Consistent, auditable coding for multi-site urgent care
A five-clinic urgent care franchise group transitioned from variable human coding review to AI-driven pre-billing chart review in Experity, gaining consistent and defensible E/M leveling, complete modifier and DME capture, and data-driven provider coaching.
Urgent care
Providers
Experity
Human coding review left revenue and consistency gaps
Share of E/M codes that were underleveled before AI review
A New England urgent care franchise practice runs five clinics with about 35 providers. At roughly 8,000 encounters a month, its fee-for-service chart volume was high enough for the team to contract review of the charts for revenue integrity to a vendor that relies primarily on humans for chart review.
The vendor was able to stop some of the revenue leak associated with underleveled E/M codes and missing modifiers and DME services. But they took 48 to 72 hours to return charts, adding days to AR cycles. Moreover, the output varied: “Some months, it seemed like they downcoded more than others,” the group’s medical director said. The inconsistency was concerning from both a revenue integrity and financial point of view.
Billing staff also applied payer-specific modifier rules inconsistently, and the medical director estimated that as many as 40% of the DME products dispensed in the clinic sometimes never made it into an order in the chart. His goal was consistency: coding that didn’t depend on which reviewer touched the chart.
Pre-billing E/M corrections written back to Experity
Fee-for-service encounters reviewed before billing
Charta built a two-way integration with Experity that pulls signed notes daily and runs them through analyses designed for accurate E/M leveling, modifier completeness (including modifiers 25 and QW), and missing procedural CPT and DME codes. Corrected codes and a justification log are written back to the charge entry page. Payer-specific rules were built into the analyses by one of Charta’s AI engineers and applied consistently to each encounter.
Net revenue uplift and data-driven provider coaching
Projected annual ROI, net of the downcoding and procedure code deletions
Over a single month, Charta reviewed more than 6,900 E/M codes and found 18% undercoded and 7% underdocumented for the originally coded level. Annualized to 12 months, Charta projects about $757,000 in gross upside and roughly $473,000 net of recommended downcodes and procedure code removals.
The practice’s medical director also uses Charta to coach providers, working through about 15 charts per provider in an hour. “The best part about Charta is that each review breaks down the code,” he says. “Why was it a three? Why was it a four? What was missing?” Providers welcomed the reporting, and he expects the aggregate data across thousands of charts to show where each provider needs training.