Documentation & Coding

Operative Notes This Complex Deserve a Documentation System That Understands Them.

InstaNote captures the full surgical record: laterality, implant detail, procedure specificity, and the modifier context coders need. InstaCode takes it from there. Together, they close the loop from the OR to the claim.

HITRUSTeSOne PlatformHIPAAInpatientOutpatient

Provider dictating patient notes into mobile phone sitting at their desk

24 HoursCoding turnaround from operative note to billable code.

75%Reduction in documentation time.

AAPC/AHIMACredential standard on every human review and exception.

800+Trusted by providers with their most complex cases.

Trusted by 800+ healthcare organizations

Designed to work within the EHR environments you already use

Epic

Athenahealth

eClinicalWorks

NextGen

Cerner

Meditech

Built for Surgical & Ortho Complexity

The Question Every Surgical Practice Asks First. Is This Built for My Environment?

Generic documentation and coding tools are not designed for the level of precision required by surgical and orthopedic notes. These are the gaps that drive denials, and why they require a platform that understands the environment rather than one adapted from a general-purpose solution.

Arthroscopy, joint replacement, and fracture care notes require specific language: laterality, implant detail, approach, and findings by compartment. Generic templates do not support it. Notes that lack this specificity cannot be coded accurately, regardless of how good the downstream coding system is.

Surgical billing relies on stacking logic that is difficult to apply consistently under high caseloads. Modifier -59, -XS, -RT/-LT, -51, -22, applied in the wrong sequence, will process incorrectly even when the procedure was coded right. The error rate compounds with volume.

The 90-day global period creates systematic leakage on returns to the OR, unrelated post-op procedures, and complications. The most common error is not billing something that should be billed. It is failing to capture what should be, because the documentation did not make the case for a separate charge.

Side-of-body coding on surgical procedures cannot be implied from context. It must be stated explicitly in the note. When documentation treats laterality as assumed rather than documented, the billing error that follows is not a coding mistake. It is a documentation problem that the coding system inherited.

Hardware pass-through and implant codes must link directly to the surgical procedure. Gaps between what is documented and what is submitted lead to post-service denials for the practice's highest-value encounters, the procedures where the difference between captured and uncaptured revenue is largest.

A coder working through 40 surgical encounters applies the same modifier logic on the last case as the first. At scale, consistency is a system requirement, not a training outcome. Manual review cannot meet the precision surgical coding demands across a full day's caseload.

A Different Starting Point

When Documentation and Coding Share the Same Foundation, Denials Stop Being Surprises.

Reactive denial management addresses surgical claims after they have already failed. InstaNote and InstaCode bring coding intelligence closer to operative documentation, surfacing modifier gaps, global period risk signals, and documentation inconsistencies earlier, while encounters are still active and corrections are still easy to make.

Without InstaNote + InstaCode

✕Operative notes built in generic templates without surgical-specific structure
✕Modifier logic applied manually across high case volume
✕Global period conflicts identified after the claim is already denied
✕Laterality buried in narrative, assumed from context rather than stated explicitly
✕Coding decisions made in isolation from the operative record
✕Audit preparation assembled after the request arrives

With InstaNote + InstaCode

✓Custom templates structured around what coders need and expect
✓ACE Engine applies modifier stacking rules consistently, every encounter, regardless of case volume
✓Global period risk signals surfaced before submission, not after denial
✓Laterality captured in the documentation structure, stated rather than implied
✓Coding intelligence generated directly from InstaNote operative documentation
✓Full traceability from operative note to submitted code, built into the workflow rather than assembled afterward

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Why Bundled Matters

InstaNote Creates the Documentation Quality, InstaCode Delivers Coding Accuracy

Documentation Built for Coding

InstaNote's custom templates include the fields that downstream coding depends on. Custom required-field validation ensures that laterality, procedure specificity, and complexity indicators are documented before the note closes.

Autonomous Coding From the Operative Record

InstaCode reads InstaNote documentation directly. Modifier logic and laterality coding are applied from the operative record. Global period compliance is applied across the practice's encounter history, catching both missed revenue and audit exposure before codes are finalized.

Credentialed Review on What Needs It

Complex cases, ambiguous documentation, and exception encounters route to AAPC/AHIMA-credentialed coders, not to an exception queue that sits unreviewed. Every decision is logged. Every exception has an accountable reviewer.

Any Note, Not Just Our Note

InstaCode works from dictation, EHR-generated operative notes, and existing documentation sources. Add InstaNote to close the documentation-to-coding loop, or start with InstaCode and bring InstaNote in when the organization is ready.

Built On the EHR You Already Use

No New Infrastructure. No Change to How Surgeons Document.

InstaNote connects to the practice's existing EHR. InstaCode works from InstaNote, dictation, or EHR-generated operative notes. Deployment in as little as four weeks. It works where you work.

✓Standards-based EHR integration across Epic, Athena, eCW, NextGen, Modernizing Medicine, and Oracle Health
✓Coding happens in PerformPlatform or directly in the EHR, depending on the team's preference
✓In-house coders, DeliverHealth coders, or a hybrid model, all supported on the same platform
✓Deployment in as little as four weeks from contract to live
✓Surgical workflow does not change. InstaNote integrates into the documentation flow already in use.

Core Capabilities

Built for the Full Surgical Coding Workflow

InstaNote and InstaCode are designed as a system. Each is capable on its own. Together, they address the full chain from operative documentation to submitted claim.

✓Custom and procedure-specific surgical templates
✓Required field validation that flags incomplete notes before finalization, surfacing documentation gaps at the point of care rather than at the claim
✓Laterality, bilateral staging, and procedure specificity captured in structured fields when configured in the template
✓Dictation and ambient capture options suited to the surgical environment, supported by an expansive clinical vocabulary
✓Templates developed with surgical and orthopedic clinical input

✓ACE Engine applies modifier logic (−22, −51, −59, −XS, −RT/−LT, −78, −79, −24) from operative documentation automatically
✓Global period conflict detection with risk signals surfaced before submission, not after denial
✓Laterality verification cross-referenced from InstaNote source documentation
✓NCCI edit compliance logic that prevents known bundling violations before claims leave the system
✓PerformPlatform reporting: coding accuracy by surgeon, encounter type, modifier category, and turnaround time
✓Full audit trail from operative note to submitted code, available for QA, payer review, and internal audit

Designed for the Whole Organization

One Platform. Outcomes That Matter Across the Revenue Cycle.

InstaNote and InstaCode are built for organizations where coding quality, revenue integrity, and compliance accountability are shared concerns across the organization, not siloed by department.

Revenue Cycle Leaders

Earlier visibility into surgical coding accuracy and claim denial risk, before claims reach submission. Global period compliance applied across the practice's encounter history, catching missed revenue and audit exposure at the coding layer. 24-hour turnaround from operative documentation to billable code.

Coding Teams

Clearer signals from InstaNote documentation structured for coding specificity. Less rework on complex surgical cases. AAPC/AHIMA-credentialed review on exceptions, not an unreviewed queue. PerformPlatform tracks accuracy by coder, procedure type, and modifier category.

Compliance and Audit Functions

Full traceability from operative note to submitted code, built into the workflow rather than assembled when the audit request arrives. Every exception has a credentialed reviewer and a documented decision trail.

Practice and Operational Leadership

Deployment in as little as four weeks. InstaCode works with the existing EHR and documentation source. Coding can run with in-house staff, DeliverHealth coders, or a hybrid model, without rebuilding the operational workflow around the platform.

See the Platform

The Workflow

From Operative Documentation to Submitted Claim

Same foundation, with multiple execution paths and a single consistent model.

No change to how providers document. Deployment in as little as four weeks.

Connect the Documentation Source

InstaNote connects to the existing EHR. Operative notes, dictation, or EHR-generated surgical records all serve as the coding source.

ACE Engine Surfaces Coding Intelligence

The Autonomous Coding Engine analyzes documentation and generates coding output covering modifier logic, global period compliance, laterality verification, and implant code linkage applied from the operative record. Risk signals are surfaced at this stage, before submission.

Review, Submit, Track

Credentialed coders review exceptions and complex cases. Every decision is logged. Coded claims return within 24 hours of documentation receipt, with a full audit trail attached and ready for QA or payer review.

Deployment in as little as four weeks. Current DeliverHealth customers can be live in 1 to 2 weeks.

Schedule a Conversation

See What This Looks Like in a Surgical Environment

A 20-minute call to understand where the practice is today and whether InstaNote and InstaCode are worth a closer look. No presentation. A few questions about current workflows, case volume, and where revenue cycle friction tends to show up.

No Commitment. One Conversation.

✓Review of how coding is currently handled and where denials or revenue gaps tend to originate
✓A quick look at case volume, EHR environment, and current documentation workflow to understand the context
✓An honest read on whether InstaNote and InstaCode are the right fit for the practice's situation
✓A clear next step if there is something worth exploring further, no open-ended follow-up

✓ AAPC/AHIMA Credentialed✓ 24-Hour Turnaround✓ Standards-Based Integration

Request an Overview

The Why

What Surgical and Orthopedic Organizations Know Before They Go Live.

Documentation and coding from the same source, not two separate systems with a gap coders have to bridge
Modifier logic and global period compliance that holds at volume, applying the same rules on case 40 as case 1
AAPC/AHIMA-credentialed review on every exception. No autonomous decisions without a documented reviewer.
Purpose-built for surgical and orthopedic coding. Not adapted from a general-purpose solution.
Deployment in as little as four weeks, with no infrastructure project and no change to how surgeons document
In-house coders, DeliverHealth coders, or a hybrid model. Same platform, no forced workflow change.