Ambience’s compliance-first approach to documentation

Our approach combines external audits, rigorous internal reviews, and customer collaboration to safeguard accuracy, revenue, and compliance.

Why compliance matters in healthcare


Compliance for U.S. health systems means meeting a latticework of federal regulations, payer policies, and industry-standard coding rules (ICD-10-CM/PCS, CPT, HCPCS, and more). When clinical documentation drifts from those rules, the financial fallout is swift:


  • OIG audits alone flagged $3.44B in recoveries last year – money that regulators expect to claw back from providers.1

  • Coding-related denials alone jumped 124% in 2024, and inpatient claims have been hit the hardest (200% jump).2

  • Every denied claim costs an average of $25 to rework for practices and $180 for hospitals, draining margins and staff capacity.3

What does this mean for health systems implementing AI scribes?

By this point, almost every health system has piloted an AI scribe. But rapid adoption has outpaced the ability to evaluate their efficacy.

With this wave of “coding naive” AI scribes, the risk multiples downstream because documentation at the point-of-care isn’t generated with CDI or coding logic in mind, creating far-reaching implications for RCM efficiency, revenue integrity, and audit readiness.

AI coding tool accuracy

In a head-to-head evaluation, Ambience outperforms the previous generation of AI computer-assisted coding tools at E/M accuracy

Ambience

0%

‍AI Coding Tool‍

0%

E/M coding accuracy across specialties, through rigorous AAPC auditing. E and M coding accuracy ranges from:

90-100%

What does this mean for health systems implementing AI scribes?

Tools that simply transcribe conversations or generate generic notes may seem helpful — but they often miss the clinical and coding context needed for accuracy, reimbursement, and compliance.

Ambience takes a different approach. As a coding-aware ambient AI, it doesn’t just document what was said -  it reads from the EHR to understand existing diagnoses, risk factors, and visit context. It then surfaces accurate codes and substantiates them with aligned clinical documentation, so what's captured in the note directly supports what gets billed.

This makes Ambience essential for health systems looking to reduce rework, avoid denials, and create defensible documentation at scale.

Core Capabilities

Coding-Aware Ambient AI

Coding-Native AI Scribes

Real-time ICD-10, E/M, add-on code suggestions
Integrated coding logic (e.g., MEAT criteria, medical necessity, time-based codes)
Risk-adjusted coding support (e.g., HCC capture)
Specialty-specific CDI across care settingsICD-10 write-back into major EHRs and Epic EDG Master File integration
Audit-ready structure with defensible documentation and real-time compliance coaching
Integrated diagnosis context (EHR read & write)
Built-in capability of Ambience

Metrics

Coding-Aware
Ambient AI

Coding-Native
AI Scribes

ICD-10 substantiation accuracy
97%, 

AAPC-audited

E/M coding accuracy, across specialties
90-100%,
AAPC audited

Diagnosis capture improvement (lift in MEAT Compliant documentation)
20% lift
Add-on code utilization uplift
62% increase
HCC Capture rate Increase
10% increase

Remember:

Coding-naive solutions may generate what seems to be a well-written note, but they ultimately lack billing specificity and structure, shift the burden downstream to CDI and coding teams, and increase the risk of denials, undercoding, and audit exposure.

Ambience is coding-aware,
by design

At Ambience, coding is not an afterthought. It’s foundational.

Real-time CDI
built-in

Our platform embeds coding logic into every note, letting clinicians document once, with the confidence that CDI, coding, and quality requirements are already satisfied.

Guidance at the
point-of-care

Code suggestions are surfaced right at the end of the encounter, guiding clinicians and helping them internalize documentation elements needed to support a compliant chart.

Real-time documentation compliance nudges

Ambience now provides clinicians with real-time prompts to address documentation gaps before they sign off, based on transcript and EHR context. This feature helps ensure support for billed diagnoses is present at the point of care, not just flagged later by coders or CDI.

Comprehensive
coding support

Whether it’s surfacing risk-adjusted diagnosis, justifying modifier-25, or suggesting the appropriate E/M level, Ambience supports accurate, compliant documentation across 100+ specialties and subspecialties.

Validated by
independent audits

Ambience is the only ambient documentation platform with third-party validation from AAPC, one of the key industry authorities on medical coding and compliance.

What Makes Ambience Coding-Aware?

  • Real-time ICD-10/E&M suggestions at the point of care
  • Smart detection of add-on and Modifier-25 opportunities
  • Deep EHR diagnosis sync (read & write)
  • Real-time compliance nudges during documentation
  • Audit-ready notes built to support defensible billing
Download the Ambience Coding Audit Summary

See how our our specialty-specific coding-aware ambient AI scored in top specialties in audits with the AAPC.

Ambience Healthcare will handle your data pursuant to its Privacy Policy

Footnotes


1. U.S. Department of Health and Human Services, Office of Inspector General. (2023, December 1). HHS-OIG’s efforts result in $3.44 billion in expected recoveries, according to latest report [Press release]. https://oig.hhs.gov/newsroom/news-releases-articles/2023-fall-sar/


2. MDaudit. (2024, November 20). 2024 MDaudit benchmark report highlights urgent need for continuous financial risk monitoring amid surging denials and audits. https://www.mdaudit.com/news/2024-benchmark-report-highlights/


3. Poland, L., & Harihara, S. (2022, April 25). Claims denials: A step-by-step approach to resolution. Journal of AHIMA. https://journal.ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution