ILLUSTRATIVE PRODUCT SCENARIO· Synthetic reference software demonstration — not client metrics· Synthetic demo
Chapter 06 · Financial Health Architecture
Hospital Revenue Cycle Management (RCM) & Claims Adjudication
End-to-end hospital financial control coordinating clinical charge aggregation, certified ICD-10/CPT coding review, rule-based claim scrubbing, ANSI ASC X12 EDI 837 clearinghouse batching, and automated ERA 835 remittance reconciliation.
Claims Ledger Matrix
Illustrative Claim Ledger & Clearinghouse Batches
Ref Standard: EDI 837I FormatsRef Standard: ERA 835 Remittance
CLM-88401 — Claim Scrubber & Coding Audit
BlueCross National PPO · Total Billed: $4,850.00
Linked Encounter: ENC-2048 · Patient: Synthetic Patient 84092
Status: Scrubber Passed
Assigned ICD-10-CM Diagnosis Codes
I21.0 (STEMI of anterior wall)
I25.10 (Atherosclerotic heart disease)
Billed CPT Procedure Codes
92928 (Percutaneous transcatheter placement)
99223 (Initial hospital care Level 3)
OPERATIONAL EXCEPTION · CLAIM SCRUBBER HOLD
Missing Anatomical Modifier (RT / LT) on Femoral ORIF Claim CLM-88402
Commercial payers automatically reject unilateral orthopedic procedures lacking anatomical modifiers. Digital Elliptical’s claim scrubber pre-empts costly claim denials by holding unvalidated claims before transmission, requiring certified medical coders to verify operative notes and append modifiers.