
- Which coding domains would you prioritize in a pilot (select up to three)?
- What acceptance criteria or specific test cases should the pilot include to validate readiness for scale?
Barriers That Kill Pilots Before They Start
- When pilots have failed here before, what single issue killed momentum the fastest?
- What level of EHR or billing integration access can you provide for a realistic pilot (select closest)?
- How does your compliance/legal team prefer we handle PHI and audit trails during pilots?
- What cultural concerns do coders raise about automation, and how have you addressed them historically?
- If we could guarantee a clear audit trail and human-in-loop controls, would that materially change your openness?
Small Steps That Prove Big Value
- Would you consider a 4–8 week pilot that uses your real charts to project accuracy and days-in-AR impact?
- What sample size and chart types would you want included to make the pilot credible?
- Which pilot objective matters most to you initially (choose one)?
- Who would be the pilot's executive sponsor and the operational lead (name/role)?
- Realistically, what resources can you commit for a pilot (time, FTEs, data access) and when could you start?
- What would your team need to see in a pilot report to sign off on commercial expansion?
Final Check: Commitments, Concerns, and Next Steps
- After this conversation, what is the single most important question you need answered before moving forward?
- Which stakeholders should we include in the next meeting to accelerate decision-making?
- What timeline would you prefer for a pilot proposal and statement of work?
- Is there any historical context, recent audits, or vendor evaluations we should review before proposing a pilot?
- Would you like us to prepare a tailored pilot plan that includes suggested KPIs, sample selection, and a compliance checklist?
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Solution Experience
Validate how our AI-assisted coding delivers the targeted outcomes using the customer’s real chart examples, projected accuracy, and impact on days-in-AR and denial risk.
Experience Meetings
- Pre‑Work & Current State Confirmation
- Baseline Metrics & Consequence Workshop
- Live Chart Validation (Hands‑On Solution Experience)
- Impact Modeling, Acceptance Criteria & Pilot Scope
- Executive Validation & Go/No‑Go
- Have a clear decision path and timeline for moving from validation to a pilot engagement.
- One‑sentence Future State Reminder
- Demonstrate concrete, case‑level proofs that map directly to the customer's prioritized outcomes.
- Obtain explicit validation from customer SMEs that the AI results represent operationally meaningful improvement.
- Identify any exceptions, integration blockers, or documentation gaps that must be addressed to realize the benefits.
- Seller to deliver a case‑by‑case results packet showing suggestions, confidence, and mapped impact for the sample set.
- Customer coders to review and annotate any disputed cases and return feedback within the agreed timeframe.
- Technical owner to note any integration or workflow requirements observed during cases for the Impact Modeling meeting.
- Recap Validated Proof Points
- Agree on a quantifiable pilot model tied to validated proofs with explicit assumptions and sensitivity bounds.
- Define unambiguous acceptance criteria and scope that will be used to evaluate pilot success.
- Introductions & Purpose
- Seller to deliver the pilot statement of work with modeled projections and the acceptance criteria embedded.
- Customer to route pilot SOW for internal approvals and return feedback/approval date.
- Schedule pilot kickoff meeting with technical, coding, compliance, and project owners once SOW is approved.
- One‑slide Current State & Consequence
- Obtain an explicit executive go/no‑go decision and sponsorship for the pilot.
- Ensure executives understand the validated proofs and the measurable expected impact of the pilot.
- Agree on governance and reporting cadence for pilot oversight if approved.
- Customer executive to record and communicate the go/no‑go decision and name executive sponsor.
- Seller and Customer project leads to schedule pilot kickoff or iterate SOW based on executive feedback.
- Prepare a short 'what success looks like' dashboard template for pilot monitoring and share with governance stakeholders.
- Have a single, agreed one‑sentence statement of the current state and who is impacted.
- Confirm a secure list of de‑identified chart examples and baseline metrics to be used in the Solution Experience.
- Assign owners and deadlines for data delivery and any technical access required for pre‑runs.
- Customer to deliver specified set of de‑identified chart samples and baseline metric extracts by agreed date.
- Seller to provide data transfer instructions, data agreement template, and a pre‑run plan for the sample set.
- Assign single points of contact for clinical, coding ops, and IT for the Solution Experience.
- Recap Confirmed Current State
- Convert baseline metrics into explicit, quantified consequences that create urgency for change.
- Agree on and prioritize the specific operational outcomes the customer cares about for the Solution Experience.
- Define 2–3 measurable success signals that the upcoming validation must demonstrate.
- Seller to produce a short consequence model (spreadsheet) using the customer’s baseline metrics illustrating potential revenue, days‑in‑AR, and denial impact.
- Customer to validate and sign off on the baseline numbers and prioritized outcome list.
- Schedule the Live Chart Validation session and confirm which specific sample charts will be used as proofs.
- One‑sentence Current State
- Present Pilot Impact Model
- Live/Pre‑run Case Walkthroughs
- Present Baseline Metrics
- Proof Summary (Key Cases)
- Define Pilot Scope & Duration
- Translate Metrics to Consequences
- Comparison: AI vs Current Coded Result
- Pilot Recommendation & Expected ROI
- Data & Sample Chart Checklist
- Prioritize Outcomes
- Quantify Projected Accuracy and Impact
- Decision & Sponsorship Ask
- Set Acceptance Criteria & SLAs for Pilot
- Metric Baseline Capture
- Pre‑work & Timeline
- Next Steps / Decision Path
- Closeout & Immediate Next Steps
- Validation & Clarifying Questions
- Confirm Success Signals for the Experience
- Capture Exceptions and Operational Notes
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Solution Scope
Define scope and acceptance criteria for modules (ICD‑10/CPT/HCPCS suggestions, routing, documentation alerts), integrations, training, and accuracy benchmarking.
Scope Configuration
- Configure HL7/FHIR integration with EHR and billing
- Deploy automated code suggestion (ICD-10/CPT/HCPCS) with confidence scores
- Train ML models on organization-specific clinical documentation
- Implement automated chart routing by complexity and risk
- Enable documentation gap alerts and denial risk flags
- Integrate auto-coded claims into billing queue for review
- Deploy real-time EHR coding assistant interface
- Provision coder productivity dashboards and scheduled reports
- Configure role-based review workflows and escalation rules
- Process historical backlog with bulk auto-coding
- Provision audit trail and claim traceability logs
- Deploy rules engine for claims quality and compliance
Scope Questions
Configure HL7/FHIR integration with EHR and billing
- Which EHR and billing systems do you need integrated?
- Which data exchange standards are required for your environment?
- What interface types are needed (select all that apply)?
- What is your expected throughput (encounters/messages per day) for integration?
- Which authentication and network security methods must the integration support?
- Are there any required field mappings, transformations, or code set translations we should prepare for? (list specific fields or examples)
Deploy automated code suggestion (ICD-10/CPT/HCPCS) with confidence scores
- Which code sets do you want enabled for suggestions?
- What initial confidence threshold should be used to surface suggestions to coders?
- How should low-confidence suggestions be handled in workflow?
- What are your acceptance criteria for suggestion accuracy on pilot (e.g., precision or agreement with gold-standard)? Please specify numeric targets if available.
- Should each suggestion include supporting text snippets (citation of clinical text) and explainability notes?
- What latency requirement do you have for returning suggestions in interactive workflows?
Train ML models on organization-specific clinical documentation
- How many labeled/coded charts can you provide for initial training and validation?
- What historical timeframe should training data cover (e.g., last 1 year, 3 years)?
- Do you have a gold-standard annotated dataset (coder-validated) available?
- Where must model training and storage occur?
- What target performance metrics (precision, recall, top-1/top-3 accuracy) do you require for a successful training run?
- Who will own labeling, validation, and adjudication of training disagreements?
Implement automated chart routing by complexity and risk
- Which routing criteria do you want to support (select all that apply)?
- How do you define complexity tiers (example: Simple / Moderate / Complex)?
- What percent of charts do you expect in each tier (approximate distribution)?
- Where should routed charts appear for coders (EHR worklist, vendor app, third-party queue)?
- What escalation paths and SLAs should be applied for high-risk or time-sensitive charts?
- What acceptance criteria will determine routing accuracy in the pilot?
Enable documentation gap alerts and denial risk flags
- Which denial-risk rules should be enabled initially (select all that apply)?
- What alert severity levels do you want (e.g., informational, warning, critical)?
- How should alerts be delivered to users?
- Should any alerts automatically hold claims from submission until resolved?
- What thresholds (confidence, severity) should trigger an alert?
- What remediation workflow do you want when an alert is raised (assign to coder, open CDI task, require clinician addendum)?
Integrate auto-coded claims into billing queue for review
- Which billing / claims systems must receive auto-coded claims?
- How should auto-coded claims be flagged in the billing queue?
- Do you require a two-step approval process before claims are transmitted?
- What volume of auto-coded claims do you anticipate per day to be pushed to billing?
- What reconciliation, sampling, or QA controls do you require before claim submission?
- If a claim is rejected by billing, what rollback or remediation workflow should occur?
Deploy real-time EHR coding assistant interface
- Which EHR UI integration approach do you prefer?
- Should the assistant allow inline editing of suggested codes and documentation notes?
- Who should be able to modify codes in-EHR (roles/permissions)?
- What UI training model do you prefer for go-live?
- What latency/availability targets must the assistant meet for clinical workflows?
- Do you require UI interactions to be captured in audit logs (who changed what and why)?
Provision coder productivity dashboards and scheduled reports
- Which KPIs must appear on dashboards (select all that apply)?
- What reporting cadence do you require for scheduled reports?
- Do you need role-based dashboard views (e.g., coder vs manager vs compliance)?
- Which export formats or integrations are required for reports?
- Would you like automated alerts for KPI threshold breaches (e.g., productivity drops, accuracy below target)?
- Who should receive scheduled reports and at what distribution list or groups?
Configure role-based review workflows and escalation rules
- Which roles should be included in review workflows?
- For which scenarios should escalation be automatic (e.g., suspected overcoding, high denial risk)?
- What SLA timelines do you want applied to each escalation level?
- How should notifications be sent for escalations?
- Do you require automatic handoffs to other teams (CDI, compliance) and if so, what information should be included?
- Should the workflow include SLA tracking and reporting for each role?
Process historical backlog with bulk auto-coding
- How many historical charts comprise the backlog you want processed?
- What is your desired timeline to clear the backlog?
- Do you want a phased pilot (sample subset) before full-run bulk processing?
- What QA sampling rate or acceptance criteria do you require for backlog auto-coding?
- How should backlog-processed claims be handled for submission (submit after QA, hold for clinical signoff, or do not submit)?
- Are there any archival, retention, or audit requirements for processed backlog records?
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Mutual Commit
Finalize commercial terms, pilot objectives, SLAs on accuracy/productivity, compliance controls, and mutual responsibilities to proceed.
Agreement Modules
- Non-Disclosure Agreement (NDA)
- Master Services Agreement (MSA)
- Statement of Work (SOW)
- Pricing & Commercial Terms
- Pilot Agreement / Statement of Objectives
- Service Level Agreement (SLA)
- Data Processing & Security Addendum (DPA / BAA)
- Compliance & Audit Rights
- Integration & Implementation Plan
- Training & Change Management Agreement
- Accuracy Benchmarking & Validation Plan
- Governance & Roles Matrix
- Change Order & Scope Management
- Termination & Transition Plan
- Liability, Indemnification & Insurance
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Deployment
Plan and execute integration, local algorithm training, pilot rollout, coder enablement, and go‑live validation with clear owners and timelines.
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Success
Confirm outcomes against agreed benchmarks, transition operational ownership, and maintain a shared channel for issues, enhancements, and periodic accuracy reviews.
Success Reviews
- Success Validation Workshop
- Operational Handoff & Runbook Transfer
- Cadence Setup: Quarterly Governance & Accuracy Review
- Enhancement Prioritization & Continuous Improvement
- Compliance & Audit Readiness Review
Issues & Enhancements
- Assign owners and clear acceptance criteria for the top priorities to drive execution in the next cycle.
- Reach a clear decision (Accept / Accept with Remediation / Extend Pilot) and confirm next steps and owners.
- Produce a gap remediation plan (if required) that lists fixes, owners, timelines, expected impact on KPIs, and validation criteria.
- If accepted, prepare and circulate the operational handoff package (runbooks, SLAs, access lists) within 5 business days.
- Identify and tag a set of 100 representative charts (or agreed sample size) for a follow‑up audit and schedule the audit window.
- Handoff Objectives & Sign‑off Criteria
- Ensure the customer's operations team has the runbooks, access, and training necessary to operate the system independently.
- Agree and document SLAs, escalation paths, and RACI for ongoing support and incident response.
- Schedule and confirm a shadowing/overlap window to reduce operational risk during transition.
- Deliver the final runbook package (PDF/Confluence links) and obtain customer sign‑off.
- Provision production access and service accounts to named users and confirm logging and audit settings.
- Schedule the 2‑week shadowing period and assign vendor and customer shadowing owners and daily check‑in times.
- Review Measured KPIs & Improvement Targets
- Produce a prioritized backlog of enhancements tied to measurable outcomes and agreed implementation timelines.
- Agree a controlled model retraining and validation cadence to maintain or improve accuracy without increasing risk.
- Governance Purpose & Cadence
- Publish the prioritized enhancement backlog with RICE (or chosen) scores and assigned owners.
- Schedule the first model retraining window and define the validation test cases and rollback plan.
- Estimate implementation effort for the top three items and commit to delivery windows.
- Audit Trail & Evidence Inventory
- Validate that sufficient audit evidence and traceability exist for external and internal audits.
- Agree retention policies, reporting expectations, and owner responsibilities for audit responses.
- Run a mock audit to confirm evidence pack completeness and identify any gaps to remediate.
- Assemble and deliver a sample evidence pack for an agreed sample of charts and confirm receipt and completeness.
- Document and publish the retention policy and audit response SLAs in the shared compliance folder.
- If gaps are identified, create an audit remediation plan with owners and deadlines.
- Agree a repeatable governance cadence, metrics, thresholds, and sampling methodology for objective accuracy reviews.
- Establish the remediation workflow and escalation steps to ensure timely response to KPI regressions.
- Create and provision the shared communication channel and reporting templates for all future reviews.
- Create the recurring calendar invites and assign owners for pre‑reads and presentations for the next 12 months.
- Configure and share the governance dashboard and the audit sampling plan with the governance group.
- Provision the agreed shared channel and post the governance templates and the SLA thresholds there.
- Introductions & Meeting Objectives
- Validate measured outcomes against each agreed benchmark with evidence sufficient for an acceptance decision.
- Identify and document any gaps, their root causes, and a remediation plan with owners and timelines if acceptance is conditional.
- KPI Definition & Thresholds
- Present Candidate Enhancements & Impact Estimates
- Runbook & Playbook Walkthrough
- One‑Sentence Current State & Consequence Recap
- Compliance Controls & Governance
- Sampling & Audit Methodology
- Prioritization Exercise
- Mock Audit / Sample Review Workflow
- One‑Sentence Future State Reminder
- Roles, RACI & Support Model
- Quantitative Outcome Review (Proof)
- Model Retraining & Validation Cadence
- Monitoring, Dashboards & Alerting
- Remediation & Escalation Workflow
- Retention & Reporting Policies
- Remediation & Escalation for Audit Findings
- Training Completion & Shadowing Plan
- Evidence Walkthrough (Chart‑level Samples)
- Roadmap, Owners & Timelines
- Shared Channel & Reporting Templates
- Schedule Next Reviews & Owners
- Gap Analysis & Root Cause Mapping
- Access, Credentials & Compliance Check
- Decision & Remediation Options
- Next Steps, Owners & Communication