The Revedy Workflow: Architecture & Lifecycle Overview
The Revedy Revenue AI Platform operates as an integrated, five-stage pipeline that governs the medical coding and billing lifecycle from initial clinical documentation receipt to post-submission payer response and appeals. This reference document defines each stage of the workflow, the underlying clinical and regulatory validation engines, and the human-in-the-loop governance controls that ensure audit-ready revenue integrity.
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1.End-to-End Pipeline Architecture
Traditional revenue cycle management (RCM) relies on disconnected point solutions for computer-assisted coding, claim scrubbing, coverage verification, and denial management. When these functions operate in silos, clinical evidence captured during encounter documentation is lost before claim adjudication—resulting in preventable medical necessity rejections, NCCI bundling errors, and high administrative costs to collect.
Revedy unifies proactive pre-submission claim scrubbing and reactive post-submission appeals automation against a single Healthcare Knowledge Graph. Every stage preserves verbatim clinical provenance, linking procedures, diagnoses, modifiers, and payer policies into a single auditable record.
Figure 1.0 — Revedy Core Coding, Medical Necessity & Payer Response Pipeline
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2.Workflow Stage Specifications
Each encounter progresses sequentially through five distinct processing stages. Below is the operational specification for each stage illustrated in Figure 1.0, detailing what the engine ingests, how rules and policies are evaluated, and what artifacts are produced.
Stage
01
Multi-channel document ingestion, classification, and clinical parsing.
Receive Case Documentation
The workflow begins when clinical and administrative case files are transmitted to Revedy via our RESTful API (V2/V3 endpoints), automated SFTP batch pipelines, or the web-based case portal. The platform normalizes heterogeneous file formats—including unstructured EHR progress notes, multi-page operative reports, neurophysiological monitoring logs, lab panels, and scanned PDFs—into a structured encounter context.
ClinicalDocument, OperativeNote, DiagnosticReport, PayerResponse) and identifies the clinical specialty for downstream model routing.Stage
02
Procedural extraction, client rule customization, and carrier edit validation.
Code CPT (Procedural Coding & Rule Engine)
Once the encounter context is assembled, Revedy's agentic CPT engine executes a three-tier procedural analysis. Rather than relying on static keyword matching, an orchestrator agent selects specialized clinical tools—such as E/M medical decision-making (MDM) calculators, time-unit aggregators for IONM monitoring, or multi-vessel surgical parsers—and then layers organization-specific and payer-specific rules before finalizing the procedural code set.
-25, -26, -59, -TC, -95) backed by verbatim quotes from the clinical record.95941 to HCPCS G0453 for Medicare claims).Specialty & Capability Reference
Proactive Claim Scrubbing & Undercoding Detection
During CPT extraction, the engine simultaneously audits for both overcoding that triggers bundling denials and undercoding (missed add-on codes or unbilled time units) that causes revenue leakage. See Denial Management & Claim Scrubbing for detailed rule coverage.
Stage
03
ICD-10-CM diagnosis extraction, specificity resolution, and pointer mapping.
Code ICD-10 (Diagnosis Assignment & Specificity)
In Stage 03, the engine assigns ICD-10-CM diagnosis codes in strict accordance with the official CMS and CDC Coding Guidelines required under HIPAA. The engine resolves documented conditions to the highest level of clinical specificity (laterality, acuity, episode of care, and manifestation) and validates relational constraints across all diagnoses on the claim.
Excludes1 (mutually exclusive conditions that must never be billed together), Excludes2, and Code First / Use Additional sequencing rules.Companion Reference Document
Configurable ICD-10-CM Coding Modes (Modes 01, 02, and 03)
Organizations can configure how conservatively the engine assigns diagnosis codes and generates physician queries. Review the companion specification, ICD-10-CM Coding Modes Reference Document, for worked examples and regulatory citations.
Stage
04
Pre-submission policy cross-referencing, gap detection, and risk scoring.
Medical Necessity Validation & Risk Scoring
Before a claim is released for billing, Stage 04 evaluates the combined CPT/HCPCS and ICD-10-CM code pairings against Revedy's Healthcare Knowledge Graph. This graph continuously indexes CMS Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), Medicare Coverage Articles, and commercial payer medical policies by state and carrier.
Capability Reference
Automated Medical Necessity Verification
Explore how our Healthcare Knowledge Graph maps procedures to covered diagnosis lists across Medicare and commercial plans in Automated Medical Necessity Validation and Medical Necessity for Medical Coding.
Stage
05
Automated denial ingestion, policy synthesis, and appeal generation.
Payer Response & Automated Appeals
When a payer returns an adjudication response, Explanation of Benefits (EOB), or claim denial notice, Stage 05 closes the revenue cycle loop. Automated SFTP and API listeners match incoming payer correspondence to the original encounter, evaluate the payer's denial rationale against clinical evidence, and assemble an audit-ready appeal package.
Capability Reference
Turning Denials into Defensible Revenue Recovery
Learn how automated evidence synthesis replaces generic appeal templates in Payer Response & Appeals Automation.
3.Data Artifacts & Knowledge Sources by Stage
The table below summarizes the primary inputs, authoritative knowledge graph datasets, and structured outputs generated across each stage of the Revedy workflow.
| Stage | Primary Inputs | Authoritative Sources Queried | Output Artifacts & Gates |
|---|---|---|---|
01 Ingestion | EHR clinical notes, operative reports, diagnostic logs, DOCX/PDF files, audio transcripts | Document classification taxonomy; specialty-detection models; OCR extraction pipelines | Indexed Encounter JSONSource Span Map |
02 Code CPT | Indexed encounter text, timestamps, anatomical sites, payer/carrier metadata | AMA CPT®, CMS HCPCS, CMS RVU & CLFS fee schedules, NCCI PTP edits, MUE tables, client rulebook | CPT / HCPCS LinesUnits & ModifiersNCCI Audit Log |
03 Code ICD-10 | Assessment/plan, problem list, signs/symptoms, abnormal lab and imaging findings | CDC/CMS ICD-10-CM Official Guidelines, Excludes1/Excludes2 tables, AHIMA/ACDIS query standards | Box 21 ICD-10-CM SetBox 24E PointersGATE:Provider Query (Mode 03) |
04 Medical Necessity | Proposed CPT/ICD-10 pairings, clinical evidence spans, payer & state jurisdiction | CMS Medicare Coverage Database (LCDs, NCDs, Articles), commercial medical policies | Claim Risk ScoreCoverage Gap ReportGATE:ICAT Auditor Queue |
05 Payer Response | 835 ERA files, EOBs, CARC/RARC denial codes, payer denial letters | Original encounter record, DOS-specific LCD/NCD/commercial policy, NCCI & CPT guidelines | Denial Root-Cause BriefCitation-Backed Appeal Letter |
4.Governance, Human-in-the-Loop & Security Controls
Across all five stages of the workflow, Revedy enforces strict architectural safeguards to prevent “black-box” AI behavior, protect against False Claims Act (FCA) exposure, and maintain enterprise-grade data security.
Human-in-the-Loop (ICAT) Governance
Revedy is built to augment—never blindly replace—certified coders and clinical auditors. Through our Human-in-the-Loop (HITL) Intelligent Coding Audit Tool (ICAT), low-confidence encounters or policy exceptions are automatically routed to review queues. Auditors inspect AI recommendations side-by-side with highlighted clinical evidence and can approve or refine codes in a single click. Organizations can also augment their coding workforce with dedicated AI coding agents to scale throughput without sacrificing human oversight.
Verbatim Clinical Provenance
Every CPT code, unit calculation, modifier, ICD-10-CM diagnosis, and medical necessity determination generated by the workflow is permanently linked to its exact character span in the source documentation, the governing rule or policy citation, and a cryptographic timestamp. No code is assigned without traceable clinical evidence.
Temporal Policy & Code Versioning
Healthcare coding sets and payer coverage rules change quarterly and annually. The Revedy Healthcare Knowledge Graph tracks chronological valid_from and valid_to dates for all ICD-10-CM updates, NCCI edits, and Medicare/commercial policies—ensuring both pre-submission scrubbing and retrospective appeals are evaluated against the rules in effect on the Date of Service.
HIPAA Compliance & Enterprise Security
All workflow stages execute within a strictly HIPAA-compliant security architecture backed by Business Associate Agreements (BAAs), HITRUST CSF readiness, OAuth 2.0 authentication, and end-to-end encryption in transit and at rest. For health systems requiring complete data residency control, the entire workflow can also be provisioned via dedicated on-premises or private cloud deployment.
5.Related Reference Documentation & Capabilities
For deeper technical specifications on individual components of the Revedy workflow, consult the following platform documentation and capability guides.
(1)
ICD-10-CM Coding Modes Reference Document
Detailed regulatory specification of Revedy's three configurable ICD-10-CM coding modes (Mode 01 Literal Only, Mode 02 Standard Outpatient Guidelines, and Mode 03 Candidate Diagnoses with AHIMA/ACDIS Compliant Queries), including worked clinical examples.
https://revedy.io/icd10-coding-modes(2)
Human-in-the-Loop (HITL) Governance & Specialty AI Insights
Architectural overview of the Intelligent Coding Audit Tool (ICAT), side-by-side citation verification, auditor approval workflows, and specialty-specific denial prevention benchmarks.
https://revedy.io/ai-insights(3)
Core Platform Capability Guides: Coding, Medical Necessity & Payer Response
Deep-dive functional overviews for each core stage of the revenue cycle pipeline: Pre-Submission Claim Scrubbing & Denial Prevention, Automated Medical Necessity Validation, and AI Payer Response & Appeals Automation.
https://revedy.io/capabilities/coding(4)
Security, HIPAA Compliance & API Integration Documentation
Enterprise security specifications covering HIPAA compliance, HITRUST CSF readiness, and SOC 2 controls, data security protocols, and RESTful API integration endpoints.
https://revedy.io/security