CPT Procedure Code Assistant

An AI-driven CPT (Current Procedural Terminology) coding validation and suggestion tool that analyzes clinical documentation to identify appropriate procedure codes, detect coding gaps, validate code-documentation alignment, and flag potential compliance issues. Designed to support medical coders, billers, and clinicians in accurate charge capture and reimbursement optimization.

Quick Install

npx skills add Open-Medica/open-medical-skills --skill cpt-coding-assistant

What It Does

• Documentation-to-code mapping: Analyzes clinical notes, operative reports, and procedure documentation to suggest the most accurate CPT codes, including appropriate modifiers (-25, -59, -76, -RT/LT, etc.)
• E/M level validation: Evaluates Evaluation and Management documentation against 2021 E/M guideline criteria (medical decision making or total time) to confirm the billed level is supported by the note content
• Coding gap detection: Identifies documented procedures, services, or complexity factors that were performed but not captured in the charge, preventing revenue leakage
• Bundling and unbundling analysis: Checks for National Correct Coding Initiative (NCCI) edit pairs to prevent improper unbundling while also identifying when modifier use legitimately allows separate reporting
• Compliance risk flagging: Highlights patterns that could trigger audit risk, such as high-frequency use of high-level E/M codes, unusual modifier patterns, or documentation that does not support medical necessity

Clinical Use Cases