medical-billing v1.0.0A

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---
name: medical-billing
description: Analyze medical billing software for claims processing, revenue cycle optimization, code validation, payer rules, denial management, and compliance.
version: "1.0.0"
category: analysis
platforms:
  - CLAUDE_CODE
---

You are in AUTONOMOUS MODE. Do NOT ask questions. Analyze the entire billing codebase systematically for completeness, correctness, and optimization opportunities.

TARGET:
$ARGUMENTS

If no arguments provided, analyze the entire project in the current working directory
for medical billing capabilities. If a specific area is named (e.g., "claims",
"denials", "coding"), focus there but still note cross-cutting issues.

============================================================
PHASE 0: BILLING SYSTEM CHARACTERIZATION
============================================================

Identify the billing system type and scope:

1. Detect tech stack (package.json, requirements.txt, pom.xml, etc.).
2. Classify the billing system:
   - Practice management system (PMS)
   - Revenue cycle management (RCM) platform
   - Claims clearinghouse
   - Billing service / billing module within EHR
   - Patient billing / payment portal
   - Coding assistance / CAC tool
3. Identify billing-specific dependencies and integrations:
   - EDI libraries (X12, ANSI 837/835/270/271/276/277)
   - Code sets (ICD-10, CPT, HCPCS, revenue codes)
   - Payer APIs (Availity, Change Healthcare, Trizetto, etc.)
   - Payment processors (Stripe, Square, patient payment gateways)
   - Clearinghouse integrations
4. Map billing data models:
   - Claims / encounters
   - Charges / line items
   - Payments / adjustments
   - Patients / guarantors / subscribers
   - Payers / insurance plans
   - Providers / rendering/billing/referring

============================================================
PHASE 1: CLAIMS PROCESSING ANALYSIS
============================================================

Review claims processing pipeline:

CLAIM CREATION:
- Check claim data model against X12 837P (professional) or 837I (institutional).
- Verify required fields: patient demographics, subscriber info, provider NPI,
  diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), place of service,
  date of service, charges, units.
- Check for claim type differentiation (primary, secondary, tertiary).
- Verify coordination of benefits (COB) handling for secondary claims.
- Check for claim splitting logic (when required by payer rules).

CLAIM VALIDATION:
- Check for pre-submission claim scrubbing:
  - ICD-10 code validation (format, active status, specificity).
  - CPT code validation (format, gender/age edits).
  - Diagnosis-procedure linkage validation.
  - NCCI edit checking (procedure-to-procedure bundling rules).
  - Medically unlikely edit (MUE) checking (units validation).
  - Place of service / procedure compatibility.
  - Modifier validation (appropriate modifier for procedure).
  - Timely filing verification (days from DOS to submission).
- Flag missing validation steps that lead to preventable denials.
- Check for payer-specific validation rules.

EDI TRANSACTION HANDLING:
- 837P/837I (Claim Submission):
  - Verify proper X12 segment generation (ISA, GS, ST, BHT, CLM, SV1/SV2, etc.).
  - Check for loop structure correctness (2000A/B/C, 2300, 2400).
  - Verify trading partner ID configuration.
- 835 (Electronic Remittance Advice):
  - Check for 835 parsing implementation.
  - Verify payment/adjustment posting automation.
  - Check CARC/RARC code handling (Claim Adjustment Reason Codes).
  - Verify contractual adjustment vs patient responsibility separation.
- 270/271 (Eligibility):
  - Check for real-time eligibility verification.
  - Verify benefit parsing (copay, deductible, coinsurance, out-of-pocket).
  - Check for eligibility caching strategy (reduce redundant calls).
- 276/277 (Claim Status):
  - Check for automated claim status inquiry.
  - Verify status tracking and notification.

CLAIM LIFECYCLE:
- Map claim statuses: draft -> validated -> submitted -> acknowledged ->
  adjudicated -> paid/denied/partially_paid -> appealed -> closed.
- Verify status transition rules and audit trail.
- Check for automated resubmission on correctable rejections.
- Verify batch vs real-time submission support.

============================================================
PHASE 2: CODING AND CODE VALIDATION
============================================================

Review medical coding implementation:

ICD-10-CM DIAGNOSIS CODING:
- Check for ICD-10-CM code lookup / search functionality.
- Verify code specificity enforcement (highest level of specificity required).
- Check for code combination rules (e.g., manifestation codes require etiology first).
- Verify excludes1 / excludes2 edit checking.
- Check for annual code set update mechanism (effective October 1 each year).
- Verify code description storage and display.
- Check for laterality enforcement where applicable.
- Verify 7th character extension handling (e.g., fracture initial/subsequent/sequela).

CPT/HCPCS PROCEDURE CODING:
- Check for CPT code validation and lookup.
- Verify modifier handling and validation:
  - Modifier 25 (significant, separately identifiable E/M)
  - Modifier 59 / X{EPSU} (distinct procedural service)
  - Modifier 26/TC (professional/technical component)
  - Modifier 76/77 (repeat procedure)
- Check for HCPCS Level II code support (supplies, DME, drugs).
- Verify add-on code rules (must be reported with primary code).
- Check for code bundling rules enforcement.
- Verify annual code update mechanism.

REVENUE CODES (INSTITUTIONAL):
- Check for revenue code assignment logic.
- Verify revenue code / CPT code compatibility.
- Check for charge description master (CDM) management.

CODING AUTOMATION:
- Check for computer-assisted coding (CAC) features.
- Verify auto-coding suggestions from clinical documentation.
- Check for coding confidence scores and review workflows.
- Verify encoder integration if present.

============================================================
PHASE 3: REVENUE CYCLE ANALYSIS
============================================================

Review end-to-end revenue cycle:

CHARGE CAPTURE:
- Check for charge capture completeness mechanisms.
- Verify charge entry workflow (manual and automated).
- Check for missing charge detection (appointments without charges).
- Verify fee schedule management (Medicare, commercial, self-pay).
- Check for charge lag tracking (days from DOS to charge entry).

PAYMENT PROCESSING:
- Check for payment posting workflow (electronic and manual).
- Verify ERA (835) auto-posting accuracy.
- Check for patient payment processing (credit card, payment plans, statements).
- Verify payment allocation logic (FIFO, specific claim, balance forward).
- Check for overpayment detection and refund workflows.

ACCOUNTS RECEIVABLE:
- Check for AR aging analysis (0-30, 31-60, 61-90, 91-120, 120+ days).
- Verify AR follow-up workflow and task assignment.
- Check for collection agency integration.
- Verify bad debt write-off workflow.
- Check for AR dashboard and reporting.

DENIAL MANAGEMENT:
- Check for denial tracking and categorization.
- Verify denial reason code analysis (CARC/RARC mapping to actionable categories).
- Check for denial trend reporting (by payer, provider, procedure, reason).
- Verify appeal workflow implementation:
  - Appeal letter generation
  - Supporting documentation attachment
  - Appeal deadline tracking
  - Appeal outcome tracking
- Check for root cause analysis on recurring denials.
- Verify corrected claim (frequency code 7) submission workflow.

PRIOR AUTHORIZATION:
- Check for prior authorization request workflow.
- Verify auth tracking (pending, approved, denied, expired).
- Check for auth-to-claim linking (verify auth exists before claim submission).
- Verify auth expiration alerting.
- Check for auth requirement rules engine (which procedures/payers need auth).

FINANCIAL REPORTING:
- Check for key RCM metrics:
  - Days in AR
  - Clean claim rate
  - First-pass resolution rate
  - Denial rate (by category)
  - Collection rate
  - Cost to collect
  - Net collection rate
- Verify month-end / period-close procedures.
- Check for revenue forecasting capabilities.

============================================================
PHASE 4: PAYER RULES ENGINE
============================================================

Review payer-specific rules handling:

PAYER CONFIGURATION:
- Check for payer master data (payer ID, name, EDI info, contacts).
- Verify per-payer configuration capability:
  - Filing deadlines
  - Required attachments
  - Authorization requirements
  - Coding preferences (modifier usage, bundling exceptions)
  - Payment terms and expected reimbursement

RULES ENGINE:
- Check for configurable rules engine (not hardcoded payer logic).
- Verify rule types supported:
  - Pre-submission edits
  - Coding edits
  - Authorization rules
  - Filing limit rules
  - Reimbursement calculation rules
- Check for rule versioning and effective dates.
- Verify rule testing/simulation capability.

CONTRACT MANAGEMENT:
- Check for payer contract terms storage.
- Verify fee schedule loading (by payer, by contract).
- Check for expected reimbursement calculation.
- Verify underpayment detection (actual vs expected payment).
- Check for contract renewal tracking.

============================================================
PHASE 5: COMPLIANCE REVIEW
============================================================

Review billing compliance:

ANTI-KICKBACK / STARK:
- Check for referral tracking and source documentation.
- Flag any automated referral fee or bonus calculations tied to referral volume.
- Verify fair market value documentation for compensation arrangements.

FALSE CLAIMS ACT:
- Check for upcoding detection (higher-level codes than documented).
- Verify unbundling detection (separate billing for bundled services).
- Check for duplicate claim detection.
- Verify medical necessity documentation linkage.

COMPLIANCE CONTROLS:
- Check for coding audit trail (who coded, when, what changed).
- Verify supervisor review workflows for high-risk claims.
- Check for compliance alert configuration (unusual patterns).
- Verify provider credential verification before billing (NPI active, enrolled).

PATIENT BILLING COMPLIANCE:
- Check for surprise billing protections (No Surprises Act compliance).
- Verify good faith estimate generation for self-pay patients.
- Check for price transparency compliance (machine-readable files).
- Verify patient financial assistance screening.

============================================================
OUTPUT
============================================================

## Medical Billing Analysis Report

**Project:** [name]
**Stack:** [detected technologies]
**System Type:** [PMS/RCM/clearinghouse/etc.]
**Date:** [date]

### Revenue Cycle Coverage

| Module | Implemented | Completeness | Issues |
|---|---|---|---|
| Charge Capture | [Yes/No] | [%] | N |
| Claim Creation | [Yes/No] | [%] | N |
| Claim Validation | [Yes/No] | [%] | N |
| EDI Transactions | [Yes/No] | [%] | N |
| Payment Processing | [Yes/No] | [%] | N |
| Denial Management | [Yes/No] | [%] | N |
| Prior Authorization | [Yes/No] | [%] | N |
| AR Management | [Yes/No] | [%] | N |
| Payer Rules | [Yes/No] | [%] | N |
| Reporting | [Yes/No] | [%] | N |

### Code Validation Assessment

| Code Set | Validation | Lookup | Annual Updates | Edits | Status |
|---|---|---|---|---|---|
| ICD-10-CM | [Yes/No] | [Yes/No] | [mechanism] | [specificity/excludes] | [OK/GAPS] |
| CPT | [Yes/No] | [Yes/No] | [mechanism] | [bundling/modifiers] | [OK/GAPS] |
| HCPCS | [Yes/No] | [Yes/No] | [mechanism] | [coverage] | [OK/GAPS] |
| Revenue Codes | [Yes/No] | [Yes/No] | [mechanism] | [compatibility] | [OK/GAPS] |

### EDI Transaction Support

| Transaction | Direction | Implementation | Automation | Status |
|---|---|---|---|---|
| 837P (Claims) | Outbound | [Yes/No] | [batch/realtime] | [OK/GAPS] |
| 837I (Claims) | Outbound | [Yes/No] | [batch/realtime] | [OK/GAPS] |
| 835 (Remittance) | Inbound | [Yes/No] | [auto-post?] | [OK/GAPS] |
| 270/271 (Eligibility) | Both | [Yes/No] | [realtime?] | [OK/GAPS] |
| 276/277 (Status) | Both | [Yes/No] | [automated?] | [OK/GAPS] |

### Denial Prevention Gaps
[List of missing validations that cause preventable denials, ranked by estimated volume impact]

### Revenue Leakage Risks
[List of charge capture gaps, underpayment detection gaps, or process failures that leak revenue]

### Detailed Findings

| # | Area | Severity | File | Issue | Revenue Impact | Fix |
|---|------|----------|------|-------|----------------|-----|
| 1 | Claims | High | path/to/file.ts | Missing NCCI edit check | Preventable denials | Implement NCCI bundling rules |

### Optimization Roadmap
[Ordered by revenue impact, then effort]

============================================================
NEXT STEPS
============================================================

After reviewing the analysis:
- "Run `/healthcare-api` to build missing EDI or claims API endpoints."
- "Run `/clinical-data-review` to verify coding data models against standard code sets."
- "Run `/healthcare-compliance` to audit broader regulatory compliance."
- "Run `/healthcare-ops` to evaluate billing workflow efficiency in the operational context."
- "Run `/database-review` to optimize billing data model performance for AR reporting."

============================================================
DO NOT
============================================================

- Do NOT modify any code -- this is an analysis skill, not a build skill.
- Do NOT provide specific CPT or ICD-10 coding guidance for patient encounters -- that is clinical coding, not software analysis.
- Do NOT expose actual patient billing data found in code or test fixtures -- redact amounts and identifiers.
- Do NOT skip EDI transaction analysis -- EDI is the backbone of claims processing.
- Do NOT assume single-payer operations unless the code confirms it.
- Do NOT ignore denial management -- denial rates directly impact revenue.
- Do NOT install external tools -- analyze code, schemas, and configuration directly.
- Do NOT provide legal advice on compliance -- flag issues for compliance officer review.