Capture Audit
AI-powered chart audit for outpatient billing. Paste a clinical vignette, get the right primary E/M, add-on codes, modifiers, and missed wellness opportunities — with the documentation gaps for each suggestion.
What an audit returns
Every audit reads your vignette as the documentation-of-record and returns four things, with citations to CPT and HCPCS code rules.
Primary E/M with rationale
The correct office-visit code (99202-99215) based on documented MDM elements or total time. Includes the specific element that drove the level (problems, data, risk) and a documentation gap if one element is weak.
Add-on codes you missed
G2211 continuity, 99497 ACP, prolonged services (99417 / G0316), AWV add-ons (G0444 depression, G0537 ASCVD risk, G0136 SDOH), tobacco cessation, and more. Each with the documentation hook that justifies it.
Modifier and bundling guidance
Modifier 25 when paired with a same-day procedure, modifier 33 for AWV-paired preventive services, telehealth modifiers (95 / GT) and POS rules. Flags incompatible combinations like G2211 with modifier 25.
Missed preventive opportunities
Annual wellness, depression screen, ASCVD risk assessment, tobacco cessation counseling, ACP, advance care planning at AWV, SDOH screening. For each, the documentation gap that, if closed, makes it billable.
Sample output
Example result for a routine primary care follow-up vignette (T2DM and HTN, prescription adjustment, ACP discussion):
99214Office visit, established, moderate MDMTwo chronic conditions with treatment changes, prescription drug management documented. Moderate MDM met.
G2211Continuity complexity add-onContinuity primary care relationship documented. Cannot be combined with modifier 25.
99497Advance care planning, first 30 minDocumentation gap: capture the specific topic (ACP) or screen result (PHQ-2 or PHQ-9 score) to make this billable.
G0444Depression screen, 5 to 15 minDocumentation gap: capture the specific topic (ACP) or screen result (PHQ-2 or PHQ-9 score) to make this billable.
How it works
- 1
Paste the vignette
Drop the note text into the form. Deidentify first: remove names, dates of birth, MRNs, addresses. Capture Audit treats the content as a one-time prompt; nothing is stored beyond rate-limit counts.
- 2
Get suggestions
Claude reads the documentation against CMS 2026 PFS rules and the 2021 E/M Documentation Guidelines. It returns the primary E/M, add-ons, modifiers, and missed opportunities, each with the documentation element that supports or blocks it.
- 3
Compare to what you billed
Enter the codes you billed (optional). The audit returns a code-by-code comparison: matched, missed, overbilled. The dollar math (gap per visit, annualized at your panel size) is a Pro feature.
Daily caps and what you get per tier
| Tier | Price | Audits per day | Includes |
|---|---|---|---|
| Free | $0 | 3 | Coding suggestions only, dollar math locked |
| Pro | $19/mo | 30 | Full dollar math, Missed Opportunities detail, lifetime gap tracker |
| Pro Plus | $39/mo | 100 | Everything in Pro + Epic SmartPhrase library |
| Pro Max | $59/mo | 500 | Everything in Pro Plus + Owner P&L, Contract Review unlimited |
PHI policy
RVUDoc is not a HIPAA-covered entity. Do not paste protected health information. Deidentify notes before submitting: remove names, dates of birth, medical record numbers, addresses, phone numbers, and any direct identifiers. We treat every vignette as a one-time prompt and do not store the content beyond rate-limit counts. Capture Audit is an educational reference, not billing or legal advice; always verify against your payer contracts and compliance team before submitting a claim.
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