Audit
Denial Risk
Probability that a submitted diagnosis or procedure code is rejected, downcoded, or sent to medical review.
Definition
Denial risk is a forward-looking estimate of the likelihood that a payer will reject or downcode a claim line. Common drivers include missing supporting documentation, mismatched age / sex restrictions, missing required companion codes (e.g., a manifestation code without its etiology), and codes that lack medical necessity for the place-of-service.
AutoICD's denial-risk capability is a documentation-quality reasoner: it asks the LLM to inspect the submitted codes against the chart, flag combinations that would typically attract a CO-50 (medical necessity), CO-16 (information missing), or CO-11 (diagnosis inconsistent with procedure) denial, and quantify expected rework cost using CMS-published per-claim rework estimates.
The current implementation does not yet ingest payer-specific LCD / NCD coverage rules; it relies on documentation-quality reasoning and CMS-published age / sex code restrictions. Plan-specific medical policy support is planned for a later release.
When to use
- •You're seeing high denial rates and want to triage before billing.
- •You're building pre-bill checks into a coding workflow.
- •You want a conservative second opinion on borderline coding decisions.
Try it in AutoICD API
Estimate denial risk on a submitted bill
curl -X POST https://autoicdapi.com/v1/audit \
-H "Authorization: Bearer $AUTOICD_API_KEY" \
-H "Content-Type: application/json" \
-d '{
"text": "F75 here for routine well visit. No acute concerns.",
"submitted_codes": ["Z00.00", "I10"],
"capabilities": ["denial"]
}'Language: bash. View full API docs · Get an API key.