RCM & insurance

Complete coding and review claim documentation

Check diagnosis, procedures, DRG metadata and required supporting information before claim construction.

Current source · source reviewed · 7 min read

Before you begin

Clinical documentation for the encounter.
Authorized coding access and the applicable terminology releases.

1. Review the clinical documentation

Confirm the performed care, diagnoses, procedures and required supporting facts. Route missing or ambiguous clinical documentation back to the accountable clinician through the local review workflow.

2. Record coding and audit status

The coding API records principal diagnosis, diagnoses, procedures, morphology, DRG system/code and grouper metadata, documentation queries and findings. Complete/audited status records corresponding timestamps and coder.

3. Inspect the claim coding panel

In claim detail, read status, coded time, diagnoses/procedures, DRG and each terminology release. A DRG code without an established grouper version needs review.

4. Check required attachments and validation

Review attachment completeness and structural/business findings before submission. A clean profile check alone does not prove current terminology or correct financial arithmetic.

Version each coding domain

Diagnosis, procedure, billing terminology and DRG configuration can change independently. Avoid treating one combined version string as proof that all code sets were current.

Facility and claim profiles

Current builders distinguish institutional, professional, pharmacy, oral and vision claims. Their requirements differ; use the configured profile for the actual service context.

Troubleshooting

The claim has documentation exceptions

Open the specific finding, correct the clinical or coding fact with its owner, and rebuild/revalidate. Do not insert dummy vitals or unsupported diagnosis codes to pass a gate.

Source evidence

References are pinned to the private MANSOQ source repository. Repository access is required to open these links.