- Denied claims create costly rework, write-offs, and revenue leakage across provider organizations
- Most denials begin upstream, before the claim is submitted, when documentation lacks specificity or coding logic is not applied consistently
- IMO Health’s analysis of 39 million patient encounters found common opportunities to prevent denials through better primary diagnosis selection and greater clinical specificity
- EHR-native, in-workflow guidance can help clinicians identify and resolve issues earlier, without adding external tools or downstream review burden
- Trusted, continuously maintained clinical terminology can reduce rework, protect revenue, and improve ROI across revenue cycle workflows
Reducing rework
Provider organizations are stuck in an endless spiral of rework, write-offs, and revenue loss, triggered by denied claims. As payer requirements become increasingly complex, preventing denials has become a strategic priority.
With the United States revenue cycle management (RCM) market size estimated to surpass $175 billion by 2034, denial rates are steadily climbing1 – 50% of providers reported increases in 2023 alone.2 In fact, denials management ranks as the most time-consuming RCM task among three-quarters of healthcare leaders.2
Managing denials after they occur is costly and resource intensive. IMO Health’s analysis of 39 million patient encounters found that preventing denials at the source – with EHR-native, in-workflow solutions powered by trusted clinical content – offers a more effective route to reducing rework and preventing revenue leakage.
We’re on a mission to eliminate rework. Are you ready to join us?
The challenges of revenue cycle management
Exceptional patient care is not enough to sustain a profitable clinical practice today. Prompt and accurate payment for services is equally vital to safeguard financial performance. This process, known as RCM, spans the healthcare continuum, from registration and appointment scheduling to final collection of payment.
Trusted clinical data is the foundation of effective RCM. Accurate, standardized terminology supports documentation, coding, reimbursement, and data governance, helping organizations reduce denials, capture appropriate reimbursement, and avoid administrative rework. Without it, even routine encounters can result in preventable claim denials and write-offs.
Inaccurate or incomplete clinical data can also trigger peer-to-peer reviews, pulling clinicians and support staff away from patient care, and distracting them with preventable administrative work. Many organizations respond by adding staff to manage denials and appeals, increasing costs without addressing the underlying cause.
Denials begin long before the claim
Denials almost always start upstream; they rarely begin with the claim itself.
In surgical care, inaccurate procedure data, outdated code mappings, or missing clinical specificity can lead to scheduling errors, incorrect site-of-care decisions, prior authorization delays, and medical necessity denials before a patient ever reaches the operating room.
Further complicating the matter is the looming end of Medicare’s IPO list and the growing complexity of payer requirements. These factors make maintaining accurate CPT®/HCPCS mappings and standardized clinical terminology essential across care settings.
The same principle applies throughout the revenue cycle. ICD-10-CM coding conflicts, including Excludes1 edits, missing laterality, and diagnosis specificity issues can delay reimbursement, increase rework, and contribute to preventable revenue leakage.
Rather than identifying these issues after claims are submitted, leading organizations are embedding trusted clinical terminology and decision support directly into clinical and operational workflows, allowing teams to prevent many denials before they occur.
CASE STUDY
Maintaining accurate code mappings with IMO Core Periop
Maintaining accurate clinical data internally is resource-intensive and expensive. One Midwestern health system spent 15 months building and maintaining CPT/HCPCS mappings for surgical-based procedures. Despite these efforts, inaccurate mappings continued to contribute to prior authorization denials, IPO-related reimbursement challenges, and costly write-offs.
After implementing IMO Core Periop, the organization corrected 1,800 CPT/HCPCS codes, reduced claims requiring rework, and decreased annual write-offs by more than $6.4M.
A proactive approach to denials management
To quantify the challenges of increasingly complex payer rules, IMO Health analyzed 39 million patient records from 20 distinct sites, using several large electronic health record (EHR) vendors.
We found that 8.8% of all encounters nationwide were initially coded with non-primary diagnoses, resulting in rework, denials, or write-offs. For example, a UPD (unacceptable primary diagnosis) might look like W21.02XA: Struck by football, initial encounter. The injury itself (incurred from an external cause) should be the primary diagnosis.
We also discovered that 25% of all encounters were documented with codes that could have been refined for greater specificity. For example, M25.569: Pain in unspecified knee could be refined to M25.561: Pain in right knee.
These findings support the conclusion that many denials are both predictable and preventable when clinicians receive timely guidance at the point of care. Rather than relying on downstream reviews and manual intervention, health systems have an opportunity to identify and address many documentation and coding issues before claims are submitted.
IMO Health’s portfolio of EHR-compatible content solutions supports this approach by embedding trusted clinical terminology directly into existing workflows. From Procedure Validation Sets (PVS), which help streamline perioperative workflows, to IMO Core’s real-time documentation guidance, our content solutions translate administrative coding and payer logic into clinician-friendly language – while preserving physician autonomy.
Continuously maintained by expert coders, mappers, and clinical informaticists, IMO Health’s content stays current with evolving coding standards, payer requirements, and regulatory changes – reducing the burden of ongoing maintenance while helping organizations protect revenue.
Common unspecified diagnoses that lead to denials
| Unspecified term | ICD-10-CM | Specified term | ICD-10-CM |
|---|---|---|---|
| Cellulitis of unspecified toe | L03.039 | Cellulitis of left toe | L03.032 |
| Malignant neoplasm of colon, unspecified | C18.9 | Malignant neoplasm of transverse colon | C18.4 |
| Malignant neoplasm of female breast | C50.919 | Malignant neoplasm of upper-outer quadrant of left female breast | C50.412 |
| Post-traumatic stress disorder, unspecified | F43.10 | Post-traumatic stress disorder, acute | F43.11 |
In short, IMO Health’s portfolio enables health systems to:
- Catch issues early – Identify potential denials before submission.
- Guide clinicians – Translate payer rules into clear, actionable prompts.
- Resolve in workflow – Correct documentation without leaving the EHR.
- Maintain continuously – IMO Health experts keep terminology and mappings current.
CASE STUDY
The MetroHealth System: An administrative coding success story
Like nearly all health systems across the US, The MetroHealth System, a non-profit public health system located in Cleveland, Ohio, faced significant RCM challenges, causing them to lose revenue. For starters, they were seeing a high volume of denied claims due to UPD and unspecified laterality. They were also spending precious time and resources clarifying clinical details, correcting codes, and resubmitting claims. Something needed to change.
In early 2024, MetroHealth implemented value sets available in IMO Health’s library for non-primary codes and unspecified codes. Leveraging these value sets, they configured their EHR to send clinician-facing alerts, prompting them to correct non-primary codes or add specificity before patient encounters were closed and claims submitted.
The impact was immediate. By leveraging our solution, MetroHealth saw the following results:
67% reduction in denials
Resolution of 75% of opportunities with a “soft stop” notification
Over 2,000 hours of coding saved
A 10x annualized ROI
The bottom line
Preventing denials starts long before a claim is submitted. It starts with trusted clinical data embedded into physician workflows, helping healthcare organizations reduce rework, protect revenue, and give clinicians more time to focus on patient care.
For more than three decades, IMO Health has helped healthcare organizations improve clinical data quality through expert-maintained content. Today, that same expertise helps organizations keep pace with evolving payer requirements and strengthen revenue cycle performance through AI-native, EHR-compatible content solutions.
It’s time to stop the cycle of denials, rework, and write-offs – with prevention, not more tools. We’re ready when you are.
To learn more, contact us at sales@imohealth.com or 847-272-1242 to talk with a team member today.
For a complimentary data quality assessment, please go to imohealth.com/data-quality-assessment.
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1U.S. Revenue Cycle Management Market Size, Share and Trends 2024 to 2034. 02 Sep 2024. Accessed via: https://www.precedenceresearch.com/us-revenue-cycle-management-market
2Top 8 Healthcare Revenue Cycle Trends for 2024. 28 Nov 2023. Accessed via: https://akasa.com/blog/revenue-cycle-trends/
