Key points
- Bill on the day of the visit and the clinic is paid sooner, with the afternoon clear for patients. The workflow runs in one direction, from signed note to confirmed code to invoice or claim.
- Since 2021, US office visit codes are chosen by medical decision making or by total time, so the note carries the evidence for the code.1
- Medicare requires a claim to be filed within 1 calendar year of the date of service, and billing on the day leaves the whole window for corrections.2
- wai drafts the note and suggested codes for the clinician to review and sign, and Admin builds the invoice or claim from what was signed.56
Summary
Run billing in one direction, from the signed note to the clinician-confirmed code to the invoice or claim, on the day of the visit. Software drafts the note and suggests codes from it, the clinician confirms both, and the admin team bills what was signed.
The invoice ready before the patient reaches the car park, and the afternoon clear for patients. The note is drafted during the consultation with codes suggested from it, the clinician confirms both while the visit is fresh, and the admin team bills from the signed record the same day.
See it in your clinicThirty minutes on your own patients and doctors.
Request a demoSee one consultation become a draft note, suggested codes for the clinician to confirm and a ready invoice, in fifteen minutes.
| Step | Owner | Output | Check that keeps it clean |
|---|---|---|---|
| Consultation | Clinician | Draft note written during the visit | Decision making and time captured in the note |
| Note signed | Clinician | Signed note on the patient record | Signed the same day as the visit |
| Codes suggested | Drafted by software from the signed note | Suggested procedure and diagnosis codes | Every code traceable to a line in the note |
| Codes confirmed | Clinician | Final code set | Clinician accepts, changes or removes each code |
| Invoice or claim built | Admin team | Patient invoice, insurer claim or both | Policy, authorisation and patient details match the record |
| Submitted and paid | Admin team | Payment or rejection | Rejections worked as a queue with one owner |
| Reconciled | Admin team | Payment matched to invoice and visit | Every payment matched by day end |
The note sets the code
The AMA's 2021 revisions to office visit codes removed history and examination as elements for choosing the code level, and let physicians select the level by medical decision making or by total time on the date of the encounter.1 A code is supportable when the note shows the reasoning or the time.
The clinician knows both best at the moment of signing, and a code suggested from a complete note is confirmed in seconds then.
Take a follow-up visit where the clinician reviewed outside results, adjusted two medicines and arranged a referral. A note that records that reasoning makes the suggested level easy to confirm, and a note that says only that the patient was reviewed supports the minimum.
The workflow, step by step
Each step in the table has one owner and one check, and the gain comes from doing them in order on the day of the visit.
Same-day billing protects the deadline
Under 42 CFR 424.44, a Medicare claim for services furnished since 2010 must be filed no later than 1 calendar year after the date of service, with narrow exceptions.2 Commercial payers set their own limits in each contract, and the clinic's billing calendar holds the shortest of them.
A claim built on the day of the visit leaves almost the whole window for corrections and resubmission. Track the days from visit to bill every week, and clear anything over five working days.
The chain a clinic owns
A 2019 JAMA review of 54 publications estimated the yearly cost of administrative complexity in US health care at $265.6 billion.3 The share a clinic controls is its own chain from note to payment, run once and correctly on the day.
Draft, confirm, bill
wai drafts the visit note during the consultation and prepares suggested coding for the clinician to review and sign, and only the clinician signs clinical documents.5 wai Admin then takes the codes extracted from consult notes, prepares claims for insurers, raises invoices and reconciles every charge in the clinic's accounts.6
For notes that document more work than the code chosen, see AI medical coding and undercoding.
UK private clinics use the CCSD Schedule
In UK private healthcare, the CCSD Schedule holds the standard codes for procedures and diagnostic tests, overseen by a group made up of representatives from four major private healthcare insurers.4 The code must match what the signed note records, and the submission chain is set out in Healthcode billing for private clinics.
Where to start
Take twenty signed notes from last month with their codes. For each, check whether the note supports the level chosen or a higher one, and how many days passed between visit and bill.
Move code confirmation to the moment of signing and give the rejection queue one owner. Within a month the clinic bills on the day and clinicians confirm codes in seconds. Rejections are covered in reducing claim denials, and collection in invoices and payment chasing.
Bring ten anonymised notes and their codes. We show suggested codes from each note, the clinician's confirmation and the invoice that follows.
Frequently asked questions
Does the AI choose the billing code?
wai suggests codes from the note, and the clinician reviews, changes and signs them.5 The admin team bills what the clinician confirmed.
Why confirm codes at the moment of signing?
The code level depends on medical decision making or total time, which the clinician knows best right after the visit, and both belong in the note.1
How long do we have to file a Medicare claim?
For services furnished since 2010, no later than 1 calendar year after the date of service, with limited exceptions.2 Check each commercial contract for its own limit.
Does this work for UK insured patients?
Yes. The code set is the CCSD Schedule, and the code matches what the signed note records.4
Who owns rejected claims?
One named person on the admin team, working rejections daily, with the clinician brought in when the note needs an addendum.
What should we measure first?
Days from visit to bill, the first-pass acceptance rate and the share of suggested codes the clinician changes. Review them monthly.
Sources
- 1American Medical AssociationCPT evaluation and management (E/M) code and guideline changesRead 14 October 2026Read source
- 2Electronic Code of Federal Regulations, US Government, 202642 CFR 424.44, Time limits for filing claimsRead 14 October 2026Read source
- 3JAMA, Shrank, Rogstad and Parekh, 2019Waste in the US Health Care System, Estimated Costs and Potential for Savings (PubMed abstract)Read 14 October 2026Read source
- 4Clinical Coding and Schedule Development GroupCCSD, a common language for private healthcareRead 14 October 2026Read source
- 5wai, 2026AI medical scribe for cliniciansRead 14 October 2026Read source
- 6wai, 2026wai Admin, the front desk and back officeRead 14 October 2026Read source
Every visit billed the same day, from the note the clinician signed.
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