What you need
Data sources
- Billing database — submitted claims, assigned ICD-10 and CPT codes, modifiers, reimbursement amounts, and denial history
- EHR system — encounter records, clinical notes, diagnoses, procedures performed, and order details
Knowledge spaces
- Coding manuals — upload ICD-10-CM, CPT, and HCPCS reference materials with code descriptions, inclusion/exclusion notes, and coding guidelines
- Payer-specific rules — upload billing requirements for major payers, including documentation standards, modifier rules, and bundling logic
| Component | Name | Definition |
|---|---|---|
| Object | Claim | Maps to the claims table in the billing database. Represents a submitted insurance claim with codes, amounts, and status |
| Object | Encounter | Maps to encounters in the EHR. Represents the clinical visit that supports the claim |
| Metric | Coding Accuracy Rate | Percentage of claims where assigned codes match the documented diagnoses and procedures, validated by audit |
| Metric | Denial Rate | Percentage of submitted claims that are denied by payers, segmented by denial reason |
| Dimension | Payer | Groups claims by insurance payer (Medicare, Medicaid, Blue Cross, Aetna, etc.) |
| Dimension | Denial Reason | Classifies denials by category (medical necessity, missing documentation, coding error, authorization) |
Agent setup
Create the agent
Go to Agent Space → New agent.
| Field | Value |
|---|---|
| Name | Coding Review Specialist |
| Role | Medical Coding Analyst |
| Goal | Validate medical codes against clinical documentation, identify coding errors, suggest corrections, and explain the rationale using coding guidelines and payer rules |
Set the description
You are a certified medical coding analyst who reviews claims for accuracy before submission. You cross-reference assigned ICD-10 and CPT codes against the clinical documentation in the encounter record, checking for supported diagnoses, correct modifiers, and proper code sequencing. You flag discrepancies with specific references to coding guidelines and payer rules. You suggest corrected codes when errors are found and explain the rationale. You never submit or modify claims directly — you provide validated recommendations for the coding team.
Scope data access
Grant access to:
- Billing database (claims, codes, denial history)
- EHR system (encounter records, clinical notes, diagnoses, procedures)
- Coding manuals knowledge space
- Payer-specific rules knowledge space
- Claim and Encounter objects, Coding Accuracy Rate and Denial Rate metrics
Add skills
Claim code validation
Claim code validation
Trigger: User asks the agent to review a specific claim or encounter for coding accuracy.
- Retrieve the claim record from the billing database, including all assigned diagnosis and procedure codes.
- Pull the corresponding encounter record from the EHR with clinical notes, diagnoses, and procedures performed.
- Cross-reference each assigned code against the clinical documentation to verify support.
- Check code specificity — ensure the most specific ICD-10 code is used (e.g., laterality, episode of care).
- Validate modifier usage against payer-specific rules from the knowledge space.
- Check for bundling issues — identify code pairs that should be bundled or require modifier 59.
- Return a validation report listing each code, its support status, any suggested corrections, and the guideline reference.
Denial root cause analysis
Denial root cause analysis
Trigger: User asks the agent to analyze a denied claim or a batch of denials.
- Retrieve the denial details from the billing database, including the payer’s denial reason code and remarks.
- Pull the original claim codes and the supporting encounter documentation.
- Map the denial reason to the payer-specific rules to understand the requirement that was not met.
- Identify the root cause (missing documentation, unsupported code, authorization gap, or coding error).
- Recommend the corrective action — whether to appeal with additional documentation, recode, or write off.
Coding guidance lookup
Coding guidance lookup
Trigger: User asks a question about coding rules, guidelines, or payer requirements.
- Search the coding manuals knowledge space for the relevant code, guideline, or category.
- Extract the applicable coding rules, inclusion/exclusion notes, and sequencing guidance.
- Cross-reference with payer-specific rules if the query involves a particular insurance payer.
- Return the guideline text with a plain-language explanation and examples.
Automation
Playbook: Daily pre-submission coding audit
Set the trigger
Set the trigger to Schedule — Daily at 5:00 PM to audit all claims queued for submission the following business day.
Build the workflow
The workflow batch-validates coded claims against clinical documentation and flags errors for correction:
- Query all claims in “ready to submit” status from the billing database.
- Query the corresponding encounter records from the EHR system, including clinical notes and procedure details.
- Python code block — run a validation algorithm that cross-references each claim’s codes against the encounter data. The code checks for: (a) diagnosis codes supported by the clinical documentation, (b) procedure codes matching documented services, (c) modifier accuracy per payer rules, and (d) bundling conflicts. Each claim receives a validation score and a list of flagged issues.
The coding validation step uses a Python code block to perform rule-based cross-referencing of claim codes against encounter documentation. You can customize the validation rules, add payer-specific checks, and adjust the scoring thresholds.
- Condition — if a claim has any flagged issues, hold it from submission and route it to the coding team for correction.
- Action — update the claim status in the billing database (validated, held, or flagged).
- Delivery — distribute the audit results to the coding team.
Configure delivery
- Email — send the coding team a detailed audit report listing each flagged claim with the specific issues and suggested corrections
- Slack — post a summary to
#revenue-cyclewith the count of validated, held, and flagged claims and the overall coding accuracy rate
What’s next
Patient intake automation
Automate patient registration with form validation, insurance checks, and department routing.
All Healthcare use cases
See the full list.