AI Primary Care Compliance Software: Audit 100% of Your Charts
Brellium audits every primary care chart for E/M (Evaluation and Management) level and in-visit charge capture, catching undercoding before claims go out.
100% of office visits. Documentation covered by our clawback protection guarantee.
Where Primary Care Revenue Slips
A visit billed 99213 when the medical decision making (MDM) supports 99214 is revenue lost. So is every in-visit procedure the note documents but the claim leaves out.
Medicaid and FQHC visits face strict government payor audits on top. Brellium audits 100% of charts for E/M level, charge capture, and documentation pre-submission.
How Brellium Audits 100% of Your Primary Care Charts
Brellium connects to your EMR and audits every chart automatically, no manual uploads, no sampling.
MDM & E/M Coding
Validate every new (99202-99205) and established (99212-99215) office visit level against the documented MDM.
Managed Coding in Your EMR
Validated codes write back into the EMR, so corrections land in the workflow instead of a separate report.
In-Visit Charge Capture
Catch billable procedures the note documents but the claim doesn’t carry, so documented charges get billed.
Medicaid & FQHC Chart Review
Document-based chart review for Medicaid and FQHC/RHC visits, where flat per-visit rates make compliance the priority.
Clawback Protection
Backed by Confidence Coverage: if a documentation gap slips through and triggers a clawback, Brellium covers the cost 100%.
Standard Deployment
- MDM/E/M coding validation (99202-99215)
- Managed coding write-back to the EMR
- In-visit procedure charge capture
- Medicaid and FQHC/RHC document-based chart review
Enterprise Customization
- G-codes (G0402, G0438/G0439, G2211)
- Modifier-25
- Care management families (CCM, TCM, PCM, RPM, ACP)
- Async e-visits (99421-99423)
Common Primary Care Coding Risks Brellium Catches
Undercoded Office Visits
Flags visits billed below the level the documented MDM supports.
Overcoded Visit Levels
Catches billed levels the MDM documentation doesn’t support.
Missed Point-of-Care Tests
Catches rapid strep, flu, COVID, urinalysis, glucose, and A1c tests documented but not coded.
Uncaptured In-Office Procedures
Flags EKGs, spirometry, nebulizer treatments, and cerumen removal missing from the claim.
Unbilled Injection & Vaccine Administration
Catches injection (96372) and vaccine administration documented in the visit but not billed.
Government Payor Documentation Gaps
Flags Medicaid and FQHC/RHC visit documentation that won’t hold up under review.
Impact for primary care organizations
The outcomes primary care organizations see when every chart is audited before claims go out.
Built for How Primary Care Coding Works
Fee-for-Service and FQHC, Audited for Different Risks
Brellium audits fee-for-service visits for MDM level and charge capture, and Medicaid and FQHC/RHC visits for documentation compliance.
Level and Procedures, Checked on One Chart
Brellium reviews the E/M level and every in-visit procedure together, so a correctly leveled visit doesn’t go out missing the charges documented alongside it.
100% Chart Coverage. Zero Clawbacks.
Sampling leaves revenue on the table. Brellium audits every chart, with documentation compliance backed by Confidence Coverage.
FAQs About Primary Care Compliance
What’s the difference between 99214 and 99215?
99214 and 99215 are both established-patient office visits: 99214 requires moderate medical decision making and 99215 requires high. When billed on time instead, 99214 starts at 30 minutes of total time on the date of the encounter and 99215 at 40. Brellium validates the billed level against the MDM the note documents.
What are the CPT codes for primary care office visits?
Primary care office visits bill with E/M codes 99202-99215, split by patient status:
- 99202-99205: new patient, straightforward to high MDM
- 99211: established patient, minimal service that may not require a physician
- 99212-99215: established patient, straightforward to high MDM
In-visit procedures like 96372 (injection administration), 94010 (spirometry), and 69210 (impacted cerumen removal) bill separately on top of the visit.
How does MDM determine the E/M level?
MDM sets the office visit level under the AMA E/M guidelines revised in 2021, with total time as the alternative. Two of three elements must meet or exceed the level billed:
- Number and complexity of problems addressed
- Amount and complexity of data reviewed and analyzed
- Risk of complications from patient management
What is E/M undercoding?
E/M undercoding is billing an office visit below the level the documented MDM or time supports, like a 99203 on a new-patient visit that meets 99204. The claim would have held up at the higher level, so the difference is lost revenue. Brellium flags undercoded visits before submission.
What should I look for in AI-assisted E/M coding software?
AI-assisted E/M coding software should audit 100% of visits instead of a sample, validate each level against documented MDM, catch procedures missing from the claim, and return corrected codes to the EMR rather than a separate report. Brellium’s standard deployment covers all four.
We use Scribe to create our notes. Do we still need Brellium?
Yes. Scribe helps clinicians write notes faster, but it doesn’t check whether the billed E/M level and procedures match what the note documents. Brellium audits the notes your Scribe produces.