AI Clinical Documentation Integrity

AI Clinical Documentation Integrity (CDI) products leverage artificial intelligence to review and evaluate clinical documentation in support of appropriate patient care, billing, and compliance with regulatory requirements. 

These solutions can operate at the point of care, ensuring the documentation reflects the patient-clinician conversation and available clinical data, and supports the assigned medical codes. They can also operate post-encounter, between the medical coding and billing steps, to review the documentation against what has been coded and surface suggestions for revenue and quality opportunities. Many of these solutions include built-in functionality to suggest potential diagnoses that may have been missed based on information in the patient record.

While similar in concept to risk adjustment solutions, AI CDI products are predominantly used in a fee-for-service context to ensure more accurate and complete billing and improve care quality.

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Ambience Healthcare logo
Ambience Healthcare
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Ambience Healthcare

Company Info
Founded: 2020
Headcount: 11-50
Customers
Verified Customers: 12
Customers Served: Digital Health Provider, Ambulatory Practice, Hospital / Health System
Product Overview
4 Reviews
Security and Compliance Certifications: HIPAA
Ambience Healthcare offers a suite of AI-driven tools designed to enhance clinical documentation and workflow. AutoScribe serves as an AI medical scribe that generates comprehensive documentation during patient visits across various specialties. Other tools include AutoCDI for real-time coding and compliance, AutoAVS for sending patients personalized after-visit summaries to reduce in-basket messages, and AutoRefer for managing specialist referrals. These solutions integrate with existing EHR systems and support multi-lingual environments and complex workflows.
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MarianaAI
Claimed

MarianaAI

Company Info
Founded: 2023
Headcount: 11-50
Customers
Customers Served: Digital Health Provider, Hospital / Health System, Ambulatory Practice
Product Overview
Security and Compliance Certifications: SOC 2 Type 1, HIPAA
MarianaAI's CARE platform automates clinical workflows with AI tools like the AI Medical Scribe, which transcribes multi-lingual medical encounters in real-time and generates clinical notes and codes. The platform also creates detailed Patient Portraits, summarizes patient histories to improve care and optimize HCC/RAF scores, and automates medical coding. Additionally, it auto-drafts responses and triaging messages for patient communication.
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SmarterDx
Claimed

SmarterDx

Company Info
Founded: 2020
Headcount: 51-200
Customers
Verified Customers: 12
Customers Served: Hospital / Health System
Product Overview
Security and Compliance Certifications: HIPAA
SmarterDx is a clinical AI tool that performs detailed second-pass reviews of patient discharge data, analyzing chart notes, labs, medications, and vital signs, to identify missed differential diagnoses, clinical documentation, and other coding opportunities. This enables more accurate revenue capture and better patient outcomes.
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Brellium

Brellium

Company Info
Founded: 2021
Headcount: 11-50
Customers
Verified Customers: 7
Customers Served: Ambulatory Practice, Digital Health Provider, Hospital / Health System
Product Overview
Security and Compliance Certifications: SOC 2 Type 1, HIPAA
Brellium automates the medical chart review process. It audits clinical documentation and billing notes according to custom criteria, identifying discrepancies, errors, and gaps. The platform connects with EHR systems to provide real-time reporting, helps improve documentation quality, and allows for same-day billing validation. It is designed to reduce the workload on CDI teams, enhancing accuracy and efficiency in auditing thousands of charts.
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Evidently

Evidently CDI

Company Info
Founded: 2020
Headcount: 11-50
Customers
Customers Served: Hospital / Health System
Product Overview
Security and Compliance Certifications: HIPAA
Evidently CDI integrates with EHRs to improve documentation of patient care, improving data accuracy for clinical, administrative, and regulatory purposes. By ensuring that patient records are precise and up-to-date, Evidently’s CDI solution helps healthcare providers improve patient care, support compliance with industry standards, and optimize reimbursement processes.
Iodine AwareCDI logo
Iodine Software

Iodine AwareCDI

Company Info
Founded: 2010
Headcount: 201-500
Customers
Customers Served: Ambulatory Practice, Hospital / Health System
Product Overview
Iodine AwareCDI enhances clinical documentation from admission through post-billing review by identifying missing elements in patient documentation based on clinical evidence, improving documentation integrity and revenue capture. The product prioritizes cases for review, increases query and response rates, spots gaps in patient documentation, reduces denials, predicts final discharge DRGs, minimizes audit risk, automates the query process, and identifies coding opportunities.
Company Info
Founded: 2011
Headcount: 5001-10000
Customers
Customers Served: Hospital / Health System, Ambulatory Practice, Health Plan
Product Overview
Security and Compliance Certifications: HIPAA
Optum Enterprise CAC (Computer-Assisted Coding) and CDI 3D is an integrated platform designed to enhance clinical documentation and coding accuracy through the use of NLP. The system reviews cases, identifying opportunities for documentation improvement and coding specificity, and automating workflows to reduce administrative burden. It includes modules for audit and compliance, analytics and reporting, and workflow management.
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Regard

Regard

Company Info
Founded: 2017
Headcount: 11-50
Customers
Verified Customers: 10
Customers Served: Digital Health Provider, Ambulatory Practice, Hospital / Health System
Product Overview
Security and Compliance Certifications: SOC 2 Type 2, HIPAA
Regard is an AI-driven tool designed to assist clinicians in analyzing patient data more efficiently. It integrates with electronic medical records (EMR) to extract insights from unstructured clinical data, suggest diagnoses, and generate clinical notes. This "medical co-pilot" helps healthcare providers make informed decisions and reduces documentation time. Key functionalities include automating administrative tasks, providing diagnostic support, and enhancing clinical practice by making patient information more accessible and actionable within the EMR system.
Semantic Health logo
Semantic Health

Semantic Health

Company Info
Founded: 2019
Headcount: 11-50
Customers
Verified Customers: 1
Customers Served: Hospital / Health System
Product Overview
Security and Compliance Certifications: SOC 2 Type 2, HIPAA
Semantic Health offers an AI-driven platform designed for real-time medical coding, auditing, and clinical documentation improvement (CDI). It performs pre-bill audits, reviewing 100% of coded charts to detect errors and identify revenue opportunities with minimal workflow disruption. The platform integrates with major EHR systems and provides insights for various healthcare providers, including acute care and pediatric hospitals.
Company Info
Founded: 1902
Headcount: 10000+
Customers
Customers Served: Hospital / Health System, Ambulatory Practice
Product Overview
Security and Compliance Certifications: HIPAA
The 3M 360 Encompass System integrates computer-assisted coding (CAC) and CDI into a single platform. It uses NLP and AI to automatically suggest medical codes based on patient documentation, improving the accuracy and efficiency of the coding process. The system prioritizes high-risk cases for review, tracks quality metrics like Hospital Acquired Conditions (HACs), and supports real-time clinical intelligence reporting. It aims to enhance compliance, optimize reimbursement, and facilitate better patient care by providing comprehensive tools for coders and CDI specialists.
Company Info
Founded: 1902
Headcount: 10000+
Customers
Customers Served: Hospital / Health System, Ambulatory Practice
Product Overview
Security and Compliance Certifications: HIPAA
CDI Engage One by 3M CDI that uses AI to provide real-time clinical insights to physicians and CDI teams. It integrates into both front-end and back-end workflows, analyzing EHR notes and narrative documents to identify gaps in patient care and documentation. This helps clinicians document a complete and compliant patient story before saving notes in the EHR, thus reducing the need for retrospective queries. It also supports back-end workflows with evidence-based analysis, worklist prioritization, and a clinically driven review process.
Company Info
Founded: 1902
Headcount: 10000+
Customers
Customers Served: Hospital / Health System
Product Overview
Security and Compliance Certifications: HIPAA
Solventum Revenue Integrity is designed to manage and prevent claim denials by analyzing clinical, coding, and payment data. Utilizing machine learning models, it predicts potential denials and provides real-time insights and recommendations throughout the patient journey. The system enhances reporting by linking clinical activities to payment outcomes and integrates workflow with denial risk alerts, guiding revenue cycle staff for timely interventions to prevent denials.