Revenue Cycle Management Glossary
A plain-English guide to the terms, metrics, and workflows that power modern RCM operations.
Code Review
What is Code Review?
Code Review is the mid-cycle process of auditing assigned medical codes (ICD-10, CPT) against clinical documentation and payer rules to ensure accuracy and compliance before a claim is finalized.
Why Code Review is Critical for CFOs and Financial Leaders
Code review acts as a final quality control layer to ensure financial stability and compliance.
- Mitigating Audit Risk: Systematic code reviews identify patterns of over-coding (upcoding) or under-coding, protecting the organization from federal audits and revenue leakage.
- Optimizing Coder Productivity: By identifying common coding errors, RCM leaders can provide targeted training, ultimately improving the efficiency of the coding team.
- Maximizing Net Collection Rate (NCR): Ensuring that the codes accurately reflect the complexity of care leads to the highest possible reimbursement allowed by contract.
Use Cases: Elevating Coding Quality
- Automated Audit Sampling: RCM software can automatically flag a percentage of coded charts for manual review based on high-dollar value or specific complexity, ensuring that auditors focus on the highest-risk claims.
Real-time Coding Assistance: AI tools provide real-time suggestions during the coding process, acting as a "pre-review" that catches errors before they reach the official audit stage.