Automated Clinical Logic for Flawless Billing
Explore the internal pre-authorization logic connecting ICD-10 diagnoses to CPT procedural requirements. Prevent unspecified denials, capture missing bundles, and automate modifier logic.
◆ Coding Logic Simulator
Select a clinical scenario to see how IR Logic dynamically maps diagnoses, bundles procedural codes, and flags required modifiers.
Select a scenario from the left to view logic rules.
◆ High-Value Misses & Advanced Logic
These procedures have high reimbursement but are frequently coded incorrectly. IR Logic enforces strict pre-requisites to prevent denials.
Spine Procedures
Lumbar/Thoracic Kyphoplasty logic checks.
Sedation Capture
Universal prompt for invasive procedures.
Tumor Ablation
Chest wall cryo / tumor ablation diagnosis matching.
◆ Payer-Specific Intelligence & Auth
Reimbursement strategies must adapt to specific payer rules. IR Logic integrates relative fee schedules and dynamic OOP warnings to protect practice revenue.
Relative Reimbursement Rates
Comparison of payer rates (Baseline = 100%). Highlights the importance of capturing high-yield codes by payer.
⚠ Max OOP Pre-Auth Warning
Cigna / UHC Rule: If total estimated patient cost exceeds remaining Max Out-Of-Pocket, trigger immediate notification for billing staff.
Aetna / BCBS Specifics
Specific diagnostic prerequisites must be strictly flagged in the pre-auth portal.