Where the clinical record meets the claim — code capture, documentation sufficiency, and the gap between what was done and what gets billed for it.
This page is a deliberate stub. It exists so the concept has a home and a link from the demo hub; the frame below is scaffolding for the real write-up. No coding logic, no rules, and no figures have been decided, and nothing here is wired to an engine.
Two failure directions, and they pull against each other. Under-coding leaves work uncompensated because the documentation does not support what was actually done. Over-coding is a compliance exposure. Both are usually documentation problems rather than intent problems — the encounter happened, the note did not carry the evidence.
The interesting question is whether the supporting evidence can be surfaced at the point of documentation, while the clinician still remembers the visit, instead of reconstructed weeks later by a coder working from an incomplete note.
| Piece | Status | Note |
|---|---|---|
| Code reference data | NEW | The CPT / HCPCS / ICD-10 sets in scope, and their update cadence. Versioned, never hand-maintained. |
| Documentation sufficiency | NEW | Does the note actually support the code — the core check, and the hard one. |
| Setting mismatch | NEW | Codes valid in one place of service and not another; a known recurring class of error. |
| Clinician-facing surface | EXTEND | Suggestions at documentation time, never silent auto-application. |
| Audit trail | NEW | Every suggestion, acceptance, and override recorded — non-negotiable for anything touching a claim. |
No specific codes, no dollar figures, no worked billing examples. Concrete codes on a placeholder page get read as guidance and repeated, and an incorrect one carries real regulatory consequence. Those land once the scope and the reference-data owner are settled.