Revenue Cycle Management

Coders review clinical documentation and assign diagnosis codes (ICD-10-CM, 70,000+ codes), procedure codes (CPT, 10,000+ codes; HCPCS Level II for supplies and drugs), and modifiers. You code for specificity (laterality, encounter type, complication/comorbidity designation), ensure code combinations are valid (CCI edits, MUE limits), and code to the highest supportable specificity without upcoding. For inpatient, you assign DRG-driving diagnoses (principal diagnosis, MCC/CC designation) that directly determine reimbursement. Coding accuracy affects revenue, compliance, risk adjustment, and quality reporting simultaneously.

You submit claims (837P for professional, 837I for institutional) to payers through clearinghouses, manage the remittance cycle (835 ERAs), post payments, identify and work denials, and file appeals. Denial rates run 5–15% of claims for most organizations; each denial costs $25–50 to rework. You categorize denials by type (eligibility, authorization, coding, medical necessity, timely filing), track root causes, and report denial trends. Appeals require clinical documentation, payer-specific formats, and often medical director-to-medical director peer-to-peer conversations. The No Surprises Act and state balance billing laws add another compliance layer.

You obtain prior authorizations from payers before delivering services: submitting clinical information (diagnosis, proposed treatment, medical necessity rationale, prior treatments tried and failed), tracking authorization status, managing authorization expiration dates, and appealing denials. Prior auth is one of the most cited administrative burdens in healthcare: physicians report spending an average of 13 hours per week on prior auth activities. Delays in authorization delay patient care. CMS and several states have passed or proposed prior auth reform legislation, but the administrative burden persists.