--- agentTools: projectIndex: https://docs.embercopilot.ai/llms.txt --- # Audit Submitted Charges Reviews previously submitted charges against the clinical documentation to identify coding compliance issues. The audit evaluates each submitted charge for: - **Documentation support** — whether the clinical note supports the billed procedure - **Overcoding / undercoding** — whether the E/M level or procedure complexity matches the documentation - **Bundling issues** — procedures that should be bundled under NCCI edits - **Modifier accuracy** — missing, incorrect, or unnecessary modifiers - **Missing charges** — procedures documented but not billed - **Diagnosis linkage** — whether ICD-10-CM codes support medical necessity for each procedure Each finding includes a severity level, explanation, and suggested corrective action. # OpenAPI definition ````json { "openapi": "3.0.3", "info": { "title": "Medical Coding API", "description": "AI-powered medical coding engine for healthcare organizations, specialty groups, and hospitals.\n\nThe Medical Coding API analyzes clinical documentation to produce accurate, guideline-compliant\ncoding outputs across three core capabilities:\n\n- **E/M Coding** — Evaluate clinical documentation against CMS Medical Decision Making (MDM)\n criteria to determine the appropriate Evaluation & Management CPT code and complexity level.\n- **Charge Capture** — Generate a complete charge list for an encounter, including CPT/HCPCS\n procedure codes, ICD-10-CM diagnoses, and applicable modifiers.\n- **Coding Audit** — Review previously submitted charges against the clinical documentation\n to identify overcoding, undercoding, bundling issues, missing modifiers, and unsupported charges.\n\n### Rate Limiting\n\nAll endpoints enforce a maximum of **3 concurrent requests** per API key. Exceeding this limit\nreturns a `429 Too Many Requests` response.\n", "version": "1.0.0", "contact": { "name": "API Support", "email": "support@embercopilot.ai" } }, "servers": [ { "url": "https://api.embercopilot.ai/v1", "description": "Production server" } ], "security": [ { "ApiKeyAuth": [] } ], "tags": [ { "name": "Coding Audit", "description": "Review submitted charges against clinical documentation for compliance" } ], "paths": { "/coding/audit": { "post": { "tags": [ "Coding Audit" ], "summary": "Audit Submitted Charges", "description": "Reviews previously submitted charges against the clinical documentation to identify\ncoding compliance issues. The audit evaluates each submitted charge for:\n\n- **Documentation support** — whether the clinical note supports the billed procedure\n- **Overcoding / undercoding** — whether the E/M level or procedure complexity matches the documentation\n- **Bundling issues** — procedures that should be bundled under NCCI edits\n- **Modifier accuracy** — missing, incorrect, or unnecessary modifiers\n- **Missing charges** — procedures documented but not billed\n- **Diagnosis linkage** — whether ICD-10-CM codes support medical necessity for each procedure\n\nEach finding includes a severity level, explanation, and suggested corrective action.\n", "operationId": "auditCharges", "requestBody": { "required": true, "content": { "application/json": { "schema": { "$ref": "#/components/schemas/AuditRequest" }, "examples": { "standard": { "summary": "Audit office visit charges", "value": { "inputText": "Established patient presents with acute bronchitis, productive cough for 5 days. Lungs with bilateral wheezing. Administered nebulizer treatment in office. Prescribed azithromycin.", "charges": [ { "procedureCode": "99214", "modifiers": [], "diagnoses": [ { "code": "J20.9" } ] }, { "procedureCode": "94640", "modifiers": [], "diagnoses": [ { "code": "J20.9" } ] } ], "patientType": "Established", "placeOfService": "Office" } } } } } }, "responses": { "200": { "description": "Audit completed successfully", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/AuditResponse" }, "examples": { "withIssues": { "summary": "Audit findings with issues", "value": { "findings": [ { "type": "overcoded", "severity": "warning", "procedureCode": "99214", "message": "E/M level 99214 (moderate MDM) is not supported by the documentation. The note describes a single acute uncomplicated problem with straightforward data review and low risk, consistent with low MDM.", "suggestedAction": "Downcode to 99213 (low MDM)." }, { "type": "missing_modifier", "severity": "error", "procedureCode": "99214", "message": "E/M service billed on the same date as a separately billable procedure (94640) without modifier 25.", "suggestedAction": "Append modifier 25 to the E/M code to indicate a significant, separately identifiable E/M service." }, { "type": "supported", "severity": "info", "procedureCode": "94640", "message": "Nebulizer treatment is supported by documentation of bilateral wheezing on lung exam.", "suggestedAction": null } ], "summary": { "totalChargesReviewed": 2, "supportedCount": 1, "issueCount": 2 }, "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789", "requestTimestamp": "2026-04-21T14:30:00Z" } } } } } }, "400": { "$ref": "#/components/responses/BadRequest" }, "401": { "$ref": "#/components/responses/Unauthorized" }, "429": { "$ref": "#/components/responses/RateLimitExceeded" }, "500": { "$ref": "#/components/responses/InternalServerError" } } } } }, "components": { "securitySchemes": { "ApiKeyAuth": { "type": "apiKey", "in": "header", "name": "Authorization", "description": "API key for authentication. Include in the `Authorization` header using Bearer format:\n```\nAuthorization: Bearer sk_live_...\n```\n" } }, "responses": { "BadRequest": { "description": "Bad request due to invalid input", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" }, "examples": { "missingInput": { "summary": "Missing required field", "value": { "error": { "code": "MISSING_REQUIRED_FIELD", "message": "inputText is required", "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } } } }, "Unauthorized": { "description": "Unauthorized - Invalid or missing API key", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" }, "example": { "error": { "code": "UNAUTHORIZED", "message": "Invalid or missing API key", "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } }, "RateLimitExceeded": { "description": "Too Many Requests - Concurrent request limit exceeded", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" }, "example": { "error": { "code": "RATE_LIMIT_EXCEEDED", "message": "Rate limit exceeded. Maximum 3 concurrent requests per API key.", "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } }, "InternalServerError": { "description": "Internal Server Error", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" }, "example": { "error": { "code": "SERVER_ERROR", "message": "An unexpected error occurred", "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } } }, "schemas": { "AuditRequest": { "type": "object", "required": [ "inputText", "charges" ], "properties": { "inputText": { "type": "string", "description": "Clinical documentation to audit the submitted charges against." }, "charges": { "type": "array", "description": "Previously submitted charges to review for compliance.", "items": { "$ref": "#/components/schemas/SubmittedCharge" } }, "placeOfService": { "type": "string", "enum": [ "Office", "Inpatient Hospital", "Outpatient Hospital", "Emergency Room", "Nursing Facility" ], "description": "Clinical setting where the visit occurred. Used to validate E/M code families and place-of-service-specific rules." }, "patientType": { "type": "string", "enum": [ "New", "Established" ], "description": "Whether the patient is new or established to the rendering provider." }, "specialty": { "type": "string", "enum": [ "Family Medicine", "Internal Medicine", "Ophthalmology", "Dermatology", "Orthopedics", "Cardiology", "General Surgery", "Emergency Medicine", "Psychiatry", "Neurology" ], "description": "Provider specialty. Used to apply specialty-specific coding rules during audit." } } }, "SubmittedCharge": { "type": "object", "required": [ "procedureCode" ], "properties": { "procedureCode": { "type": "string", "description": "CPT or HCPCS procedure code that was billed.", "example": "99214" }, "modifiers": { "type": "array", "items": { "type": "string" }, "description": "Modifiers submitted with the charge.", "example": [ "25" ] }, "diagnoses": { "type": "array", "items": { "$ref": "#/components/schemas/SubmittedDiagnosis" }, "description": "ICD-10-CM diagnoses linked to this charge." } } }, "SubmittedDiagnosis": { "type": "object", "properties": { "code": { "type": "string", "description": "ICD-10-CM diagnosis code.", "example": "J20.9" } } }, "AuditResponse": { "type": "object", "properties": { "findings": { "type": "array", "description": "List of audit findings, one per issue identified. Charges with no issues receive a `supported` finding.", "items": { "$ref": "#/components/schemas/AuditFinding" } }, "summary": { "type": "object", "description": "Aggregate counts for the audit.", "properties": { "totalChargesReviewed": { "type": "integer", "description": "Number of submitted charges that were evaluated.", "example": 2 }, "supportedCount": { "type": "integer", "description": "Number of charges fully supported by documentation.", "example": 1 }, "issueCount": { "type": "integer", "description": "Number of findings with severity warning or error.", "example": 2 } } }, "requestId": { "type": "string", "description": "Unique identifier for this request.", "example": "8fd9a734-b39c-4f44-9c5a-7e123456789" }, "requestTimestamp": { "type": "string", "format": "date-time", "description": "ISO 8601 timestamp of when the request was processed.", "example": "2026-04-21T14:30:00Z" } } }, "AuditFinding": { "type": "object", "properties": { "type": { "type": "string", "enum": [ "supported", "unsupported", "overcoded", "undercoded", "missing_modifier", "incorrect_modifier", "bundling_issue", "missing_charge", "missing_diagnosis" ], "description": "Category of the audit finding:\n- **supported** — charge is fully supported by the clinical documentation\n- **unsupported** — no documentation support for the billed procedure\n- **overcoded** — documentation supports a lower-level code\n- **undercoded** — documentation supports a higher-level code\n- **missing_modifier** — a required modifier was not submitted\n- **incorrect_modifier** — a submitted modifier is not applicable\n- **bundling_issue** — procedure should be bundled per NCCI edits\n- **missing_charge** — a procedure documented but not billed\n- **missing_diagnosis** — an ICD-10-CM code that should be linked but is absent\n" }, "severity": { "type": "string", "enum": [ "info", "warning", "error" ], "description": "Severity of the finding:\n- **info** — no action required (e.g., charge is supported)\n- **warning** — potential issue that should be reviewed\n- **error** — compliance issue that should be corrected before submission\n" }, "procedureCode": { "type": "string", "nullable": true, "description": "The CPT/HCPCS code this finding relates to. Null for `missing_charge` findings where the code was not submitted.", "example": "99214" }, "message": { "type": "string", "description": "Human-readable explanation of the finding.", "example": "E/M level 99214 (moderate MDM) is not supported by the documentation." }, "suggestedAction": { "type": "string", "nullable": true, "description": "Recommended corrective action. Null when no action is needed.", "example": "Downcode to 99213 (low MDM)." } } }, "ErrorResponse": { "type": "object", "properties": { "error": { "type": "object", "properties": { "code": { "type": "string", "description": "Machine-readable error code.", "example": "MISSING_REQUIRED_FIELD" }, "message": { "type": "string", "description": "Human-readable error message.", "example": "inputText is required" }, "requestId": { "type": "string", "description": "Unique identifier for this request, useful for support inquiries.", "example": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } } } }, "x-readme": { "explorer-enabled": true, "proxy-enabled": true }, "_id": { "buffer": { "0": 104, "1": 54, "2": 62, "3": 85, "4": 23, "5": 39, "6": 101, "7": 0, "8": 15, "9": 87, "10": 149, "11": 43 } } } ````