Clinical Docs
Audit clinical notes for billing compliance, documentation gaps, and coding quality
What You Can Do
This skill audits clinical notes against documentation standards, billing/coding requirements, and quality benchmarks. You extract de-identified notes from Epic or Cerner, and Claude flags missing HPI/ROS/PMH elements, E/M level indicators, medical necessity gaps, timing compliance issues, and clinical inconsistencies. It's designed for compliance reviews, billing optimization, clinician training, and audit preparation without exposing PHI.
Features
identifies missing or incomplete elements that impact billing accuracy and code assignment
reviews HPI, ROS, PMH, assessment/plan for missing sections and vague language
detects medical necessity gaps, underdocumentation, and coding support deficiencies
flags countersigned note delays, addenda rule violations, and documentation window issues
catches clinical contradictions, missing justifications, and unclear clinical reasoning
processes plain text only; supports batch review without PHI exposure
compatible with Epic Chart Review and Cerner Reporting Workbench exports
Example Output
Example 1: E/M Documentation Gap
- Note Type: Office Visit—Established Patient
- Flag: ROS incomplete—only 2 systems reviewed (requires 10+ for MDM-2)
- Impact: Supports 99214 max; consider 99215 with full ROS
- Recommendation: Document all systems reviewed or document number explicitly
Example 2: Medical Necessity Missing
- Note Section: Assessment—Hypertension control
- Flag: No justification for frequency of follow-up (no exam findings, labs referenced)
- Impact: May deny as not medically necessary
- Recommendation: Link plan frequency to exam findings or labs
Example 3: Timing Compliance Issue
- Flag: Countersignature dated 4 days post-encounter (policy allows 24 hours)
- Impact: Potential compliance risk; may affect billing submission
- Recommendation: Escalate to provider for policy review
What's Included
- SKILL.md instruction file with de-identification guidance:
- Clinical documentation audit checklist (HPI, ROS, PMH, assessment/plan elements):
- E/M coding level reference guide (99213–99215 indicators):
- Compliance flagging matrix (documentation standards, timing rules, quality thresholds):
- Epic/Cerner export templates for safe note extraction:
Who It's For
- Physicians and Advanced Practice Providers — optimize documentation for accurate billing and reduce compliance risk
- HIM Specialists & Compliance Officers — conduct systematic audits and prepare for internal/external reviews
- Coding & Revenue Cycle Teams — identify documentation gaps impacting code assignment and claim denial rates
- Medical Directors & Quality Leaders — assess clinician documentation patterns and design training interventions
- Hospital/Clinic Compliance Programs — scale documentation review without manual chart inspection
Best For
- Compliance audits and pre-audit preparation
- E/M billing optimization and code level validation
- Clinician documentation training and feedback
- Batch clinical note quality reviews
- Identifying systemic documentation gaps and training needs
- Medical necessity and coverage requirement verification
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