Cardiology Revenue Integrity

Every code assignment follows explicit, auditable rules — not probabilistic guesses. The engine covers the full spectrum of cardiology procedures:

• EP Ablation — SVT, AF, VT ablation coding with proper modifier logic (93653, 93656, +93657)
• Cath Lab — Left/right heart cath, coronary angiography, PCI with stent codes and vessel-specific modifiers
• Device Implants — Pacemaker, ICD, CRT, leadless device, and lead revision hierarchies
• Echo & Imaging — TTE, TEE, stress echo, strain imaging with appropriate technical/professional splits

Zero-hallucination guarantee: Every output traces back to a published rule. If no rule matches, the agent flags for human review instead of guessing.

When a claim comes back denied, the agent doesn't just log it — it fights back:

• CARC/RARC Analysis — Parses Claim Adjustment Reason Codes and Remittance Advice Remark Codes to classify the denial type (medical necessity, bundling, auth, etc.)
• Priority Scoring — Ranks denials by dollar impact, overturn probability, and filing deadline urgency
• AI Appeal Drafts — Generates payer-specific appeal letters citing relevant LCD/NCD policies, procedure notes, and medical necessity rationale
• Pattern Detection — Surfaces systemic denial trends (e.g., "Payer X denying 93306 at 34% rate this quarter")

Every appeal letter is drafted for human review — the agent proposes, you approve.

CardioCode doesn't just process claims — it remembers outcomes and gets smarter over time:

• Denial-Feedback Learning — Every denial is analyzed, categorized, and fed back into the rule engine
• Corrections → Memory Rules — When a human corrects a code or modifier, the agent creates a new rule: "For payer X, procedure Y always requires modifier Z"
• Confidence Scoring — Each rule carries a confidence score that grows with evidence. New rules start cautious; proven rules execute autonomously
• Practice-Specific Adaptation — Your denial patterns are different from every other practice. The agent becomes an expert in your payer mix

Memory is transparent. Every learned rule is visible, editable, and deletable. No black box.

End-to-end claims management through every X12 transaction:

• 837P Submission — Professional claim generation via Stedi API with full loop validation before submission
• 276/277 Status — Automated claim status inquiries with real-time tracking dashboard
• 835 ERA Parsing — Electronic Remittance Advice parsing that auto-reconciles payments against expected amounts
• Exception Handling — Automatically flags underpayments, unexpected adjustments, and missing claims for review

Built on Stedi infrastructure — modern X12 EDI without the legacy headaches.

AI does the work, humans stay in control:

• Agent Notifications — The agent surfaces items that need attention: low-confidence codes, high-value claims, unusual patterns
• Approve / Reject / Modify — One-click approval for confident items, easy modification for edge cases
• Conversation Threads — Chat with the agent about specific claims. Ask "Why did you code 93306 instead of 93303?" and get a rules-based explanation
• Audit Trail — Every action, decision, and override is logged with timestamp and reasoning

The agent asks before acting on anything it's not confident about. As trust builds, the threshold adjusts.

Clinical Documentation Improvement powered by cardiology-specific intelligence:

• HCC Gap Detection — Identifies Hierarchical Condition Categories that are clinically supported but not documented, focusing on cardiology-prevalent HCCs (CHF, AF, CAD, PAD)
• RAF Impact Scoring — Quantifies the Risk Adjustment Factor impact of closing each gap, prioritized by revenue opportunity
• Documentation Queries — Generates specific, actionable queries for physicians: "Patient's echo shows EF 35% — please document systolic heart failure severity for HCC 85"
• Compliance Guardrails — Every suggestion is backed by clinical evidence in the chart. No upcoding — ever.

CDI is about accuracy, not gaming. Capture what's already true in the clinical record.