Medical Billing Compliance Checker

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Overview of your billing compliance metrics

Claims Processed

12,345

+12%

Compliance Rate

98.7%

-0.5%

Error Summary

234

+5%

Claims Processing

Claims Processed Over Time

12,345

Error Distribution by Type

234

Last 30 Days

+5%

Type A

Type B

Type C

Type D

Type E

Predictive Insights

Predicted Rejection Rate (Next Month)

3.2%

Potential increase due to new payer policies.

Top 3 Predicted Error Types

Diagnosis-Procedure Mismatch
Missing Prior Authorization
Incorrect Modifier Usage

Key Compliance Requirements & Software Features

Rules

All Rules

120

Active Rules

100

Inactive Rules

20

Draft Rules

5

Archived Rules

10

Rule Editor

Create and manage billing rules and regulations

Rule Name

Rule Category

Rule Description

Rule Priority

Rule Logic

Rule Expression ⓘ

Version Control

Version Number

Version Notes

New Claim

Enter claim details for compliance checking.

Patient Name

Date of Birth

Diagnosis Codes ⓘ

Procedure Codes ⓘ

Charges

Enable Real-time Validation

Check Summary

Total Checks

150

Errors

5

Warnings

12

Detailed Results

Check ID	Rule Name	Description	Suggestions
Check-001	Diagnosis Code Validation	Invalid diagnosis code 'XYZ123' found. This code does not match the current coding standards.	Update the diagnosis code to a valid ICD-10 code.
Check-002	Procedure Code Validation	Procedure code 'ABC456' is flagged as potentially outdated. Consider using a more recent code.	Review the procedure code and update if necessary.
Check-003	Modifier Validation	Modifier 'LM' is not applicable to the procedure code 'DEF789'.	Remove the modifier or update the procedure code.
Check-004	Billing Amount Validation	Billing amount exceeds the expected range for the procedure code 'GHI012'.	Verify the billing amount and adjust if needed.
Check-005	Patient Information Validation	Missing patient date of birth. This information is required for billing.	Add the patient's date of birth to the billing data.

Claim History

Claim ID	Patient Name	Submission Date	Status	Errors/Warnings

Code Search

Search for ICD-10, CPT, and other medical codes

ICD-10

CPT

Other Codes

Payer Policies

Health Topics

Loading health topics...

Code Details

Select a topic or search to view details.

Payer Policy Library

Browse and search for payer-specific policies and guidelines.

Payer Name	Payer ID	Effective Date	Description
Medicare	12345	Edit
Blue Cross Blue Shield	67890	2023-10-15	Details on services requiring pre-approval.

Reports

Generate and view various billing compliance reports.

Compliance Trends

Monthly Compliance Rate

98.0%

Stable over last 6 months

Top 5 Rejection Reasons

Incorrect Diagnosis Code (25%)
Missing Prior Authorization (20%)
Invalid Procedure Code (15%)
Duplicate Claim (10%)
Modifier Error (8%)

Custom Report Generator

Report Type

Date Range

Settings

Configure system settings, payer information, and user roles.

General Settings

System Name

Default Time Zone

Payer Management

Payer Name	Payer ID	Actions
Medicare	12345	Edit
Blue Cross Blue Shield	67890	Edit
Aetna	11223	Edit

User Management

User Name	Email	Role	Actions
Sophia Clark	sophia.clark@example.com	Edit
Ethan Carter	ethan.carter@example.com	Billing Specialist	Edit
Olivia Bennett	olivia.bennett@example.com	Auditor	Edit

Code Management

Integrations

EHR/PMS Integration Status

Payer API Key

Notifications

View system alerts, compliance updates, and user messages.

Critical Error: Invalid Diagnosis Code Pattern

A claim submitted on 2024-07-01 contained an invalid ICD-10 diagnosis code format. Please review and correct.

New Payer Policy Update: Medicare

Medicare has released new guidelines for telehealth services, effective August 1, 2024. Review the updated policies in the Code Search section.

Compliance Rate Increase

Your overall compliance rate has increased by 0.5% in the last week. Keep up the good work!

Audit Log

View system audit trail and change history.

Timestamp	User	Action	Details