What is Charge Capture for Medical Billing and how do you make it more effective

iVECoder is an advanced AI-based medical coding tool that analyzes clinical documentation in real time using NLP (natural language processing) and payer-based logic. It helps clinics and coders by:

• Suggesting accurate codes based on documethe ntation context
• Highlighting reasons a claim might be denied from a payer's perspective
• Updating quarterly with CCI edits and new regulatory changes. 
• Providing real-time support to coders and clinicians alike

Unlike codebooks that update once a year, iVECoder ensures clinics are working with current coding and payer guidelines every quarter.

Coders depend on the accuracy and clarity of clinical documentation. Clear communication between providers and coding staff helps bridge the gap between care and billing. Encourage:

• Regular huddles between coders and providers
• Shared understanding of coding requirements
• Feedback loops for common documentation issues

This collaborative approach prevents miscoding, undercoding, and overcoding.

Documentation that happens in real-time or near real-time is more complete and accurate. Encourage providers to document as close to the point of care as possible. Support this with:

• Voice-to-text or dictation tools
• Templates customized by specialty
• Training on medical necessity and specificity

The closer the documentation is to the clinical event, the more likely it will capture the full scope of care.

Internal audits can detect recurring coding mistakes, documentation gaps, or missed charges. Use these reviews to:

• Identify patterns of denial or delay
• Benchmark against national standards
• Train providers and coders on emerging issues

Pair audits with dashboards or data analytics to monitor real-time trends and performance.

A dermatologist performs a shave biopsy and cryotherapy during the same visit. The clinician documents only the procedure notes, without detailing anatomical sites.

✅ Coder Success: The coder clarifies that the biopsy and cryo were done on separate lesions and uses modifier -59 to unbundle and bill CPT 11301 (shave biopsy) and CPT 17000 (cryosurgery) appropriately. This prevents underpayment or denial.

Result: Clean claim submission and full reimbursement for both services.

A radiologist performs a CT angiography but the technician forgets to mention contrast usage in the procedural summary.

✅ Coder Success: By reviewing the radiology report and order notes, the coder identifies contrast was administered and bills CPT 71275 instead of a non-contrast CT.

Result: Prevents $250+ loss due to downcoding and ensures correct RVUs are captured.

An oncology clinic administers multiple chemo drugs in a single session. The EMR only logs one administration code.

✅ Coder Success: The coder adds appropriate infusion codes such as CPT 96413 (initial hour) and 96415 (each additional hour), and uses J-codes for each drug. They also apply modifiers when multiple sessions occur in a single day.

Result: Recovers thousands in missed infusion billing and aligns with Medicare NCCI guidelines.

A patient presents for an annual wellness visit but also discusses hypertension management during the appointment.

✅ Coder Success: The coder splits the visit into CPT G0439 (AWV) and CPT 99213-25 (problem-focused E/M), justifying the modifier with supporting documentation of medical necessity.

Result: Doubles reimbursement for a single visit, ensuring both preventive and problem-based care are compensated.

A therapist provides therapeutic exercise, manual therapy, and gait training during a 45-minute session. Only one CPT code is selected in the EMR.

✅ Coder Success: The coder reviews treatment logs and time spent, billing 97110, 97112, and 97140 appropriately based on 8-minute rule units.

Result: Increases claim from 1 unit to 3, boosting revenue and avoiding compliance flags for undercoding.