Development of a Cloud-Based Medical Coding and Claims Processing System

The client faces inefficient coding processes, frequent human errors, and claim denials due to coding inaccuracies, leading to revenue loss and compliance risks. Existing workflows are manual and siloed, hindering productivity and accuracy.

A mid to large-sized healthcare organization aiming to streamline medical coding, billing, and claims processing through innovative software solutions.

• Develop a cloud-based system to automate and accelerate medical coding activities.
• Reduce human errors in coding to increase billing accuracy.
• Enhance claim processing efficiency and reduce reimbursement denials.
• Integrate coding tools with existing electronic health record systems.
• Improve productivity metrics for medical coders and billing staff.

• Clinical statement review and coding assignment based on international classification standards.
• Automated calculation of care costs and reimbursement based on coded data.
• Support for editing inpatient and outpatient claims with specialized coding editors.
• Tools for examining alternative DRGs and performing DRG analysis.
• Claim grouping and pricing calculations for DRG, APC, ASC, and EAPG categories.
• Import/export functionalities for patient records.
• Embedded coding references, official documents, and additional research resources.
• Search functionality for codes, terms, and synonyms within code sets.
• Generation of detailed productivity and performance reports.

• Electronic health record (EHR) systems for seamless data import/export.
• Medical coding reference databases and classification standards.
• Insurance claims processing systems to automate submission and status updates.

• System must support multi-user concurrent access with minimal latency.
• Ensure data security and HIPAA compliance for all stored and transmitted data.
• Achieve high system availability with 99.9% uptime.
• Scalable architecture to accommodate future feature expansion.
• User interface must be intuitive and facilitate quick task completion.

The new system aims to improve coder productivity by automating routine tasks and reducing errors, leading to fewer claim denials and increased revenue recovery. Anticipated improvements include a significant reduction in coding errors, enhanced regulatory compliance, and streamlined workflows that ultimately improve patient billing accuracy and operational efficiency.