RCI for Billers & Coders

Coding guidance, payment expectations, filing deadlines, and denial resolution

15-20% of claims are denied on first submission. 35% of providers say staffing is their top RCM problem. Experienced billers retire and the knowledge leaves with them. You spend your day making sure claims get paid — RCI gives you the billing knowledge you need before you submit, and the tools to fix it when something goes wrong.

What RCI does for you

Before you bill

Task	How RCI helps	Endpoint
Find the right code	AI agent researches CPT/HCPCS codes and tells you which one fits, with documentation requirements	POST /v1/agents/code-research
Know the billing form	CMS-1500 or UB-04? RCI determines this from the facility type	POST /v1/knowledge/billing-guide
Check modifiers	Which modifiers apply to this procedure at this facility in this setting?	POST /v1/knowledge/resolve
Estimate payment	Expected Medicare reimbursement based on RVU × GPCI × conversion factor	POST /v1/knowledge/payment-calc
Know the filing deadline	Payer-specific timely filing limits so you never miss a window	L4 payer rules
Check prior auth	Does this payer require prior authorization for this service?	L4 payer rules

When a claim is denied

Task	How RCI helps	Endpoint
Understand the denial	AI agent interprets CARC/RARC codes and explains what went wrong	POST /v1/agents/denial-resolution
Get appeal deadlines	Payer-specific appeal levels with exact deadlines	L4 payer rules
Build the appeal	AI generates an appeal strategy with recommended documentation	Denial resolution agent
Check medical necessity	If denied for medical necessity, AI validates against NCD/LCD criteria	POST /v1/agents/medical-necessity

Example: Complete billing workflow

1. You receive an order for CPT 99214 at facility 170001

curl -X POST https://api-dev.rcintell.com/v1/knowledge/resolve \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "170001",
    "cpt": "99214",
    "payer": "Medicare",
    "care_setting": "outpatient"
  }'

RCI tells you:

• Billing form: CMS-1500 / 837P
• Place of service: 22 (Outpatient Hospital)
• Expected payment: $107.42
• Filing deadline: 12 months from date of service
• Modifier requirements: Site-of-service differential applies

2. The claim is denied — CARC 197 (prior auth not obtained)

curl -X POST https://api-dev.rcintell.com/v1/agents/denial-resolution \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Claim denied for lack of prior authorization",
    "carc": "197",
    "rarc": "N479",
    "ccn": "170001"
  }'

RCI tells you:

• CARC 197: Precertification/authorization/notification absent
• Recommended action: Request retroactive authorization, then appeal
• Appeal deadline: 60 days (Medicare Redetermination)
• Appeal level: Redetermination → QIC → ALJ → Medicare Appeals Council

3. You’re unsure about the correct code for a procedure

curl -X POST https://api-dev.rcintell.com/v1/agents/code-research \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Patient had a laparoscopic cholecystectomy with intraoperative cholangiography. What CPT codes?",
    "ccn": "170001"
  }'

RCI’s AI agent researches the codes and returns the primary CPT, add-on codes, documentation requirements, and common modifiers.

What you get from each knowledge layer

Layer	What it means for billing
L1 Location	GPCI values determine how much payment is adjusted for your area
L2 Facility	Tells you which claim form to use and which payment system applies
L3 Setting	Place of service code and whether facility or non-facility rates apply
L4 Payer	Filing deadlines, appeal windows, prior auth requirements — the rules you live by
L5 Service Group	Documentation requirements and coding rules for the procedure category
L6 Service	The actual dollar amount — RVU breakdown and expected reimbursement

Related APIs

Need	Guide
Cited payer policy	Payer policies
340B manufacturer rules	340B
Prior auth before you bill	Prior authorization
Raw CMS fee schedule rows	Fee schedules
Which endpoint to pick	Which API to use