Coder Workbench: A Risk Adjustment Solution

The Coder Workbench solution is designed for Medicare Advantage health plans and risk adjustment organizations. It supports health plan leaders such as Vice Presidents of Operations, Directors of Risk Adjustment, and Compliance Officers, as well as the day-to-day work of risk adjustment coders, quality assurance auditors, and managers responsible for coding accuracy and audit response.

The platform is used for multiple risk adjustment coding initiatives, including retrospective chart review projects with integrated claim linking and regulatory audit response through the Regulatory Audit Module, supporting audits such as RADV, OIG, and internal mock audits.

Coder Workbench uses clinically trained, non-generative AI to read and interpret unstructured medical records, including scanned PDFs. The technology applies optical character recognition (OCR) and natural language processing (NLP) to understand full clinical notes—such as provider type, note type, section, dates of service, and clinical context—so it can accurately identify diagnoses that are documented by the provider.

The system distinguishes between active, historical, negated, and ruled-out conditions and surfaces only current, risk adjusted diagnoses within the project year supported by documentation. It also identifies and organizes clinical supporting documentation (i.e. MEAT criteria) and presents all evidence transparently for coder review.

Yes. The Regulatory Audit Module within Coder Workbench is designed to support multiple audit types, including CMS MA RADV audits, HHS ACA RADV audits,  OIG audits, IPM audits, and internal mock RADV audits. The module provides structured workflows, project management dashboards, detailed patient-level coding results with confidence scores, and exportable reporting to help teams manage audit timelines, documentation, and stakeholder reporting.

The platform is designed to support compliant risk adjustment coding by embedding CMS and ICD-10-CM coding principles directly into the workflow. It surfaces diagnoses and supporting documentation transparently, allowing coders to apply their professional judgment while clearly seeing how each condition is supported within the medical record.

The platform includes a fully integrated coding, quality assurance, rebuttal, and arbitration workflow that supports compliant risk adjustment practices from initial review through final resolution. All coding actions, supporting evidence, and review outcomes are captured within a single system, providing traceability and consistency across teams, vendors, and audit activities.

The Regulatory Audit Module helps teams prioritize the strongest encounter for submission by analyzing documentation and classifying each condition as a match, higher, lower, or additional HCC as compared to what is being audited. For each diagnosis, the platform provides a confidence score based on documentation completeness and clinical support.

Final coding decisions are made by coders and auditors, who review all supporting evidence directly within the workflow. The platform also verifies required administrative elements—such as provider signatures, eligible note types, and correct dates of service—so teams can focus on encounters that are both defensible and administratively complete.