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Provider Documentation-Quality Scorecard

Most clinics have never had their documentation quality measured. This shows it, provider by provider, against the same rules for everyone. We walk you through one in fifteen minutes, on sample charts.

What You See

  • Average documentation score per provider
  • How many charts it covers, and which way that score is moving
  • The findings that recur most across charts

Documentation-completeness signals. Not a claim about coding accuracy, medical necessity, or billing risk. Not a verdict on care. No dollar amount or billing outcome is implied.

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ICD-10 Coding Review

Once the scorecard shows where documentation is thin, coding review looks at what sits behind it. It reads the visit note and looks for two things. First, ICD-10 codes the note already supports that were never submitted. Second, conditions the note points at without documenting, which cannot be billed until a provider documents them. Each suggestion names the code, the finding it rests on, and why. A provider accepts or declines every one. Nothing is submitted on your behalf.

How It Works

  1. Upload a clinical document (PDF). The chart appears in your dashboard queue
  2. The system extracts clinical context from each section: HPI, Review of Systems, exam, Assessment & Plan
  3. System validates billed codes against documentation and identifies missed opportunities
  4. Each finding is color-coded: red (action required), yellow (review), green (clean)
  5. Provider reviews in the interactive workspace: approve, reject, or modify each suggestion

The key difference: Providers stay in control. Every suggestion comes with clinical evidence and rationale. Every recommendation is transparent and reviewable.

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Launching Shortly

Automated Compliance Audits

AI-assisted documentation review with clinical oversight. Launching shortly; findings will be advisory only and are not a substitute for clinical or coding judgment. The human is always in the loop. We believe audits cannot be fully automated for compliance reasons. Our approach keeps providers in control.

How Audit Automation Will Work

  1. You define the rules: Tell us what a complete chart looks like for your practice, including required documentation sections, minimum detail thresholds and compliance requirements
  2. We translate to criteria: Your audit rules will become evaluation logic, checking for required sections, cross-section consistency, and compliance standards
  3. Every chart gets evaluated: Each document will be scored 0–100, and charts that need attention are flagged
  4. A human decides every finding: Each flagged chart will reach a reviewer with the criterion it missed and the section it came from. A chart that comes back with no issues found is the module's read, not a sign-off
  5. Approve and sign off: Reviewers approve findings, add notes, or escalate, with full audit trail

The intent: automation handles the first pass and names what it found, with the criterion behind each finding. Humans handle compliance sign-off. Audit automation is launching shortly and is not yet available to clinics.

Get Notified When Audits Launch
Coming Soon

CPT Code Analysis

ICD-10 coding review reads the chart and surfaces codes the documentation already supports. Audit automation is launching shortly and is advisory only. CPT code analysis is the next module in development, on the same scoring, dashboard and reporting infrastructure.

  • Automated CPT opportunity identification
  • Same evidence-backed approach with rationale for every suggestion
  • Integrated into existing dashboard and reporting workflow
Join CPT Early Access Waitlist

CPT module coming soon