Would your clinical documentation survive a payer audit?

The problem

Documentation gaps are found too late.

• Clinical and billing supervisors spend hours reading charts and re-explaining the same rules, one clinician at a time
• Feedback doesn't stick, so the same documentation gaps show up again at the next audit
• Leadership can't see which clinicians create risk until a prepayment review or record request arrives

What you get

Who it's for

Questions

Does it guarantee my claims will be paid or my audit will pass?

No. It checks documentation against published requirements and professional standards so you can find gaps early. Payers make their own determinations, and no tool can predict them.

What happens to the notes I review?

Identifiers are removed on your device first, and you confirm the de-identification before anything is sent. Notes are reviewed in memory and not stored; saved results keep the code, scores and finding types only. You remain responsible for de-identifying records before review.

Which payers and codes are covered?

Medicare is covered in every state: national Medicare rules plus the local psychiatry and psychology policy of the Medicare contractor for your state. State Medicaid rules are built in for Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, the District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin and Wyoming. Some cover only certain programs (for example, New York's rules are for OMH-licensed clinics, Massachusetts' for mental health centers and California's for county specialty mental health), and each review says so. Other states' Medicaid, Medicaid managed care plans and commercial plans are being added; until then those reviews use professional documentation standards, and each review says which rules it used. Any CPT or HCPCS code can be reviewed; each code shows whether its support is verified, partial or general.

How do we know the training is working?

The practice dashboard compares each clinician's reviews before and after their training: average readiness before and after, and whether each gap still appears. When a gap shows up in at least two reviews, and in at least half of the reviews that checked it, after the clinician completed the module that teaches it, it's flagged so you can follow up with a targeted spot check, an action plan or supervision. It shows documentation patterns, not a judgment of the clinician.

Will it rewrite my notes?

No. It suggests wording built only from your answers to its questions. For signed notes it drafts an addendum and leaves the original unchanged. It never adds times, data or services you didn't confirm.

Is the training accredited for continuing education?

No. The modules are practical documentation training with knowledge checks. They do not carry continuing-education credit.

CPT® is a registered trademark of the American Medical Association. Clinical Audit IQ doesn't reproduce CPT descriptors. Not affiliated with or endorsed by CMS, any Medicare contractor or the Kentucky Department for Medicaid Services. Training modules don't carry continuing-education credit.