Automatic billing/coding from surgical notes

Purpose

1. Automate the extraction, interpretation, and submission of billing and ICD/CPT medical coding data from head and neck surgical notes, reducing manual entry, automating compliance checks, accelerating remittance, and automating communication with payors and EMRs.

2. Automating identification of billable procedures, diagnostic codes, and modifiers directly from dictated or transcribed clinical documents in the surgical domain.

3. Provide end-to-end automated workflows for claims generation, error-checking, eligibility verification, payer submissions, denial tracking, and automated document storage in compliance with healthcare data privacy regulations.

Trigger Conditions

1. Automatedly triggered when a surgical note is finalized in the EHR or dictation software.

2. Automatedly activated by upload or creation of a PDF/Word operative note file in a designated storage folder.

3. Automation initiates when the head and neck surgery encounter status is “completed” or “signed off”.

Platform Variants

1. Cerner Millennium

• Feature/Setting: PowerChart “Documentation Signed-Off” trigger + Discern Rules to export notes to automation endpoint.
  

2. Epic Systems

• Feature/Setting: Automated Data Routing using Epic Bridges Interface, HL7 outbound triggers for “Procedure Finalized.”
  

3. Allscripts

• Feature/Setting: Note Finalization Event via Open API; configure webhook to post note text for automated coding.
  

4. Meditech Expanse

• Feature/Setting: Event-Driven Exports upon document “finalization” through MEDITECH Data Repository API.
  

5. AdvancedMD

• Feature/Setting: Automated Billing API; use “New Chart Note” webhook to trigger auto-coding.
  

6. athenahealth

• Feature/Setting: Encounter API automates pulling finalized op notes for automated billing.
  

7. DrChrono

• Feature/Setting: Clinical Note Lock Event triggers push to automated coding API.
  

8. Google Cloud Healthcare API

• Feature/Setting: FHIR Resource “DocumentReference” automate triggers on upload.
  

9. Amazon Comprehend Medical

• Feature/Setting: Automate through Medical NLP API for extracting ICD, CPT, and SNOMED codes from text.
  

10. Microsoft Azure Health Data Services

• Feature/Setting: Automate with Text Analytics for Health—API extracts clinical concepts for billing.
  

11. Nuance Dragon Medical One

• Feature/Setting: Document Finalization automation via SDK event, send to webhook.
  

12. M*Modal Fluency for Transcription

• Feature/Setting: Automated transcript export event to API for coding automation.
  

13. Redox Engine

• Feature/Setting: Automated “Clinical Document” event mapping to downstream billing workflow.
  

14. Health Gorilla

• Feature/Setting: Document Matching Engine, automate upload event pushes for auto-coding integration.
  

15. Mediware

• Feature/Setting: Automated “Case Closed” event triggers to billing/coding API.
  

16. NextGen Healthcare

• Feature/Setting: EHR Automation API—automatically push clinical notes when status changes to final.
  

17. Xtract Solutions

• Feature/Setting: Coding Intake API, trigger on new document event for automation.
  

18. TrueCode Encoder

• Feature/Setting: Automate with REST API for coded abstraction and automated billing file output.
  

19. Veradigm

• Feature/Setting: Automated Chart Automation via EHR Connectors, push notes for coding.
  

20. CloudConvert

• Feature/Setting: Automate document OCR conversion, watched folder triggers coding automation.
  

21. eClinicalWorks

• Feature/Setting: Automated Documents API for pulling completed notes for auto-coding integration.
  

22. OpenEMR

• Feature/Setting: Automated “Encounter Finalized” event with webhook for billing automation.
  

Benefits

1. Automated billing automates claim submissions and reduces denials from coding errors.

2. Automates charges posting for faster reimbursement.

3. Improves accuracy and compliance through automated parsing and cross-checking.

4. Automates workload, freeing up staff resources for care delivery.

5. Enables automated audit trails and documentation for regulatory review.

6. Reduced revenue leakage and coding backlog through continuous automation.

7. Automates notifications to payers and practice managers of claim status or coding issues.

8. Achieves consistent billing through automated and standardized workflows.

9. Increases operational efficiency by automating repetitive documentation and billing flows.