Plain-English guides to professional coding & charge capture.
Source-cited explainers written by the Capsa Coding team for coders, CDI, compliance, and revenue-cycle leaders. We cover the professional CPT/HCPCS side of coding — what Capsa Charge Capture actually works on — and how to measure coding accuracy honestly.
Revenue integrity
What is charge capture?
How signed clinical documentation becomes billable charges — and where professional revenue leaks when it doesn't. The foundational guide.
Read the guide Pillar · missed chargesRevenue leakage & missed charges
Why missed charges are silent, what causes professional charge-capture leakage, and how to put a number on it without overcorrecting into audit risk.
Read the guide Metric · denialsClean claim rate & denials
What clean claim rate measures (benchmark 95%+), how it relates to the denial rate, and how coding accuracy upstream protects the claim downstream.
Read the guideAccuracy, audit & documentation
How to measure coding accuracy
Why a single “accuracy %” misleads, and how precision and recall map directly to audit risk and revenue leakage.
Read the guide Audit · audit-defensibleCoding audits, explained
Prospective vs retrospective, internal vs external (including RAC), what auditors look for, and what makes coding audit-defensible.
Read the guide Documentation · CDIWhat is clinical documentation integrity?
What CDI is, what CDI specialists do, how CDI differs from coding, and the standards bodies (AHIMA, ACDIS) behind it.
Read the guideAI & the coder
AI medical coding, explained
How AI coding works, the spectrum from CAC to autonomous to transparent decision support, and how to evaluate accuracy and audit-defensibility.
Read the guide ComparisonCAC vs autonomous coding
Computer-assisted vs autonomous coding — how much a human does, and the transparency and measurement axis both leave out.
Read the guide The roleAI coding vs human coders
Will AI replace medical coders? The human-in-the-loop reality — what AI handles and where human judgment stays essential.
Read the guide DecisionBuild vs buy: AI coding
Building coding AI in-house vs partnering — the real cost of an in-house AI team, maintenance, and audit-readiness, plus a hybrid third way.
Read the guideCoding fundamentals
CPT vs HCPCS codes
What each code set is, who maintains it, and when you use one over the other — with examples and primary-source citations.
Read the guide The bridgeRevenue code vs CPT code
The professional-vs-facility boundary, explained: revenue codes say where on a facility claim; CPT/HCPCS say what. Why it matters for clean claims.
Read the guide ModifiersModifier 25, explained
When a significant, separately identifiable E/M can be reported on the same day as a procedure — the same-diagnosis myth, and how to keep it audit-defensible.
Read the guide E/M · educationalE/M leveling (99213 vs 99214)
How outpatient E/M levels are chosen under the 2021 MDM and time rules — an educational primer.
Read the guidePediatric coding · Capsa-validated
Vaccine administration coding
90460/90461 (counseling, per component) vs 90471–90474 (no counseling, per vaccine by route), and how they pair with the vaccine product code.
Read the guide ScreeningDevelopmental screening coding
CPT 96110 screening vs 96112/96113 testing, the documentation that supports it, and how it's reimbursed.
Read the guideCurious how this works on your charts?
Capsa Charge Capture reads your signed notes and recommends every billable CPT/HCPCS code the chart supports — each cited to verbatim chart text, then scored against what your coders actually billed.