SMART on FHIR · AI-Powered · HIPAA-Aligned

Suggest. Validate. Audit. AI for medical coding.

HIMIO gives your coding team three AI-powered modes: generate a complete ICD-10 code set from scratch, validate codes already assigned, or run a full clinical audit for DRG optimization and compliance — every code anchored to a verbatim quote from the chart.

Built for acute-care hospitals, health systems & HIM departments

Designed for healthcare revenue cycle teams

Acute Care Hospitals
Health Systems
HIM Departments
Revenue Cycle Vendors
CDI Programs
Three Modes, One Platform

Suggest. Validate. Audit.

Three distinct AI workflows built for every point in the coding process — from a blank chart to claim submission. Every code anchored to a verbatim quote from the chart.

Suggest Validate Audit
01
Suggest
Code from a blank chart

Start with an uncoded chart. HIMIO reads the full clinical documentation, extracts every codeable concept, retrieves CMS-verified ICD-10 candidates, and builds a complete code set — PDx sequenced first, all SDx and ICD-10-PCS procedures included.

  • Multi-step RAG pipeline: extract → retrieve → re-rank
  • PDx selected per Official Coding Guidelines & UHDDS
  • ICD-10-PCS procedure extraction included
  • Queries generated for ambiguous documentation
02
Validate
Check codes already assigned

Already have codes? Enter your code set and upload the chart. HIMIO cross-references every code against the documentation, flags missing MCCs and CCs with the exact note that supports them, and surfaces DRG impact — before the claim goes out.

  • Every gap backed by a verbatim evidence quote
  • UHDDS basis verified for each secondary diagnosis
  • CC/MCC checked against CMS FY2026 tables
  • DRG impact shown per missing code
03
Audit
Full clinical documentation review

A complete clinical documentation integrity review — via live Epic FHIR integration or standalone chart upload. HIMIO runs DRG optimization, compliance flag detection, POA/HAC analysis, and full-chart reconciliation, with queries ready to send.

  • SMART on FHIR live Epic integration — no uploads needed
  • DRG optimization with estimated reimbursement delta
  • Compliance flags: upcoding, POA, HAC/PSI, laterality
  • Reconciliation: missed codes, missed queries, exclusions

Live EHR Integration via SMART on FHIR

Connect to Epic and any FHIR R4-compliant EHR with a single OAuth2 login. HIMIO pulls demographics, encounters, diagnoses, procedures, labs, and documents in real time — no manual exports.

AHIMA/ACDIS Physician Queries

Non-leading, multiple-choice physician queries generated automatically — compliant with AHIMA and ACDIS standards, pre-populated with clinical indicators from the chart, ready to send in one click.

Compliance Flag Detection

Upcoding risk, POA errors, laterality mismatches, HAC/PSI exposure — each flagged HIGH, MEDIUM, or LOW with the specific guideline violated. Catch it before submission, not after a RAC demand letter.

All three modes run the same multi-step AI pipeline on a single SMART on FHIR connection to Epic or any FHIR R4 EHR — one OAuth2 login, no manual chart uploads, no PHI stored.

How It Works

Pick your mode. Upload or connect. Results in under 60 seconds.

All three modes run the same multi-step AI pipeline — the difference is what you start with and what you get back.

1

Connect Your EHR or Upload the Chart

Launch HIMIO directly from Epic via SMART on FHIR for live chart data — or upload the discharge summary, H&P, operative notes, labs, and radiology reports as PDF, DOCX, or HL7. In Validate mode, also enter the codes your coder has already assigned.

Epic SMART LaunchFHIR R4PDF / DOCX / HL7 UploadValidate: enter existing codes
2

AI Extracts Every Codeable Concept

HIMIO reads the full clinical record and extracts structured concepts — diagnoses, procedures, conditions, device status, and more — each tagged with UHDDS reportability basis, POA status, and a verbatim evidence quote from the chart.

UHDDS: EVALUATED / TREATED / MONITOREDPOA flaggingVerbatim evidence quotes
3

RAG Pipeline Retrieves & Ranks ICD-10 Candidates

Each concept is matched against the CMS FY2026 ICD-10-CM/PCS dictionary using hybrid keyword + semantic search. Candidates are re-ranked by CC/MCC designation, MS-DRG impact, and guideline specificity. PDx is selected per UHDDS and Official Coding Guidelines.

CMS FY2026 ICD-10-CM/PCSMS-DRG v43.0 grouper logicCC/MCC captureReal-time streaming
4

Review Findings, Queries & Gaps

Results stream back in real time. Review your suggested or validated code set, DRG optimization impact, compliance flags, and reconciliation buckets — missed codes, missed queries, and intentional exclusions. Generate AHIMA-compliant queries and export the full audit packet.

Missed codes → add to claimMissed queries → send to physicianIntentional exclusions → audit trailPDF export
Impact

Built for the clinical and financial realities of inpatient coding

<60s
Average time from FHIR launch to complete audit results
100%
Audit checks backed by cited clinical evidence from the chart
9+
Distinct audit check types — CC/MCC, HAC/PSI, POA, laterality and more
0 PHI
Patient identifiers stored — only encounter IDs and diagnosis codes persisted
Security & Compliance

HIPAA-aligned from the ground up

HIMIO is built with the same security controls your compliance team expects from enterprise clinical software.

Append-Only Audit Logs (HIPAA §164.312(b))

Every access, query, case action, and login event is written to an immutable audit trail. The application role cannot modify or delete log records — satisfying HIPAA access audit requirements.

No PHI Storage

Patient names, dates of birth, and MRNs are fetched from the FHIR server at audit time but never written to the HIMIO database. Only encounter IDs and coded diagnosis data are persisted.

Multi-Tenant Row-Level Security

Supabase Row-Level Security policies enforce strict tenant isolation. No facility can access another facility's cases or findings, even if they share the same database instance.

BAA-Ready Infrastructure

Designed to operate under Business Associate Agreements with all underlying technology vendors. BAA execution is supported for covered entities across our full infrastructure stack.

Security Controls Enabled
HTTPS enforced with HSTSTRANSPORT
Secure, httpOnly session cookiesSESSION
X-Frame-Options: DENYXSS
MIME sniffing preventionXSS
Referrer-Policy enforcedPRIVACY
Row-Level Security (RLS) in PostgresTENANT
Append-only audit_logs tableHIPAA
Token refresh + scoped FHIR accessOAUTH2
No PHI written to databaseMIN USE
BAA-compatible vendor stackCONTRACT
Who It's For

Built for every role in your revenue cycle team

HIMIO adapts to the workflow of each clinician and coder who touches the chart.

Healthcare Coders

Use Suggest on uncoded charts or Validate your own code set. Get verbatim evidence quotes for every code — no more second-guessing PDx sequencing or CC/MCC capture.

CDI Specialists

Run Audit on concurrent charts before rounds. HIMIO surfaces documentation gaps, POA ambiguities, and pre-drafts compliant physician queries ready to send.

Compliance Officers

Use Audit to spot-check claims before submission and run retrospective reviews. Every finding is traceable to a specific ICD-10 guideline, CMS rule, or chart line.

Physician Advisors

Review AI-drafted queries before they go to physicians. AHIMA and ACDIS standards enforced automatically — no leading questions, ever.

Revenue Cycle Managers

Track Suggest, Validate, and Audit activity across cases. See DRG optimization impact and compliance flag exposure before claims leave the facility.

Coding Staffing Services

Experienced coders, ready when you need them

Beyond AI-powered audits, Synergy HIM Tech provides flexible coding staffing for inpatient, outpatient, and HCC programs — certified professionals who integrate with your team on day one, whether you need surge support or long-term coverage.

Inpatient

Inpatient Coding

Complex acute care coding demands deep expertise in MS-DRG logic, POA indicators, CC/MCC capture, and HAC/PSI rules. Our inpatient coders bring facility-specific experience across medical, surgical, cardiac, orthopedic, and critical care service lines.

  • ICD-10-CM/PCS coding per Official Guidelines
  • MS-DRG grouping & case mix optimization
  • POA, HAC, and PSI accurate assignment
  • Discharge summary, op report & H&P review
  • CCS / RHIT / RHIA credentialed coders
  • Productivity: 4–5 complex charts per hour
Outpatient

Outpatient Coding

From ED visits to same-day surgery and ancillary services, our outpatient coders handle the full breadth of facility and pro-fee coding — with the speed and accuracy your revenue cycle demands across all payer types.

  • ICD-10-CM & CPT/HCPCS coding
  • ED, observation, ambulatory surgery, radiology
  • Evaluation & Management (E&M) level assignment
  • Modifier application & bundling rules
  • CPC / COC / CCS-P credentialed coders
  • Productivity: 10–20 charts per hour
HCC / Risk Adjustment

HCC Coding

Hierarchical Condition Category coding directly impacts RAF scores, Medicare Advantage reimbursement, and ACO performance. Our CRC-certified HCC specialists ensure chronic conditions are fully documented, accurately coded, and compliant with CMS risk adjustment models.

  • CMS-HCC & HHS-HCC model expertise
  • RAF score optimization & gap closure
  • Annual wellness visit & retrospective reviews
  • Medicare Advantage, ACA, ACO programs
  • CRC credentialed coders (AAPC)
  • Chronic condition capture & documentation review

Why facilities choose Synergy HIM Tech for staffing

95%+ First-Pass Accuracy

Every coder meets our accuracy threshold before placement. Ongoing QA audits maintain quality throughout the engagement.

Rapid Deployment

We place qualified coders within days, not weeks. Surge support, backlog clearance, or planned leave coverage — we move at your pace.

AAPC & AHIMA Certified

All coders hold active CCS, CPC, CRC, RHIT, or RHIA credentials with a minimum of 2 years hands-on coding experience.

HIPAA-Compliant Remote Coders

Fully vetted remote workforce operating from secured, HIPAA-compliant workstations — BAA executed with every engagement.

Flexible Engagement Models

Short-term surge, long-term outsourcing, or hybrid. Scale up or down as your volume demands — no long-term contracts required.

EHR-Ready from Day One

Our coders have experience across Epic, Cerner, MEDITECH, and Allscripts — minimal onboarding time, maximum productivity from the start.

95%+
First-pass coding accuracy across all service lines
48hr
Average time to place a qualified coder
3
Specialties covered — inpatient, outpatient & HCC
100%
AAPC or AHIMA credentialed coders, BAA executed
Get in Touch

Let's talk about your HIM needs

Whether you're looking for a HIMIO demo or need experienced coding staff for inpatient, outpatient, or HCC programs — we're ready to help. Fill out the form and we'll be in touch within 2 business days.

HIMIO live demo with your EHR
Inpatient, outpatient & HCC coder placement
Surge support & backlog clearance
HIPAA-compliant, BAA-ready engagements
Response within 2 business days

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