System Architecture & Capabilities

Deterministic Triage & Clinical Reasoning for Certified Coders

CAC Co-Pilot is a Cloud Run decision support engine that assists credentialed medical coders (CPC / CCS). It validates clinical encounters against regulatory codebooks, flags code collisions, and provides bounded reasoning without autonomous claim finalization.

Core Workflow

The 4-Stage Processing Pipeline

STRICT HUMAN-IN-THE-LOOP
STAGE 01 Envelope Ingress

Schema-Bounded Airlock

Every patient encounter envelope is inspected against strict schema rules (additionalProperties: false). Blocks malformed payloads, enforces zero durable PHI transmission, and guarantees $0 spend gating prior to external token burn.

✓ Ingress JSON Schema Check • ✓ Zero-Spend Gate
STAGE 02 Deterministic Logic

SQL as Law (NCCI & Codebooks)

CMS and AMA coding rules are executed deterministically on CPU via SQLite/Cloud SQL. Inspects NCCI Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUE) unit caps, and ICD-10-CM Excludes1/Excludes2 tables keyed strictly to Date of Service (DOS).

✓ PTP Conflict Detection • ✓ MUE Threshold Enforcement
STAGE 03 Clinical Reasoning

Gemini Critic & Parallel Judge

Contested or nuanced clinical cases route to Gemini on Vertex AI / Google AI Studio for bounded arbitration analysis. An independent Vertex AI compliance judge runs in parallel to score verdicts as agree, disagree, or insufficient.

✓ Structured Arbitration • ✓ Dual Model Audit
STAGE 04 Certified Coder Action

Accept, Override, or Query

The certified coder maintains complete authority over the claim. Every proposal includes verifiable citations. When clinical documentation is ambiguous, the system drafts AHIMA/ACDIS-compliant, non-leading physician queries to clarify documentation before submission.

✓ Human in the Loop • ✓ Compliant Query Assist

Compliance & Boundaries

Engineering Governance & Boundaries

What CAC Co-Pilot Delivers

  • → PTP and MUE Verification: Flags prohibited procedure combinations and unit thresholds before coder review.
  • → Excludes1 / Code First Validation: Evaluates ICD-10-CM coding hierarchies to prevent fatal claim denials.
  • → Immutable Audit Trails: Logs every evaluation event, tier assignment, and coder override into structured JSON/JSONL.
  • → Non-Leading Query Generation: Generates clinical documentation inquiries compliant with AHIMA/ACDIS practice briefs.
  • → Cloud Run Efficiency: Lightweight CPU-only service in us-central1 with zero GPU rental overhead.

Architectural Anti-Patterns & Non-Goals

  • ✕ Not Autonomous Finalization: The engine never signs, submits, or commits medical billing claims to payers without human oversight.
  • ✕ Not an EHR Replacement: Does not store primary medical records or replace hospital electronic health systems.
  • ✕ Not a Local GPU Product: Eliminates resident 8B-70B model GPU setups, eliminating expensive hardware requirements.
  • ✕ No Unverified PHI Ingress: Demo and sandbox tiers process strictly synthetic clinical charts (Synthea-derived).
  • ✕ No Direct DFT Writeback in MVP: Avoids fragile direct FHIR/HL7 writebacks during initial triage rollout.

Environment & Stack

Enterprise Cloud Infrastructure

Layer Technology Region & Constraints Compliance Role
App Runtime Google Cloud Run (FastAPI + Uvicorn) us-central1 (Iowa) CPU-only microservice; auto-scales to zero.
Identity Ingress Identity-Aware Proxy (IAP) Zero public endpoints Cryptographically enforces authorized coder seats.
Rules Engine SQLite / Cloud SQL (NCCI Codebooks) In-Process / VPC Private Deterministic CMS statutory compliance by DOS.
Clinical Critic Gemini 3.6 Flash / Vertex AI Schema-Bounded JSON Clinical documentation dispute arbitration.
Audit & Telemetry Cloud Logging / BigQuery us-central1 / US multi-region Immutable log of acceptance & coder overrides.

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