Charge Capture

Sources and review notes

These links support definition-level research and do not establish the regulatory status, safety, or suitability of any product.

CMS's 2026 Evaluation and Management guidance states that medical-record documentation must support the service level reported, claims must correctly reflect services furnished, and medical necessity requirements still apply. CMS's National Correct Coding Initiative publishes Medicare and Medicaid coding policies and regularly updated edits intended to reduce improper coding and payment. HHS-OIG's General Compliance Program Guidance describes voluntary, nonbinding risk assessment, auditing, investigation, correction, and monitoring expectations for health care compliance programs. These sources support documentation, coding, claim, and audit controls but do not define one charge-capture workflow, validate an AI recommendation, authorize a missing or higher charge, or guarantee revenue, payment, denial, or compliance outcomes. Organizations must verify each candidate against the actual encounter, order, result, supply or medication administration record, responsible provider authentication, current code and edit versions, payer policy and contract, charge master and fee schedule, duplicate and bundled-service controls, medical necessity, modifier and place-of-service rules, qualified coding and billing review, sample-based false-positive and false-negative testing, correction and refund processes, and an auditable final decision before claim submission.

• Source 1: www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
• Source 2: www.cms.gov/national-correct-coding-initiative-ncci
• Source 3: oig.hhs.gov/compliance/general-compliance-program-guidance/