Short answerAI charge capture compares what was scheduled, performed and documented with what was billed, flagging services that have documentation but no charge (or a charge with weak documentation). A coder reviews each flag before anything is added to a claim.
Missed charges are revenue that never enters the cycle, so no denial report will ever show them.
Common gaps in procedural practices
- in-office procedures documented but not charged
- injected drugs or supplies missing (J-codes with the wrong units)
- add-on codes not carried from the op note
- E/M services on procedure days that meet the modifier 25 standard but weren't billed
How the check works
- Match the schedule and procedure log with charges for each date.
- Read notes for billable services with no matching charge.
- Flag mismatches for coder review, including charges with weak documentation.
Guarding against over-coding
Charge capture should be two-sided: find missed services, and flag billed services the note doesn't support. A tool that only adds codes increases audit risk.
What practices gain
Fewer missed charges, cleaner documentation habits, and a monthly view of where charges leak by provider or location.
Related: modifier 25 in orthopedics.
This article is general billing information, not legal or coding-compliance advice. Payer rules, CPT descriptors and federal guidance change; check the current versions for your claims.