Using ambient AI for documentation and medical billing

How ambient AI scribes can help with medical coding and billing

Medical billing is a challenge that every healthcare practice faces—whether a small clinic or a large enterprise. The complexity of medical coding combined with the need for accurate documentation during patient visits can feel like a balancing act.

Fortunately, advanced AI innovations like ambient clinical documentation are emerging as practical solutions to help clinicians capture necessary codes, orders, and procedures during patient visits while generating thorough encounter summaries. Leveraging AI solutions that can document encounters while automating diagnosis codes and orders helps enable providers to place more focus on patients during the encounter, which can help foster a strong patient-provider relationship and contribute to increased satisfaction.

Here's how ambient clinical documentation works and why it holds promise for improving billing accuracy.

Coding inaccuracies hurt revenue cycle management (RCM)

Clinical documentation has traditionally been a double-edged sword. It is essential to take detailed notes during a patient visit and systematically input all diagnoses and orders to support accurate billing and claims. But the act of typing notes or selecting codes in real time can detract from the focus on meaningful patient interactions.

Many clinicians postpone documentation until after clinic hours or at home, a practice sometimes called “pajama time.” This delay can lead to incomplete or incorrect documentation, which can result in coding and other issues downstream. All of those elements together can snowball into claim denials or reimbursement delays, which may then cascade into revenue cycle inefficiencies and frustrate administrative staff.

Incorrect or incomplete documentation can also result in regulatory issues, increased audits, and rework of claims, and strain patient relationships when billing errors arise. This creates a ripple effect across the entire healthcare operation.

To address some of these challenges, many electronic health record (EHR) systems, like athenaOne®, have devised customizable encounter plans that link the reason for an encounter or follow-up diagnosis to a set of diagnoses, orders, and templates. Those inputs are then preloaded into encounter plans.

While encounter plans sets can help improve clinical workflows, they don’t eliminate the need for comprehensive and accurate documentation. The burden remains on clinicians to capture the full scope of the patient encounter, including relevant comorbidities, social and family history, and all services rendered, which directly impact billing codes.

Ambient clinical documentation potentially solves this problem by integrating AI that listens, transcribes, and contextualizes the entire clinical encounter, facilitating a full clinical record.

Ambient models help provide comprehensive encounter documentation

Ambient clinical documentation leverages AI-powered ambient listening to unobtrusively capture the entire patient visit. Ambient scribes such as athenahealth Ambient Notes document every detail discussed during the encounter, providing clinicians and billing staff with a holistic view of the clinical narrative.

An illustrative example comes from Dr. Janelle Smith at Springfield Clinic in Springfield, IL.¹ One of Dr. Smith’s patients made an appointment to discuss dental implants. During the conversation, however, Smith and the patient also discussed chronic conditions such as diabetes, osteoporosis, and bisphosphonate – since these conditions could significantly influence appropriateness and risk of getting the implants. Without Ambient Notes, Dr. Smith noted she might only have documented the dental implant consultation without capturing the full context of the chronic illnesses. But with the ambient AI scribe documenting every aspect of the visit, the technology recorded and integrated these crucial details into the clinical note.

Expanded documentation can lead to more accurate coding, reflecting not only the stated purpose of patient encounters but also any other relevant discussions during the course of the full encounter. As a result, the medical coding applied to that encounter better encompasses the visit, which can optimize billing and help practices recoup what they’re owed for services rendered.

Furthermore, ambient AI models are evolving to do more than just transcribe conversations. Models will be capable of analyzing the dialogue in real time to pre-populate ICD-10 codes, pre-populate orders, and identify clinical procedures or tests performed during the visit to add to the clinical note organically.

This comprehensive, AI-enabled documentation capability means that clinical notes become a rich, multi-dimensional record that supports more robust claims. Clinicians may feel confident that they are submitting claims that fully represent the care delivered, which can help maximize reimbursement and minimize revenue loss due to undercoding or missed services.

Improving accuracy in documentation and billing

Ambient clinical documentation holds significant promise for improving not only billing accuracy but also clinical and administrative workflows. Here’s how:

• Recenter the clinician-patient interaction: Ambient documentation eliminates the need for constant typing or clicking, allowing clinicians to maintain eye contact and engage more deeply with patients. This humanizes the encounter and can improve patient satisfaction and trust.
• Capture every detail reliably: Unlike manual notes that may omit certain details due to time constraints or cognitive overload, ambient AI can capture all relevant conversation elements – and as Smith said, do so accurately. This reduces the risk of missing key information that affects billing and coding.
• Document faster: Improving same-day chart closure rates is a priority for many practices. Smith said that, after using Ambient Notes, she’s “closer to 90-100% same-day completion” for closing clinical encounters.*
• Auto-populate diagnosis codes and orders: By using natural language processing and clinical intelligence, ambient models suggest and insert appropriate ICD-10 codes and orders into the clinical note. This automation can help reduce errors from manual coding and speed up documentation review.
• Streamline administrative handoff: Detailed and accurate notes allow billing and administrative teams to create claims more quickly and accurately. The result is a smoother revenue cycle with reduced likelihood of denials, faster payments, and reduced administrative burden.

Another advantage to Ambient Notes is its customizable approach. Clinicians can choose from different models that best match their preferred documentation or specialty-specific needs. This flexibility helps support personalization in documentation without forcing a “one size fits all” approach.

Moreover, as ambient clinical documentation continues to evolve, integration with broader EHR functionality—such as clinical decision support, population health management, and compliance monitoring—can enhance the value of this technology for both small practices and large healthcare enterprises.

Adopting ambient clinical documentation solutions invests in clinician well-being, patient experience, and financial health of healthcare organizations. It may help to address the growing frustrations associated with documentation burdens and mitigate financial risks tied to billing inaccuracies.

This comprehensive, AI-enabled documentation capability means that clinical notes become a rich, multi-dimensional record that supports more robust claims.

Fuller clinical notes for optimized billing

Medical billing fueled by ambient clinical documentation represents a potential step forward for clinical practice management. By reducing administrative overhead, allowing clinicians to focus on patients, and improving billing accuracy, ambient AI tools like Ambient Notes can help empower healthcare providers to work towards optimizing care delivery and revenue outcomes simultaneously.

If your practice is considering AI-powered documentation innovations, ambient clinical documentation offers a scalable, efficient, and clinician-friendly solution designed to improve workflows and maximize reimbursement integrity. Explore how Ambient Notes and AI-native athenaOne can help your organization embrace the promise of artificial intelligence to transform your clinical documentation and billing processes.