MEDICAL CODING AND BILLING ACCURACY PROCESS

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[ ] Fetch Unbilled Claims: Retrieve all entries from the 'Claims' data model where status is 'Encoded' and billing status is 'Pending'.
[ ] Retrieve Patient Records: Get patient demographic and encounter details from the 'Patient' and 'Encounters' data models to verify coding accuracy.
[ ] Calculate Denial Rate: Calculate the percentage of denied claims versus total claims submitted in the current period.
[ ] Sum Total Reimbursable Value: Aggregate the 'Expected Reimbursement' field from all selected claims to calculate total revenue potential.
[ ] Coding Audit Task: Create a task for a Senior Medical Coder to review the ICD-10 and CPT codes for accuracy against the clinical documentation.
[ ] Billing Verification Task: Create a task for the Billing Specialist to verify that all modifiers and insurance identifiers are correctly applied.
[ ] Update Claim Status to 'Audited': Update the status of the processed claims in the 'Claims' data model to indicate the audit phase is complete.
[ ] Create Discrepancy Log: Create a new entry in the 'Audit Discrepancies' data model whenever a coding error is identified during the task.
[ ] Notify Provider of Coding Error: Send an email to the attending physician if a discrepancy is found that requires documentation clarification.
[ ] Update Claim for Submission: Update the 'Claims' data model entry to change status from 'Audited' to 'Ready for Submission'.
[ ] Generate Claim Submission Batch: Create a new entry in the 'Billing Batches' data model to group all verified claims for the day.
[ ] Submit Batch to Clearinghouse: Send an automated email notification to the clearinghouse service with the batch details.
[ ] Daily Accuracy Report: Create a summary report containing the total claims processed, error rate, and total value audited for the day.
[ ] Remove Duplicate Entries: Delete any duplicate claim entries identified during the reconciliation process.
[ ] Urgent Denial Alert: Send an SMS to the Billing Manager if a high-value claim is flagged with a critical rejection error.

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