Bedrock Billing Documentation¶

Welcome to Bedrock Billing, the comprehensive Medicare claims processing and payment calculation platform designed for healthcare administrators, medical coders, revenue cycle managers, and software developers. Unlike the traditional CMS Web Pricers—which limit users to entering Pricer-specific variables and returning a single reimbursement figure—Bedrock Billing provides a seamless, end-to-end flow from Editors and Groupers (like the IOCE, MCE, and MS-DRG Grouper) directly into calculation pipelines, all without manual re-entry.

Compared to other commercial products, Bedrock Billing delivers a robust, high-performance solution at a lower cost with far easier developer integration—purpose-built for high-volume claim processing and modern EHR/billing system interoperability.

Core Capabilities¶

• High-Volume Claims Processing: Process thousands of claims rapidly via our RESTful API or intuitive web interface, eliminating manual bottlenecks inherent to CMS Web Pricers.
• Nightly Provider Data Sync: Pricing logic accurately leverages facility-specific data by syncing nightly with the CMS Inpatient and Outpatient Provider Specific Files (IPSF/OPSF), ensuring your calculations always reflect the most current localized rates.
• Comprehensive MS-DRG Grouping: Seamlessly integrate with the MS-DRG Grouper. We support all recent versions including: 39.0, 39.1, 40.0, 40.1, 41.0, 41.1, 42.0, 42.1, 43.0, and 43.1.
• Integrated Editor Support: Built-in support for the Integrated Outpatient Code Editor (IOCE) and Medicare Code Editor (MCE) workflows to validate and structure claims before pricing.
• Subacute Assessment Grouping: Compute IRF CMG Grouping based on MDS assessment data and HHAG Grouping based on OASIS data—capabilities not available in standalone CMS Pricers.
• EDI X12 Claim Import: Import claims directly from standard EDI 837 transaction files, reducing data entry and ensuring compatibility with existing clearinghouse workflows.
• Custom Provider & Rate Overrides: Configure organization-specific provider settings, custom DRG tables, custom fee schedules, and IOCE bypass rules to tailor calculations to your contracts.

Supported Prospective Payment Systems (PPS)¶

Bedrock Billing's calculation engine confidently supports the following Medicare Prospective Payment Systems:

• Inpatient Prospective Payment System (IPPS) — Acute care hospital inpatient stays, MS-DRG-based reimbursement.
• Outpatient Prospective Payment System (OPPS) — Hospital outpatient services, APC-based reimbursement with IOCE integration.
• Ambulatory Surgical Center (ASC) — ASC facility payments including Addendum AA/BB/FF, wage index adjustments, and multiple procedure discounting. Note: CMS does not publish an official ASC Pricer.
• Inpatient Rehabilitation Facility (IRF) — Including CMG Grouping based on MDS/IRF-PAI assessment data.
• Home Health (HHAG) — Including HHAG Grouping based on OASIS assessment data.
• Long-Term Care Hospital (LTCH) — MS-LTC-DRG-based reimbursement for long-term acute care.
• Skilled Nursing Facility (SNF) — PDPM-based reimbursement for skilled nursing stays.
• End-Stage Renal Disease (ESRD) — Dialysis facility payment calculations.
• Hospice — Routine and continuous home care, inpatient respite, and general inpatient care rates.
• Inpatient Psychiatric Facility (IPF) — Per diem payment with facility and patient-level adjustments.

Platform Architecture¶

graph TB
    A["Client Request<br>(API · Web App · EDI X12)"] --> B["Bedrock Billing Engine"]

    subgraph Phase 1: Editors
        C1["MCE<br>Medicare Code Editor"]
        C2["IOCE<br>Outpatient Code Editor"]
    end

    subgraph Phase 2: Groupers
        D1["MS-DRG Grouper"]
        D2["HHAG Grouper<br>(OASIS)"]
        D3["CMG Grouper<br>(IRF-PAI / MDS)"]
    end

    subgraph Phase 3: Pricers
        E1["IPPS · LTCH · IPF"]
        E2["OPPS · FQHC"]
        E3["IRF Pricer"]
        E4["HHA Pricer"]
        E5["SNF · Hospice · ASC · ESRD"]
    end

    B -->|Validate| C1 & C2
    B -.->|No Editing Required| E5

    C1 -->|Diagnosis Data| D1
    D1 -->|DRG Assignment| E1

    C2 -->|Line-Level Data| E2

    D2 -->|HHAG Assignment| E4
    B -->|OASIS Data| D2

    D3 -->|CMG Assignment| E3
    B -->|MDS Data| D3

    E1 & E2 & E3 & E4 & E5 --> F["Claim Response<br>(Line-Level Reimbursement Details)"]

    style B fill:#2E8B57,stroke:#fff,stroke-width:2px,color:#fff

Platform Segments¶

Web Application — For Billers & Coders¶

The Bedrock Billing web application provides a user-friendly interface for revenue cycle managers, medical coders, and healthcare administrators to:

• Process Claims — Submit claims manually, load test claims, import from JSON or EDI X12, and review line-level pricing details across all supported PPS modules.
• Browse CMS Data Viewers — Instant lookups across Fee Schedules (PFS, Clinical Lab, DME, Ambulance), Medically Unlikely Edits (MUE), DRG Tables & Weights, PFS Localities & GPCI adjustments, ZIP9 carrier mappings, ICD-10 codes, IOCE data, and Coverage datasets.
• Manage Providers — View Medicare provider details, configure custom provider overrides, and set up provider alerts.
• Customize Pricing Rules — Create custom DRG tables, custom fee schedules, configure IOCE bypass rules, and manage payer contracts via the Contract Hub.

Developer API — For Engineers & Integrators¶

Our RESTful Medicare PPS API is built for developers looking to integrate real-time claim calculations, batch operations, and reference data queries directly into their native software, EHR, or billing platform.

• Authentication — Secure API key management with organization-scoped access.
• Claims Processing — Programmatic claim submission across all PPS modules.
• Reference Data Endpoints — Query fee schedules, DRG tables, MUE data, ICD-10 codes, providers, localities, and more via REST.
• Developer Tutorials — Walkthroughs for core API integrations:
• Processing Claims via Python API
• Building a Free NPI Verification Tool
• Integrating Medicare Fee Schedules into an EHR
• Building an ICD-10 Autocomplete Search
• Rate Limits — Usage tiers from Free (100 requests/month) through Enterprise (custom limits).

Reference Library — Free Medical Coding & Fee Schedule Lookup¶

Bedrock Billing also publishes a free, publicly accessible reference library of searchable medical coding and payment data:

• Medical Coding — Browse CPT, HCPCS, ICD-10-CM/PCS diagnosis and procedure codes, APC assignments, and NCCI Correct Coding Initiative edit pairs.
• Providers & Facilities — Search healthcare providers and facilities in the national NPI registry, including Medicare-enrolled institutional providers.
• Fee Schedules — Access historical and current Medicare payment rates including the Physician Fee Schedule (PFS), ASC, and OPPS payment systems.

PPS Field Reference — CMS Web Pricer Help¶

Detailed field-by-field documentation for each CMS Prospective Payment System Pricer, scraped directly from the official CMS Web Pricer help system:

• IPPS · IRF · LTCH · SNF · ESRD · Hospice · IPF · Home Health

Quick Links¶

Support¶

For help, contact your organization administrator or reach out to [email protected].

Last updated: March 2026