01
Read the record
Identify the service, documented clinical context, site, setting and date. Resolve missing information with the appropriate clinician.
The human review framework
Better billing decisions
start with evidence.
Automation can support a review. People must still assess the record, resolve uncertainty and document the basis for a billing decision.
Content reviewed · U.S. healthcare billing · Educational reference
The interactive anatomy atlas has its own home.
Explore the 3D human body, isolate anatomical structures and study documentation checkpoints across 40 specialty learning paths.
Open the 3D anatomy atlas →A repeatable review
Four steps. A documented decision.
02
Check the applicable rule
Use the code-set version, payer policy, coverage guidance and payment period that apply to the encounter.
03
Review the exception
Escalate ambiguous documentation, conflicting edits and payer disputes to a qualified reviewer. Record the reason for the decision.
04
Keep the evidence
Retain the relevant record, policy version, review notes and changes through the organization’s approved process.
Human review is a quality-control process. It does not create a legal safe harbor or guarantee reimbursement. Applicable False Claims Act liability depends on the facts and statutory elements. Read 31 U.S.C. § 3729.
See the calculation
Small examples, explicit assumptions.
Change the inputs and inspect the result. These tools explain selected rules and arithmetic; they do not predict payer decisions. Use fictional or aggregate data only.
Drug billing-unit reconciliation
Illustration for an eligible, separately payable Medicare Part B drug from a single-dose container. Enter the labeled supply actually opened and the amount administered; the remainder is assumed discarded. Confirm the HCPCS unit and applicable setting.
Administered: 33 units · Discarded: 7 units · Total: 40 units
CMS — JW and JZ modifier FAQs ↗Physical remainder: 75 mg. Modifier example: JW. Waste included in a rounded administered unit is not billed again. A JZ example can include sub-unit waste already included in that rounding.
10-digit NDC to 11-digit billing format
Preserve the label’s original segment boundaries. Padding changes the format; it does not validate a drug, strength, package or coverage.
11-digit format: 50242-0061-01
DailyMed — Avastin package labeling ↗Inpatient documentation checkpoint
A review prompt for the two-midnight framework. These three inputs cannot decide inpatient coverage or replace the full clinical record.
Missing admission order
42 CFR § 412.3 — Inpatient admissions ↗Resolve the missing valid practitioner order before relying on inpatient status. This screen cannot establish Part A payment eligibility.
CLFS phase-in floor illustration
For an existing test subject to the phase-in provision: no reduction in 2026; a maximum 15% reduction per year in 2027–2029. This is a floor illustration, not a projected fee schedule or PAMA reporting determination.
Maximum reduction: 0% · Illustrative floor: $100.0000
Use the immediately preceding year’s rate for each successive year. Verify the published test-specific rate and any exceptions.
CMS — CLFS and PAMA reporting ↗Build your own denial-cost scenario
All defaults are hypothetical inputs, not industry benchmarks or Aethera performance claims. Enter your own validated annual data. No vendor improvement, savings or ROI is assumed.
Illustrative annual cost: $6,000.00
100 expected denied claims · Unrecovered allowed dollars: $5,000.00 · Rework: $1,000.00
Formula: claims × denial fraction × [average allowed × (1 − recovery fraction) + rework cost]. Assumes a uniform allowed amount and one rework cost per initial denial; excludes collection timing, repeat denials and implementation costs.
Try a real SHA-256 digest
This browser-only example detects changes relative to a saved digest. It is not an immutable ledger, identity check, timestamp authority, digital signature or proof that a claim is accurate. Do not enter patient information.
No digest created.
Selected code and package examples
Seven educational entries. This is not a complete CPT, HCPCS, CDT or NDC directory and does not validate a claim.
7 of 7 examples
25 · Modifier
Separately identifiable E/M service on the same day as another service.
Review the E/M work beyond the procedure-related evaluation. A different diagnosis is not required.
Source: CMS — 2026 Medicare NCCI Policy Manual59 / XE / XP / XS / XU · Modifier
Distinct-service modifiers with different circumstances of use.
Use only when documentation and the applicable edit permit it; choose the appropriate specific modifier.
Source: CMS — 2026 Medicare NCCI Policy Manual99 · Modifier
Multiple modifiers; not an emergency modifier.
Follow the claim-format and payer instructions for reporting multiple modifiers.
Source: CMS — Claims processing: multiple modifiersJW · Modifier
Eligible discarded drug amount from a single-dose container.
Applies to the relevant separately payable Part B drug claims. Do not duplicate amounts covered by administered-unit rounding.
Source: CMS — JW and JZ modifier FAQsJZ · Modifier
No separately reportable discarded amount under the applicable CMS policy.
Review container type, payment setting and the CMS sub-unit waste example.
Source: CMS — JW and JZ modifier FAQs50242-0060-01 · NDC
Avastin 100 mg / 4 mL single-dose vial.
Original package NDC: 50242-060-01. Verify the package actually used.
Source: DailyMed — Avastin package labeling50242-0061-01 · NDC
Avastin 400 mg / 16 mL single-dose vial.
Original package NDC: 50242-061-01. This is a different package from the 100 mg vial.
Source: DailyMed — Avastin package labeling
Versioned reference
Match the rate to the service period.
Selected national base amounts, before applicable adjustments. They are not final claim payments. Fiscal-year 2026 values below end September 30, 2026; use the next year’s official files for later services.
| Reference | Base amount | Effective period | Source |
|---|---|---|---|
| Physician conversion factor — qualifying APM participant | $33.57 (rounded) | CY 20262026-01-01 to 2026-12-31 | CMS reference for Physician conversion factor — qualifying APM participant ↗ |
| Physician conversion factor — non-QP | $33.40 (rounded) | CY 20262026-01-01 to 2026-12-31 | CMS reference for Physician conversion factor — non-QP ↗ |
| FQHC PPS base | $207.72 | CY 20262026-01-01 to 2026-12-31 | CMS reference for FQHC PPS base ↗ |
| ESRD PPS base per treatment | $281.71 | CY 20262026-01-01 to 2026-12-31 | CMS reference for ESRD PPS base per treatment ↗ |
| Hospice aggregate cap per beneficiary | $35,361.44 | FY 20262025-10-01 to 2026-09-30 | CMS reference for Hospice aggregate cap per beneficiary ↗ |
| IPF federal base per diem | $892.87 | FY 20262025-10-01 to 2026-09-30 | CMS reference for IPF federal base per diem ↗ |
| IPF ECT base per treatment | $673.85 | FY 20262025-10-01 to 2026-09-30 | CMS reference for IPF ECT base per treatment ↗ |
| SNF urban PT / OT base per diem | $75.73 / $70.49 | FY 20262025-10-01 to 2026-09-30 | CMS reference for SNF urban PT / OT base per diem ↗ |
Know what to verify
A source-backed topic guide.
Open a topic for the review checkpoint and its supporting reference. Always check the rule version and payer requirements for the service at issue.
Anatomy and operative documentation
Use the documented anatomical site, approach, laterality and work performed to select a procedure code. A picture or an anatomical landmark alone does not establish a billable service.
Review checkpoint: Confirm the operative report and the current code descriptor. Use anatomical references with verified provenance and the appropriate clinical context.
Debridement: tissue removed, not millimeters
Document the type of tissue actually removed and the treated surface area. Universal skin-to-muscle depth bands cannot determine the correct debridement code.
Review checkpoint: Check the applicable coverage article, documentation and area rules. A deeper wound alone does not demonstrate that deeper tissue was debrided.
Specialty review
Different specialties require different documentation and coding checks. This guide is a selection of billing topics, not an official ABMS taxonomy or a measurement of specialty clean-claim performance.
Review checkpoint: Match reviewer expertise to the service and payer requirements. ABMS member boards certify physicians; that framework is distinct from coding credentials.
Procedure-code comparison
Compare the documented procedure with the code family before applying modifiers. An interbody cage does not establish an anterior spinal approach; a nasal flap should not be assigned a scalp/arms/legs transfer code.
Review checkpoint: Verify approach, site, measurements, code-pair edits and modifier indicators. No example here represents a paid or audited patient claim.
Human review and accountability
Human review supports quality control. It does not grant legal immunity, guarantee reimbursement or establish that every coding mistake constitutes fraud. False Claims Act liability depends on the facts and the statutory elements, including knowledge.
Review checkpoint: Keep documentation of the decision and its basis. Do not substitute a credential, checklist score or hash for evidence of the services furnished.
Appeal pathways
CMS gives 65 calendar days from the organization-determination notice to request a Medicare Advantage reconsideration. This is not a universal deadline for every provider payment dispute or commercial plan.
Review checkpoint: Identify the appellant, denial type, plan, notice date and applicable appeal pathway before calculating the deadline.
Prepare a peer-to-peer discussion
Organize the clinical rationale, relevant records, denial reason and the policy the plan applied. Ask which documentation would resolve the disputed criterion.
Review checkpoint: Record the discussion and available next steps. A peer-to-peer call does not replace a formal appeal or guarantee a reversal.
Federal IDR timing
For eligible disputes, federal IDR follows a 30-business-day open negotiation period. Initiation generally occurs within four business days after that period ends, subject to applicable extensions.
Review checkpoint: Establish federal versus state jurisdiction and eligibility first. Use actual dates and the applicable business-day calendar; do not add 30 calendar days or infer a win probability.
Compare an actual contract and remittance
Medicare physician payments use work, practice-expense and malpractice RVUs, geographic adjustments and the applicable conversion factor. Commercial reimbursement depends on the actual contract.
Review checkpoint: Use the service date, locality, setting, participation status and remittance. A generic payer multiplier cannot establish an underpayment or statutory interest owed.
Clinical research billing
Separate routine care, investigational items and sponsor-paid services. Coverage and coding must be checked for the specific study and service.
Review checkpoint: Confirm study eligibility, coverage determination, sponsor agreement and required claim identifiers. This page does not certify a clinical trial or generate a submission-ready research claim.
HAC and present-on-admission review
Present-on-admission coding and the Hospital-Acquired Condition Reduction Program are different mechanisms. A diagnosis or a positive laboratory result alone does not determine either a DRG change or the hospital-wide penalty.
Review checkpoint: Resolve documentation questions through the appropriate clinical process and use the applicable fiscal-year grouper and program rules.
GME and IME payments
Teaching payments depend on the applicable direct and indirect payment methodologies, resident counts, caps, hospital factors and cost-report period.
Review checkpoint: Use the official cost-report instructions and payment system. This guide does not estimate a hospital’s entitlement from a generic resident-to-bed ratio.
340B and Medicaid
The HRSA Medicaid Exclusion File applies to Medicaid fee-for-service, not Medicaid managed-care claims. Managed-care duplicate-discount prevention requires the relevant state and plan process.
Review checkpoint: Verify the covered entity, eligible patient relationship, acquisition account and payer-specific process. MEF status alone does not establish MCO claim eligibility.
ESRD and kidney care models
The CY 2026 ESRD PPS base rate is $281.71 before applicable adjustments. A base rate is not a facility-specific final payment.
Review checkpoint: Use current facility and patient factors and model participation terms. Home-dialysis share alone cannot establish shared savings.
RHC and FQHC updates
RHC productivity standards no longer apply to cost-reporting periods ending after December 31, 2024. The CY 2026 FQHC PPS base is $207.72. G0511 is terminated; use applicable service-specific care-coordination codes.
Review checkpoint: Apply the correct cost-report period, visit rules, geographic adjustment and code-specific payment. Do not project recurring G0511 revenue or an obsolete productivity penalty.
Inpatient rehabilitation
IRF classification and patient coverage require review of the relevant criteria, documentation and payment-year rules. The facility-level 60% rule is not a stand-alone coverage decision for an individual patient.
Review checkpoint: Use the applicable CMS classification and payment files. No universal tier multiplier or hypothetical IPPS counterfactual is used here to promise a recovered amount.
Skilled nursing and PDPM
PDPM payment depends on the applicable case-mix groups, assessments, component rates and other adjustments. A functional score is not a simple percentage multiplier for PT or OT payment.
Review checkpoint: Use the official classification logic and fiscal-year rates. Verify interrupted-stay dates and assessment requirements before changing payment-day sequences.
Hospice payment limits
The FY 2026 aggregate cap is $35,361.44 per beneficiary under the applicable cap calculation. This is distinct from the inpatient-care limit.
Review checkpoint: Use the proper cap period, beneficiary allocation and official payment rates. The base cap amount alone does not determine a hospice’s liability.
Psychiatric facility and ECT rates
For FY 2026, the IPF base per diem is $892.87 and the ECT base is $673.85. The labor share is 79%, rural factor 1.18 and teaching exponent 0.7957.
Review checkpoint: Apply the CMS age, comorbidity, length-of-stay, quality-reporting and facility factors. These base rates are not final patient-specific payments.
Measure results with evidence
A clearinghouse acceptance, payer adjudication, collected payment and post-payment audit result are different outcomes. Compare like-for-like populations over a defined period.
Review checkpoint: Require a denominator, source data, dates and a documented method before publishing a clean-claim rate, AI error rate, recovered revenue or audit outcome.
What a coding check can establish
A code-format or edit check can identify an issue for review. It cannot prove medical necessity, authenticate an encounter or promise payment.
Review checkpoint: Check documentation and payer rules before approving an exception. Different diagnoses alone are neither required for modifier 25 nor sufficient proof of a separately identifiable E/M service.
Protecting patient information
HIPAA cloud use requires appropriate agreements, risk analysis and safeguards. HIPAA does not impose a universal US-only cloud rule or prohibit all shared infrastructure.
Review checkpoint: Confirm the actual hosting, access, retention and subcontractor arrangements during contracting. Do not enter patient information into these public examples.
Examples are not client outcomes.
The tools on this page use illustrative inputs. Measured claims about accuracy, collected revenue or audit outcomes require a defined population, dates, source data and a documented method. No named patient, clinician or successful appeal is implied.
Common questions
Does human sign-off guarantee compliance or payment?
No. Human review can identify errors and document decisions, but neither a credential nor a completed checklist guarantees coverage, payment or legal immunity. Review the actual record, applicable rules and payer requirements.
Can I use these examples to submit a claim?
These examples explain selected concepts. They do not validate an encounter, replace current licensed code sets or produce submission-ready claims, appeals or legal attestations. Confirm the service date, setting and payer rules.
Are the example costs and results Aethera performance data?
No. Calculator defaults are hypothetical and editable. This page does not publish measured client outcomes, AI accuracy benchmarks or promised savings.
What does the SHA-256 demonstration prove?
It compares the current example text with a saved digest. It does not authenticate a person, verify clinical accuracy or provide an immutable audit trail. The example stays in your browser unless you download it.
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