Revenue Cycle Analytics

Revenue Cycle Analytics:
Denial Management & Billing Optimization

A 5-provider practice seeing 25 patients each per day, 5 days per week, 50 weeks per year generates 31,250 encounters. If 20% are coded at Level 3 when Level 4 is supported, that is $481,250 in uncaptured revenue — every year.

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$481KAnnual undercoding loss for a typical 5-provider practice
E&M Coding Gap Analysis

Level 3 vs Level 4: A $77 Difference Per Encounter

CPT 99213 (Level 3 established patient office visit) reimburses approximately $158 under Medicare. CPT 99214 (Level 4) reimburses approximately $235 — a $77 difference on a single encounter. The 2021 E&M documentation guidelines eliminated the requirement to count history and physical exam elements, making the Level 4 threshold more achievable for complex chronic disease visits.

Vizier compares your Level 3 to Level 4 coding ratio against specialty-specific national benchmarks. When your 99213 rate significantly exceeds the benchmark, Vizier surfaces a random audit sample of those encounters — with the documentation already pulled — so your coding team can validate in minutes rather than hours.

The same analysis applies to new patient visits (99202–99205), preventive visits (99381–99397), and procedure coding. Undercoding and overcoding risks are both surfaced — protecting revenue and reducing audit exposure simultaneously.

The Undercoding Math — 5-Provider Practice
Encounters/year (5 providers × 25/day × 250 days)31,250
Undercoded at 20%6,250 encounters
Revenue gap per encounter (99214 − 99213)$77
Annual uncaptured revenue$481,250
35–45
Days in AR Benchmark
Commercial insurance
<30
Days in AR Benchmark
Medicare
Denial Management

Root Cause Denial Analysis by Reason Code

Commercial payers deny 7–12% of claims on first submission. Medicaid managed care denial rates run 15–20%. Vizier maps every denial to its reason code, tracks denial rates by payer, provider, and procedure, and surfaces the upstream workflow failure causing each category.

CO-4
Incorrect CPT Code
Procedure code inconsistent with modifier or place of service. Common with split/shared visits and modifier 25 combinations.
CO-97
Duplicate Claim
Claim submitted more than once for same service, date, and beneficiary. Often caused by clearinghouse routing delays or EHR rebilling errors.
PR-204
Service Not Covered
Service is not covered by the patient's plan, not a covered benefit, or requires prior authorization not obtained. High volume in Medicaid managed care.
CO-11
Diagnosis Inconsistent with Procedure
ICD-10 diagnosis code does not support medical necessity for the billed procedure. Requires clinical documentation review before resubmission.
CO-16
Claim Lacks Information
Missing required data elements: NPI, referral number, authorization number, or rendering provider credentials. Fix upstream in the intake workflow.
CO-22
Coordination of Benefits
Another payer may be primary. COB issues are most common in patients with both Medicare and commercial coverage (Medicare Secondary Payer rules).
Commercial InsuranceStable
Denial Rate
7–12%
Days in AR
35–45 days
Medicaid Managed CareIncreasing
Denial Rate
15–20%
Days in AR
45–60 days
Medicare Fee-for-ServiceStable
Denial Rate
3–5%
Days in AR
14–21 days
Medicare AdvantageIncreasing
Denial Rate
8–14%
Days in AR
30–45 days
Payer Performance Benchmarks

Clean Claim Rate Directly Impacts Cash Flow

A clean claim rate below 90% means more than 1 in 10 claims requires rework before payment — adding cost, delay, and write-off risk at every step. Industry top performers maintain clean claim rates above 95%.

Prior authorization denial trends are tracked by procedure code and payer, surfacing which combinations generate the most auth-related denials. Vizier identifies whether your prior auth submission rate matches your order rate — catching the gap before the denial reaches your billing team.

Days in accounts receivable is tracked by payer bucket (0–30, 31–60, 61–90, 90+). Aging above 90 days typically signals either a disputed claim, a payer contracting issue, or a missing authorization — all identified automatically by Vizier.

Revenue Cycle Analytics

See What Your Practice Is Leaving on the Table

Upload your billing data and see your E&M distribution vs. national benchmarks, denial rates by payer and reason code, and the exact dollar amount recoverable with targeted workflow corrections.

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