Revenue Cycle Management Coding Workflows

An operative note for a laparoscopic cholecystectomy includes the clause 'I also performed lysis of adhesions at the time of the case' in a dictated narrative paragraph. There is no corresponding structured order, procedure entry…

The agent surfaces two distinct candidate charges: (1) laparoscopic cholecystectomy with the appropriate CPT, and (2) lysis of adhesions with the appropriate CPT, each with an exact text citation from the operative note. The lysis of adhesions entry is flagged as narrative-only with no structured o…

A post-procedure recovery note documents that placement of an indwelling urinary catheter was offered and explicitly declined by the patient. No catheter was inserted. The verb-procedure pair 'placement of...urinary catheter' is …

The agent does NOT surface urinary catheter insertion as a billable charge candidate. The agent may note the declined procedure as an excluded observation. The agent may surface an appropriate E/M recovery charge if documentation supports it. The output explicitly acknowledges the declination langu…

At T=0h, the agent processes an operative note for encounter ENC-20260514-003 and places CPT 11406 (excision benign lesion, trunk, >4.0 cm) in the active charge candidate queue. At T+48h, the surgeon submits a signed addendum to …

The agent (1) retracts CPT 11406 from the active charge candidate list for encounter ENC-20260514-003; (2) adds the appropriate punch biopsy CPT as a new candidate charge, citing the addendum as the supporting documentation; (3) issues a change notification to the coder queue and any connected down…