Smarter Week

How to automate it

How to automate “code visits and check the documentation supports them”

Here are 2 ways to spend less time on this, best first. Each comes with steps you can follow today.

120 min
typically, every day
50%
of the time can be automated
Some setup
to set up

Fix 1 of 2

Software featureBest fix

Use computer-assisted or AI coding to suggest codes

Computer-assisted and AI coding tools read the documentation and suggest codes with the supporting text highlighted. Coders review and approve, and simple visits can be coded automatically.

Typically saves about 35% of the time4 h to set up
  1. 1Ask your revenue cycle leader what coding tools are available (Solventum 360 Encompass, Optum, Fathom, CodaMetrix or your EHR's coding assistant).
  2. 2Start with high-volume, simple visit types.
  3. 3Audit a sample of AI-coded charts each week.
  4. 4Send documentation gaps back to clinicians as education, not one-off queries.
  5. 5Only use tools your organization has approved and covered by a HIPAA business associate agreement (BAA) for anything with patient information.

Tools: Solventum 360 Encompass · Optum CAC · Fathom · CodaMetrix · Epic Penny (coding and appeals assistant)

Fix 2 of 2

Software feature

Use an ambient AI scribe to draft the visit note

An approved ambient scribe listens to the visit (with the patient's consent) and drafts the note, orders and patient instructions in the EHR. You review and sign. Most clinicians get back part of their evening, not all of it.

Typically saves about 40% of the time1 h to set up
  1. 1Ask your organization which ambient scribe is approved: Microsoft Dragon Copilot (formerly DAX Copilot), Abridge, Ambience, Suki, Nabla or the one built into your EHR (such as Epic's AI Charting).
  2. 2Do the short training and set your note preferences (sections, length, style).
  3. 3Tell each patient and get consent, as your policy requires.
  4. 4Review every draft carefully before signing; you are responsible for the note.
  5. 5Only use tools your organization has approved and covered by a HIPAA business associate agreement (BAA) for anything with patient information.

Tools: Microsoft Dragon Copilot · Abridge · Ambience · Suki · Nabla

Quick wins

Have you tried…

Have you used an ambient AI scribe that drafts your visit note while you talk with the patient?
With the patient's consent, an approved tool like Microsoft Dragon Copilot or Abridge listens to the visit and drafts the note for you to check and sign. Only use the tool your organization has approved.

Who does this task

Roles in our library that list this as one of their common tasks. Each guide covers the rest of that role’s week.

Medical billing / coding specialistPhysician / clinician

HourLeak · the 8-minute work audit

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Other common tasks for Medical billing / coding specialists