Facility Configuration Guide

HANK CODES reads your clinical documents and produces structured claims. Each claim carries CPT codes, ICD-10 codes, modifiers, provider assignments, and review alerts. This guide lists every billing decision your facility can set. Each section states the options and the default.

You do not edit the configuration yourself. Read this guide, record your choices, and give them to your Hank representative. Your representative applies them to your facility configuration.

How to use this guide

Each decision below shows the available options. The word Default marks what happens if you state no preference. Each decision also explains what changes on the claim.

Sections carry a tier. Use the tier to set your priority:

• REQUIRED: decide these before go-live.
• ADVANCED: decide these if the default does not match your billing policy.
• RARE: most facilities never change these.

This guide covers the Anesthesia specialty in Sections 1 to 13. Section 14 covers E/M visits. Section 15 covers Radiology. Section 16 covers post-op pain rounds. Ask your Hank representative for the guide that matches your specialty.

If you leave everything at default, the autocoder does the following:

• It bills medical direction with QK and QX modifiers when both an MD and a CRNA or AA are present.
• It checks all 7 TEFRA requirements and raises a review alert for each unmet requirement.
• It raises a review alert for codes below 80 to 85 percent confidence.

After you complete your choices, do the following:

1. Review your choices with your coding manager.
2. Send your choices to your Hank representative.
3. Test the configuration with sample cases before go-live.
4. Keep a signed copy for your records.

Glossary

Section 1: General controls

Tier: REQUIRED

1.1 Force review on every claim

Decide if every claim gets a review alert, whatever its confidence score.

• Yes: every claim gets a review alert.
• No: only claims with a problem get an alert. A problem is low confidence, missing data, or a rule violation. Default

What this changes: with forced review on, every claim carries a review alert. With forced review off, a high-confidence claim with no problem carries no alert. The setting is forceHumanReview.

1.2 Starting point: practice type

Select the practice type that matches your facility. The practice type sets the defaults for medical direction, TEFRA checks, and provider scenarios. You can still change any single setting in the sections below.

Why this matters: a practice type sets the correct defaults for your facility. A teaching hospital, for example, alerts on every CRNA-alone case and requires the full note set. You save time and you avoid errors.

Note: CRNA independent practice is not the same as no direction modifiers. CRNA independent still assigns QZ and AA modifiers from the staffing. Select it when you want modifier-ready claims. No direction modifiers skips every modifier. Select it when your downstream billing system adds the modifiers.

Section 2: Medical direction and TEFRA

Tier: REQUIRED

2.1 Enable medical direction billing

Decide if the autocoder bills medical direction when an anesthesiologist works with a CRNA or an AA.

• Yes, enable medical direction billing: bill both providers. The MD gets QK and the CRNA or AA gets QX. Default
• No, disable medical direction: assign providers to billing lines and add no direction modifier.

What this changes: with medical direction on, a case with both an MD and a CRNA or AA produces two billing lines. Each line carries the correct modifier for that provider. With medical direction off, the autocoder still assigns the correct provider to each line, but it adds no direction modifier at all. Your downstream billing system must add them. If you want QZ on CRNA-alone cases or AA on MD-alone cases, keep medical direction on and use the billing scenarios in Section 2.7. The setting is medicalDirection.

If you choose No, go to Section 3.

2.2 The 7 TEFRA requirements

CMS requires the anesthesiologist to meet seven requirements for Medicare medical direction billing. The autocoder evaluates eight elements, because it checks induction and emergence separately. Select the elements your facility enforces.

What this changes: the autocoder reads the documentation for evidence of each enforced element. If the documentation does not support one or more enforced elements, your choice in Section 2.3 decides what happens. An element you set to Skip reports as EXCLUDED in the TEFRA result, and it never fails the evaluation. The autocoder runs the whole TEFRA evaluation only when medical direction is on, as Section 2.1 describes.

2.3 Action when TEFRA requirements are not met

Decide what happens when the documentation does not prove every enforced TEFRA requirement.

• Bill medical direction and raise a compliance alert: the claim keeps the QK and QX modifiers, and a reviewer sees a COMPLIANCE alert. Default
• Drop to CRNA non-directed: remove the MD line. Only the CRNA bills, with the QZ modifier.
• Drop to CRNA non-directed and suppress the alert: the same as above, and no TEFRA alert appears. Use this when the drop to CRNA is your policy, not an exception.
• Drop to supervision: change the MD modifier from QK to AD.
• Keep the MD on the line and raise a HARDSTOP alert: the MD stays on the line with no modifier. A coder resolves the alert.

If you bill with an alert, you also choose:

• Alert severity from 1 to 10. Default: 8
• Alert type: HARDSTOP, COMPLIANCE (Default), FINANCIAL, or INFORMATIONAL.

Provider-conditional actions (optional): if you employ both CRNAs and AAs, you can set a different action for AA-only cases.

• The same action for all provider types. Default
• A different action for AA cases. For example, keep the MD on the line and alert for AAs, while CRNAs drop to QZ.

What this changes: "Bill with an alert" sends the claim with QK and QX, and a reviewer checks the TEFRA documentation. "Drop to CRNA" removes the MD from the claim. Only the CRNA with QZ reaches the payer. "Drop to supervision" changes the MD line from QK to AD, which reimburses less. "Keep the MD on the line" leaves the modifier decision to a coder.

2.3a Action when TEFRA requirements are met

Tier: ADVANCED

By default, normal billing proceeds when the TEFRA requirements are met. The MD and CRNA get QK and QX as you configured them. Some facilities want to override the billing scenario when TEFRA passes.

• Normal billing proceeds: use the configured scenario. Default
• Bill the MD with no direction modifier: the MD is on the line with no QK, QX, QZ, or AA modifier.

What this changes: the override puts only the MD on the line with no direction modifier. Most facilities keep the default. Use the override when a TEFRA pass at your facility means the MD can bill without a direction modifier, and a TEFRA failure triggers a fallback such as a drop to CRNA.

2.4 MD validation rules

This rule controls how strictly the autocoder verifies MD involvement.

What this changes: if you require MD evidence and the documentation contains none, the MD line gets no QK or QY modifier.

Note: two related decisions live in Section 2.7. How a CRNA without a documented MD bills is the "CRNA alone" scenario. What happens when an AA appears without a directing MD is the "AA alone" scenario. Set both there.

2.5 Time allocation

Decide how the autocoder allocates anesthesia time when it bills an MD and a CRNA or AA on separate lines.

• Both providers bill the full anesthesia time: on a 60-minute case, the MD bills 60 minutes and the CRNA bills 60 minutes. Default
• Each provider bills the documented time: not yet available. See the caution below.
• Only the primary provider bills time: not yet available. See the caution below.

What this changes: "Both full time" is the most common and the most conservative choice. The payer sees the full time on both lines.

Caution. The "documented time" and "primary only" strategies are accepted in the configuration but not applied. The autocoder puts the full anesthesia time on both lines whatever you select. Tell your Hank representative if your facility needs one of these strategies. Do not rely on this setting until the feature ships.

2.6 Handover and relief

Decide how the claim is structured when one anesthesiologist relieves another during a case.

• Keep one primary provider: bill everything under the provider with the most time. Default
• Split at handovers: create a separate billing line for each provider's time period.

If you keep one primary provider, choose how the autocoder picks the primary for each provider role. The options are most time, started the case, or finished the case. Most time is the default for the attending MD, the CRNA, the AA, and the resident.

What this changes: "Keep primary" puts all the time under one name and NPI. If one physician was present for 120 minutes and another for 60 minutes, all 180 minutes go under the first physician. "Split" produces two lines with different providers and different time ranges. A split produces more line items, and it reflects who was present at each point.

2.7 Billing scenarios by provider combination

Choose how the autocoder bills each staffing scenario.

Note: select the CRNA independent practice type in Section 1.2 if your CRNAs practice independently while an MD is present but not directing. That practice type changes the "MD directing a CRNA" scenario to bill the CRNA as non-directed with QZ, instead of the QK and QX pair.

What this changes: each scenario controls the modifier on each claim line. "MD directing a CRNA, bill both" produces two lines. The MD line carries QK and the CRNA line carries QX. "CRNA alone, QZ" produces one line with QZ. An AA alone always raises a HARDSTOP alert, per the CMS rule.

2.8 Concurrent case limits

Caution. The autocoder accepts these settings and does not apply them. The keys are maxConcurrentCases and actionWhenConcurrencyExceeded. No pipeline code reads them. The autocoder codes one case at a time, and it does not track how many cases an MD directs at once. It enforces no concurrency limit and it changes no modifier. Tell your Hank representative if your facility needs cross-case concurrency checks. Do not rely on these settings until the feature ships. Track concurrency in your practice-management system meanwhile.

The configuration still records your intent. The maximum number of cases one MD can medically direct at the same time defaults to 4, which is the CMS maximum. The recorded action when the MD exceeds the limit defaults to a drop to supervision, which would change QK to AD on the excess cases. The alternative recorded action is a HARDSTOP alert. Neither action runs today.

Two related checks do run. Each one reads a single claim:

• meddir_exceeds_4_to_1, a HARDSTOP alert at severity 9. It fires when one claim carries more than four QK modifiers.
• concurrent_time_overlap, a FINANCIAL alert at severity 7. It fires when two time-billed procedures on the claim have overlapping times.

Section 3: ASA physical status modifiers

Tier: ADVANCED

Decide if the autocoder adds ASA physical status modifiers P1 to P6 to anesthesia line items.

• Yes, add the P-modifier automatically: the autocoder reads the ASA status from the documentation and adds the matching modifier. Default
• No, do not add the P-modifier: your coders or an external workflow assign it.

What this changes: with the P-modifier on, each anesthesia line carries a P-modifier. Some payers reimburse differently by ASA status. With the P-modifier off, no P-modifier appears, and your team adds one where you need it. The autocoder also raises no alert for a missing P-modifier. The rule is asa_p_modifier_control.

Example: a facility that assigns the ASA status in a separate workflow turns the automatic P-modifier off.

Section 4: Procedure billing rules

Tier: REQUIRED

These rules control when the autocoder bills a procedure. Each rule reads the documentation details, the note source, or a special condition. Each rule can make a procedure billable, make it non-billable, or raise a review alert.

4.1 Ultrasound guidance, 76937 and 76942

CPT requires stored images for the ultrasound guidance codes.

When the documentation does not mention image storage:

When the documentation states that the images were not stored:

What this changes: if you bill the ultrasound code without storage documentation, the code appears on the claim and an alert notifies your reviewer. If you do not bill it, the code moves to the bundled and non-billable list. CPT does not support billing when the documentation states that the images were not stored. The rules are ultrasound_76937_no_storage_documented, ultrasound_76942_no_storage_documented, ultrasound_76937_explicitly_not_stored, and ultrasound_76942_explicitly_not_stored.

Example: a conservative facility bills these codes without storage documentation and lowers the alert to INFORMATIONAL at severity 5.

4.2 TEE from case events only

Decide what happens when the case event timeline records a TEE placement and the packet contains no separate TEE procedure note.

• Code it: add TEE code 93313 with modifier 59 for NCCI unbundling, and raise a review alert. Default
• Do not code it: require a procedure note before the autocoder bills a TEE.

Alert severity: Default: 5

What this changes: if you code it, the claim carries a 93313 line with modifier 59 and a compliance alert. If you do not code it, no TEE charge appears. Conservative facilities turn this rule off. The rule is tee_from_events_only.

Example: a facility that codes a TEE from the events changes the alert to INFORMATIONAL at severity 7 to reduce the review queue volume.

4.3 Lines, drains, and airways notes

Decide what happens when a procedure appears only in an LDA-type note. These notes are often checklists or tracking forms.

• Bill from LDA notes: treat a procedure in an LDA note as billable.
• Skip LDA notes: do not bill a procedure that appears only in an LDA note. Default

What this changes: with LDA notes skipped, the autocoder moves these procedures to the bundled list. If the same procedure also appears in an anesthesia procedure note, the autocoder still bills it from that source. The rule is lda_procedures. It marks the procedure non-billable and raises an INFORMATIONAL alert at severity 1.

4.4 Same-stick central line access

Decide what happens when a Swan-Ganz catheter goes through a central line introducer at the same access site.

• Bundle the central line: remove the central line charge and bill the Swan-Ganz alone, per NCCI. Default
• Bill both: both the central line and the Swan-Ganz appear on the claim.

What this changes: the default removes the central line code, because the NCCI edits bundle it with a Swan-Ganz at the same site. Only the Swan-Ganz code reaches the payer. The rule is same_stick_central_access.

4.5 Duplicate procedures

Decide what happens when the same procedure appears in more than one note.

Caution. Duplicate handling alerts; it rarely removes. The autocoder removes only an exact duplicate of an ancillary line (the same code, modifiers, diagnoses, citations, and rationale) at build time. Any other duplicate stays on the claim and raises the HARDSTOP alert duplicate_anesthesia_line_items at severity 5. A coder then decides. The rule is duplicate_procedures.

What this changes: a reviewer sees the duplicate and resolves it before the claim goes out. Radiology follows the same pattern with the FINANCIAL alert radiology_duplicate_study at severity 6. Surgery runs no generic duplicate check.

The one other exception: an MUE MAI-2 edit. That edit moves the excess line to the non-billable list and raises the FINANCIAL alert mue_mai2 at severity 5.

4.6 Failed or aborted procedures

Decide what happens when the documentation shows an attempted procedure that failed or was aborted.

• Do not bill it: remove the failed procedure from the claim. Default
• Bill it and raise an alert: keep the procedure on the claim and let a reviewer decide.

What this changes: the default removes the failed procedure code. The code appears in the bundled and non-billable list with the reason "procedure failed". The rule is failed_procedures.

4.7 NCCI bundles from the claim checking service

Decide what happens when the automated claim checking service finds an NCCI bundling edit.

• Remove the bundled code: accept the bundle and remove the code from the claim. Default
• Keep both codes and raise an alert: leave both codes on the claim for a reviewer.

What this changes: the default removes the bundled code, per the NCCI rule. The removed code appears in the bundled list with the specific edit reason. If you keep both codes, both reach the payer, and the payer may deny one. The rule is claimcleaner_bundles.

4.8 NCCI modifier preference, 59 or the X modifiers

CMS introduced the X modifiers XE, XS, XP, and XU as more specific replacements for modifier 59. Medicare prefers the X modifiers. Commercial payer acceptance varies.

• Use modifier 59 for all NCCI distinct-procedure identification. Default
• Use the X modifiers: convert modifier 59 to the most specific X modifier for the claim structure.

What this changes: with the X modifiers on, the autocoder converts modifier 59 after the claim checking service validates the claim. XE marks a separate encounter, such as a return to the operating room. XS marks a separate structure, which is a different anatomic site. XU marks an unusual non-overlapping service, such as a TEE, a nerve block, or another add-on procedure. Modifier 59 remains the fallback when no specific X modifier applies. The setting is ncciModifierPreference, with the values 59 and x_modifiers.

Example: a facility contracted with Medicare Advantage plans that require the X modifiers selects x_modifiers. A facility with workers' compensation or commercial payers that reject the X modifiers keeps 59.

4.8a Nerve block line-item diagnosis codes

This setting controls which diagnosis codes ride on a separately billed nerve-block line. By default the block line does not inherit every diagnosis coded elsewhere on the encounter. It carries its own post-op pain diagnosis only.

• G89 codes only: the block line carries its post-operative pain code, usually G89.18. Default
• G89 plus site: the block line also keeps the site-specific pain diagnosis for that block, such as a shoulder or knee pain M code with G89.18.
• Copy all diagnoses: the block line inherits every diagnosis on the encounter. This is the older behavior.

What this changes: the default keeps a clean, defensible diagnosis on the nerve-block line, and it stops unrelated encounter diagnoses from attaching to it. "G89 plus site" adds the anatomic pain code when your payers expect it. "Copy all diagnoses" restores the previous behavior. If a block line would carry no diagnosis at all, the autocoder raises a HARDSTOP alert for a coder, so no block line is ever billed without a diagnosis. The setting is nerveBlockLineIcds, with the values g89_only, g89_plus_site, and copy_all.

Note: the default changed in a recent release. Select copy_all if you want every diagnosis to copy onto your nerve-block lines.

4.9 Qualifying circumstance codes

The age-based qualifier 99100 applies to a patient younger than 1 year, or at least 70 years and 1 day on the date of service. Choose one:

• Always add it when it applies: add 99100 from the patient age, and raise no alert. Default
• Add it and raise an alert for verification: a reviewer looks at every 99100.
• Never add it automatically: a coder adds 99100 by hand.

The emergency qualifier 99140 applies to an emergent case. Choose one:

• Always add it when it applies: add 99140 when the case is emergent, and raise no alert. Default
• Add it and raise an alert for verification: a reviewer looks at every 99140.
• Never add it automatically: a coder adds 99140 by hand.

What this changes: 99100 and 99140 appear as extra line items on the claim. Some payers reimburse them separately, and others bundle them. With "never add", these codes appear only when a coder adds them. The rules are special_circumstances_99100 and special_circumstances_99140.

The default is silent. The autocoder decides the extreme age from the date of birth and the date of service, and it decides the emergency from the record. It raises no alert for either result. The billed 99100 line states the age it used in its rationale, and a withheld 99100 sits in the bundled procedures with the reason. Select "add it and raise an alert" when you want a human on every one of these add-ons.

JSON setting for a reviewer on every 99100 (use the same shape on special_circumstances_99140):

Give every key. createHRE turns the alert on. hreTag, hreSeverity, and hreReviewerRole set the type, the severity, and the suggested reviewer. hreTemplate is the text the reviewer reads. An override of action replaces only the keys it names, and so does match. The conditions list replaces wholesale: if your override names conditions, give every condition the rule needs.

99140 evidence review, off by default: the emergent_weak_evidence rule (FINANCIAL, severity 5) asks a coder only when a billed 99140 rests on weak documentation. The autocoder reads the notes the 99140 line cites. If they show neither a physical status with the E suffix nor a statement that a delay in treatment would significantly increase the threat to life or body part, the alert appears. A record that reaches you only as handwriting raises the handwritten emergency-status alert instead, so this rule leaves it alone. Turn it on with {"processingRules": {"emergent_weak_evidence": {"enabled": true}}}, then retune hreTag, hreSeverity, hreReviewerRole, and hreTemplate if you want. Select this rule instead of the 99140 opt-in above when you want a review of the weak cases only.

Payer-class gate, Medicare on by default: the autocoder decides per payer class whether the qualifying circumstance codes 99100, 99116, 99135, and 99140 are billed (the qualifyingCircumstances.suppress map). The shipped posture: on a Medicare claim it moves them out of the billable line items into the bundled procedures (Medicare bundles these codes into the base anesthesia code and does not pay them separately). Every other payer class bills them. So even with "always add when it applies", these codes are not billable on a Medicare claim by default. If a payer class you bill does not pay these codes (for example, some state Medicaid programs), your Hank representative can turn suppression on for that class only.

Decide this one deliberately. The suppression raises no alert at all: you configured it, so the autocoder does not ask. Nothing errors. If your contracts have you billing qualifying circumstance codes to every payer, tell your Hank representative to set the Medicare entry of qualifyingCircumstances.suppress to an empty list before your build is deployed. Confirm the change on a test Medicare claim before go-live. Otherwise these codes stop appearing as billable on Medicare claims, and the only trace is the entry in the bundled procedures, whose reason names the payer class that bundled the code.

Legacy keys. A configuration written before the payer class map can still carry suppressForMedicare and medicareBundledCodes. The autocoder still honors them. On such a configuration, set suppressForMedicare to false to bill the codes to Medicare. Do not use an empty medicareBundledCodes list for that purpose: on an older production build an empty list suppressed all four codes instead of none. Ask your Hank representative to move the configuration to the qualifyingCircumstances.suppress map.

Example: some facilities do not bill 99100, because their payers do not reimburse it.

4.10 OB case review

Choose how the autocoder treats every obstetric anesthesia case, which includes labor epidurals and cesarean deliveries.

• Require review for all OB cases: every OB case gets a review alert. Default
• Code them automatically: the autocoder treats OB cases like other cases.
• Alert on high-risk cases only: only an unusual OB case gets an alert.

What this changes: with review required, every OB case carries the HARDSTOP alert ob_case_review at severity 2 by default. OB cases often carry complex global-pay and fee-for-service considerations, so a coder should confirm them.

Overnight OB cases: some cases run past midnight. An epidural goes in late one evening and the cesarean delivery follows in the early hours of the next day. The autocoder uses the earliest date as the date of service, and it tells the coding step that the encounter spans midnight. For an overnight case it selects the CPT and ICD code set from the encounter end date. This behavior needs no configuration.

4.11 Cosmetic procedure detection

Choose what happens when the autocoder detects a cosmetic procedure in the surgical notes.

• Raise a HARDSTOP alert: a reviewer separates the covered portion from the cosmetic portion. Default
• Raise a high-priority review alert of another type.

What this changes: a cosmetic procedure usually needs split billing. One claim covers the medical portion, and the patient is responsible for the cosmetic portion. The HARDSTOP alert asks a coder to review the time allocation first. The rule is cosmetic_procedure_split_billing.

4.12 No primary anesthesia code found

Choose what happens when the autocoder cannot identify a primary anesthesia CPT code for the case.

• Raise a HARDSTOP alert for manual review. Default
• Raise a review alert of another type.

What this changes: without a primary anesthesia code, the claim carries no base units for the time calculation. This usually means a canceled case, a monitoring-only case, or insufficient documentation. The rule is anes_no_cpt_code.

4.13 Nerve block billed as time

Choose what happens when a nerve block is the primary anesthetic and the autocoder must bill it as time units instead of a flat fee.

• Raise a FINANCIAL alert: tell the coder that the reimbursement is lower than the flat fee. Default
• Raise no alert.

Alert severity: Default: 5

What this changes: CMS and ASRA guidance require a nerve block used as the primary anesthetic to bill under the ASA code with time units, not as a separate flat-fee procedure. The reimbursement is usually lower. A short block produces a fraction of one time unit, where the flat fee is worth several RVUs. The alert asks the coder to confirm the result. The rule is nerve_block_billed_as_time.

4.14 CPT codes that always need review

List the CPT codes that always need a review alert when they appear on a claim. Give your Hank representative each code and the reason for the review.

• Alert severity: Default: 8
• Alert type: HARDSTOP (Default), COMPLIANCE, or FINANCIAL.

What this changes: any claim with one of your listed codes carries a high-priority alert. A reviewer confirms the code. The rule is required_code_review.

4.15 Date of service more than 1 year old

Choose what happens when the date of service is more than 1 year in the past.

• Raise a HARDSTOP alert for a charge entry review. Default
• Raise a review alert of another type.
• Raise no alert.

What this changes: an old date of service usually means the case reached the autocoder in error, or the date contains a data entry mistake. The alert asks a person to confirm the date. The rule is anes_dos_age_warning.

4.16 Alerts on handwritten sources

Handwritten notes can read less accurately than typed notes. Choose the behavior for each key billing field taken from a handwritten source.

What this changes: a value read from a handwritten note can be inaccurate. The default HARDSTOP alert asks a reviewer to confirm the value. This prevents an incorrect ASA modifier, an incorrect emergency qualifier, and an incorrect anesthesia type. The rules are handwritten_asa_source, handwritten_emergent_source, and handwritten_type_source.

Automatic corroboration: the autocoder cross-checks a handwritten value against the typed and electronic sources first. If a typed note reports the same ASA status, emergent status, or anesthesia type, the autocoder suppresses the alert. The electronic source is the corroboration. These alerts fire only when a handwritten note is the sole source for the value. The same logic applies to the anesthesia start and end times. If the case event times or the staff times confirm the times on a handwritten form, the autocoder suppresses the handwritten-time alert.

4.17 Non-standard time source

Choose what happens when the anesthesia start and end times come from a source other than the standard case event timesheet.

• Raise a FINANCIAL alert: tell charge entry that the times came from a non-standard source. Default
• Raise no alert.

Alert severity: Default: 3

What this changes: the time units affect the reimbursement directly. Times from a procedure note or another non-standard source can be less accurate than the official case event timesheet. The alert asks charge entry to check the times. The rule is anes_non_case_times_source.

4.18 Neuraxial procedures without documented times

Choose what happens when the autocoder finds a neuraxial procedure, such as an epidural or a spinal, and the documentation carries no start and end times for it.

• Raise an INFORMATIONAL alert: tell the coder that the procedure may be billable for time units if the provider performed it outside the anesthesia time. Default
• Raise no alert.

What this changes: a neuraxial procedure performed outside the primary anesthesia time window can be separately billable for time units. A labor epidural placed hours before a cesarean delivery is one example. Without times the autocoder cannot calculate the time-based billing. The alert reminds the coder to check whether the times belong on the claim. The rule is neuraxial_without_times.

4.19 Combined upper and lower GI endoscopy, 00813

The autocoder combines upper endoscopy anesthesia code 00731 and lower endoscopy anesthesia code 00811 or 00812 into the combined code 00813 when it finds both in the same case.

This behavior is not configurable, because it follows standard coding practice. An INFORMATIONAL alert tells the reviewer about the combination.

What this changes: the combined code 00813 replaces both individual codes on the claim. 00813 usually carries more base units than 00731, 00811, or 00812 alone, so the reimbursement is usually higher. The autocoder keeps the rationale from both original codes in the claim details.

Section 5: Discontinuous time

Tier: ADVANCED

Anesthesia time sometimes comes in separate segments. An epidural takes one short segment, and the cesarean delivery anesthesia takes a later segment. Choose how the gap time appears on the claim.

• Add the gap time to the start of the first segment: the combined time starts earlier to account for the total minutes. Default
• Add the gap time to the end of the last segment: the combined time ends later to account for the total minutes.
• Keep the segments separate: each segment appears as its own entry on the claim.

Choose whether the autocoder raises an alert for discontinuous times.

• Yes: tell the coder about the multiple segments. Default
• No.

Alert severity: Default: 4

Gap that counts as a break: Default: 5 minutes

When the alert fires: the autocoder groups the time segments by anesthesia code before it counts them. A labor epidural line (01967) and a cesarean delivery line (01968 or 01961) are two different services, so they do not raise this alert against each other. A provider handover that touches, for example one segment that ends at 07:00 and the next that starts at 07:01, also does not raise it. A true gap inside one anesthesia code still raises it. This choice does not change the gap time placement.

What this changes: the autocoder always preserves the total minutes. This choice only changes how the minutes appear on the claim. For a total of 90 minutes across two segments, the first option shows 90 continuous minutes from an adjusted earlier start. The second option shows 90 minutes to a later end. "Separate" sends two time entries. Some billing systems cannot accept more than one time entry, so combining is the default. The rule is discontinuous_times.

Section 6: Confidence thresholds

Tier: ADVANCED

The autocoder assigns a confidence score from 0 to 100 percent to every code it selects. The score states how certain the autocoder is that the code matches the documentation. A surgical note that clearly describes a knee arthroscopy can produce 95 percent confidence on code 29881. If the note is ambiguous about a diagnostic or a therapeutic arthroscopy, the confidence drops. The autocoder raises a review alert when the confidence falls below your threshold.

The severity is fixed and you cannot configure it. Only the threshold percentages are configurable, and only for the rows below. The severity column shows the value the autocoder emits, so you know what the reviewer sees.

Thresholds you cannot set. These rows appear in the configuration and nothing reads them. Leave them alone.

What this changes: a code below your threshold still appears on the claim, and it carries a review alert. The alert tells the reviewer which code needs verification. A lower threshold produces fewer alerts and more risk that an incorrect code reaches the payer. A higher threshold produces more alerts and better accuracy.

Note on the severity numbers: some configuration files show a severity of 8 for anesthesia codes and 6 for ICD codes. Those values are inactive. The autocoder emits severity 7 for an anesthesia code and severity 5 for an ICD code. The only configurable severity in this area is the missing-note severity in Section 8.1.

Section 7: Quality check toggles

Tier: REQUIRED

Turn each validation check on or off.

What this changes: each check, when on, can raise an alert. A check that is off lets that type of problem pass silently, with no alert. With time validation off, for example, a claim proceeds even when the start time follows the end time. With the NPI check off, a claim proceeds with a blank provider NPI field.

Four settings that look like toggles and are not. These keys appear in the configuration and nothing reads them. Setting them does nothing. The right column states what controls the behavior instead.

Example: a facility whose documents make time extraction unreliable turns the time validation check off and verifies the times outside the autocoder.

Section 8: Required documentation

Tier: REQUIRED

8.1 Required note types

Select the clinical note types that must be present for a complete claim. The choices are the anesthesia pre-operative note, the anesthesia intra-operative note, the anesthesia post-operative note, the staff times, the case event times, and the surgeon procedure note. Name any other note type your facility requires.

Default: no required note types.

Note: the required note check in Section 7 must be on for this section to take effect. With that check off, the autocoder ignores a missing note whatever you select here.

Missing note alert severity: Default: 5

What this changes: when a required note type is absent from the documentation, the claim carries a COMPLIANCE alert. This catches a package that reached the autocoder without a key note, such as the post-op note. The setting is requiredNoteTypes.

Facility examples:

• Standard direction requires the pre-operative note.
• CRNA independent and MD only require no notes.
• A teaching hospital requires the pre-operative, intra-operative, and post-operative notes.
• Some facilities require only the surgeon procedure note, or no notes at all.

8.2 Required patient fields

Select the patient information fields that must be present. Every field below is required by default except the two NPI fields.

What this changes: a missing required field raises either a HARDSTOP alert or a FINANCIAL alert, as the table shows. The date of service and the billable code carry the highest default severity, because no valid claim exists without them.

Note: the autocoder first tries to fill a missing patient name, date of birth, medical record number, insurance, date of service, or surgeon name with an extra extraction pass. The alert fires only when the field is still missing after that pass.

Note: these two dates also drive the extreme-age add-on 99100. If you turn off the check for the patient date of birth, or the check for the date of service, a claim that is missing that value raises the extreme_age_99100_unverified alert (FINANCIAL, severity 6) instead, and 99100 is withheld.

Note: a date of birth that is later than the date of service always raises the patient_dob_after_dos alert (HARDSTOP, severity 8), whatever you select in the table above.

Section 9: Staff time merging

Tier: RARE

The same provider can appear in more than one note under different name formats. A timing sheet can carry an initial and a last name, and a procedure note can carry the full first name. The autocoder can merge these entries.

What this changes: a merge produces one clean entry per provider on the claim. Without a merge, one person can appear as two providers, which produces an incorrect time allocation or an incorrect medical direction result. The two safeguards prevent a merge of two different people who share an initial and a last name. The setting is staffTimeMerging.

Section 10: Paper form handling

Tier: ADVANCED

Choose how sensitive the autocoder is when it detects a handwritten document. The threshold is the share of the document that reads as handwriting.

• 0.5 percent: very sensitive. Any handwriting triggers the special processing.
• 1.5 percent: high sensitivity.
• 2.0 percent: standard sensitivity. Default
• 4.0 percent: less sensitive. Only a heavily handwritten form is detected.
• A custom percentage.

What this changes: the autocoder treats a handwritten document differently. It scores the confidence from the legibility of the handwriting, so legible handwriting can still score high. It also adds the verification alerts and the handwritten source alerts from Section 4.16. A lower threshold classifies more documents as handwritten, which produces more alerts. A higher threshold detects fewer documents, and more handwritten data is then treated as reliable electronic data.

A facility that wants every handwritten-only code routed to review, whatever the legibility, can enable claimValidation.handwrittenForceConfidence33. That setting sets the confidence to 33 on any code whose source notes are all handwritten.

Example: a facility whose providers add handwritten notes to electronic forms uses 4 percent, so only a fully handwritten document is detected.

Send page images with the coding request

The autocoder can send the page image of each note with the coding request. The image goes with the text. It never replaces the text.

Use this choice when your site submits paper anesthesia forms or printed checkbox forms. Graphium anesthesia records and Out-of-OR visit forms are the usual examples. On these forms, the text layer holds the printed option labels. The text layer does not show which box the provider ticked. The autocoder can then read an untouched option as a documented service.

What this changes: the autocoder sees the actual marks on the form, so fewer services that nobody performed reach the claim. An unticked "Labor Epid to C-Section" box no longer produces 01968 and 59514. An empty "A-Line" row no longer produces 36620. An empty "E" box no longer produces 99140. The text always stays in the request, so no documentation is lost. A handwritten page already gets its image, and this choice does not change that behavior. The autocoder sends a maximum of 10 page images for each request and removes duplicate pages. Measured cost stays the same on packets of 4 to 15 pages. The setting is imageAugmentedCoding.

Example: a Graphium site turns this choice on. A form records an epidural for labor, and the "to C-Section" box is empty. The autocoder codes the labor epidural only.

Section 11: Provider information

Tier: REQUIRED

A provider roster lets the autocoder match NPIs and detect provider types automatically. Send your Hank representative three rosters.

• Anesthesia physicians: the name, the title, and the NPI of each MD and DO.
• CRNAs and AAs: the name, the title, and the NPI of each provider.
• Surgeons and referring physicians: the name, the title and specialty, and the NPI of each physician.

What this changes: with a roster loaded, the autocoder matches a provider name in the clinical notes to that provider's NPI. The NPI then appears on the correct line items. Without a roster, the provider NPI field stays blank, and a reviewer adds it by hand. A blank NPI can cause a rejection when your payer requires one. The setting is providerMappings.

Section 12: Custom coding instructions and encounter summary

Tier: ADVANCED

12.1 Custom coding instructions

You can add facility-specific instructions that change how the autocoder selects codes. Write them in plain English. The autocoder applies them directly to its coding instructions for the area you name.

You can supply a separate instruction set for each of these areas:

• Primary anesthesia codes, 00100 to 01999.
• Nerve block coding.
• All anesthesia procedures, such as lines, airways, and TEE.
• GI endoscopy anesthesia.
• OB anesthesia.
• Surgical procedures.

What this changes: a custom instruction changes which codes the autocoder selects. Keep each instruction specific and actionable.

Examples from real facilities:

12.2 Document segmentation instructions

Send instructions if your documents carry unusual formatting that the autocoder must handle differently.

Example: an instruction can state that several separate surgeon procedure notes appear under one operative note heading, and that the autocoder must separate each one.

12.3 Extraction instructions

Send instructions if your provider names or other fields appear in an unusual format.

Example: an instruction can state that a staff name appears as the last name, a credential, the first name, and a credential, and that the autocoder must read the name correctly from that order.

12.4 Encounter summary

Choose whether the autocoder writes a plain-English summary of each encounter for the reviewer.

• Yes: write encounter summaries. Default
• No: skip encounter summaries.

Choose which procedures include a summary. The options are surgical procedures (Default) or all procedures.

What this changes: the summary appears with the claim in the review dashboard, so a reviewer understands the case quickly. If the summary step detects a concerning finding, it raises a HARDSTOP alert at severity 5 for a coder. The setting is encounterSummarizerSettings.

Section 13: ICD code limiting

Tier: RARE

Choose the maximum number of ICD diagnosis codes on each line item. The options run from 1 to 8, or unlimited. Default: 4

Choose whether the autocoder raises an alert when it drops a code.

• Yes: raise an INFORMATIONAL alert that lists the dropped codes.
• No: drop the codes silently. Default

What this changes: if the autocoder finds 6 diagnosis codes and your limit is 4, the 4 most relevant codes appear on the claim. The autocoder ranks the codes by relevance to the procedure, and it lists the dropped codes in the claim details. Most payers accept 4 ICD codes per line, and some accept up to 12. The rule is max_icd_per_line_item.

Section 14: E/M visit settings

Tier: REQUIRED for E/M facilities

These settings apply to a facility on the E/M specialty. That specialty covers office and outpatient visits 99202-99215, hospital inpatient and observation visits 99221-99239, and emergency department visits 99281-99285. An anesthesia-only facility can skip this section.

For an E/M visit, the autocoder reads the clinical note and extracts the documented medical decision-making and the total time. A deterministic engine then assigns the visit level. The autocoder never picks the level itself. When a chart could read as either an office or a hospital encounter, the autocoder decides the setting from the documentation. It uses a hospital, observation, or emergency department code only when the note states that setting. Otherwise it uses the office codes.

14.1 Qualifying encounter note

The autocoder codes an E/M visit only when the document package contains a qualifying encounter note. The default qualifying types are an office visit note, a history and physical, a progress note, and an emergency department summary.

What this changes: a package with no qualifying encounter note produces a refusal with the HARDSTOP alert eandm_qualifying_note_refusal, not a coded claim. To change which note types qualify, give your Hank representative the complete replacement list. The setting is qualifyingEncounterNotes, and it replaces the list as a whole. It does not add to the defaults.

14.2 E/M policy elections

These elections control payer-specific and billing-policy behavior. Each one ships at a safe, conservative default. The only election implemented today is the modifier 25 aggressiveness. The others are reserved for a later release. If you turn one on now, the autocoder does not change the claim. It raises the COMPLIANCE alert eandm_policy_election_not_implemented, so your choice is visible and audited, and the behavior stays at the safe default until the feature ships.

What this changes: leave every election at its default until your Hank representative confirms that a feature has shipped. Setting the modifier 25 aggressiveness to standard is the one change that alters the claim today. Every other non-default election appears as a review alert only. The setting is emPolicy.

Section 15: Radiology settings

Tier: ADVANCED

This section applies to a facility on the Radiology specialty.

The autocoder codes interventional radiology procedures automatically. The autocoder codes a package that reads as a procedure with interventional-specific checks. Vascular access, embolization, drains, biopsies, ports, and filters are examples. A diagnostic read, such as a plain film or a CT or MRI interpretation, is unaffected.

What this changes: disabling the lane turns interventional coding off for the facility. The autocoder then codes nothing for an interventional chart. Diagnostic radiology coding continues either way. The setting is irCoding.

Section 16: Post-op pain rounds

Tier: ADVANCED

Caution. Do not disable this lane without a discussion with your Hank representative. With the lane off, the autocoder codes the surgery again on every pain-round package. The surgery was already billed from its own surgery-day claim.

An acute pain service round is a visit on a day after surgery. The provider manages the patient's post-operative pain at that visit. Many facilities send the comprehensive record for the round. That record contains the original surgery documentation in the same package.

The autocoder reads the package and detects the round. It then codes the round visit, not the surgery. The detection is deterministic. It reads the note types and the wording of the record. No AI decision is involved. The extraction step collects the evidence, and a rules engine picks the code.

There are three possible outcomes.

When the signals are only partial, the autocoder does not code the round. It codes the package normally and raises the critical alert postop_pain_round_ambiguous. A person then decides which encounter the package represents.

16.1 Post-op pain rounds lane

What this changes: keep this lane enabled unless your Hank representative advises otherwise. Disabling it returns the older behavior. The setting is postOpPainRounds.

16.2 Pain rounds review gate

The review gate marks a pain-round claim for a person to check. The gate is on by default, with scope "detected". Pain rounds are infrequent, and the source forms are hard to code. A coder therefore confirms every detected round before the claim goes out. The autocoder still codes the round. The gate only decides who releases the claim.

You also choose the alert severity, from 1 to 10. Default: 7

What this changes: each claim in scope carries the HARDSTOP alert postop_pain_rounds_review_gate. The autocoder suppresses nothing and changes no code. Turn the gate off only after your coders trust the lane.

The ambiguous-package alert is separate from this gate. It always fires, whether the gate is on or off. You cannot turn it off.

Section 17: Claim validation payer context (both specialties)

Tier: ADVANCED

Caution. Do not enable this feature without a pilot. When a claim carries a commercial or Medicaid program value, the automated validation service stops applying Medicare-only corrections. The corrected claim changes shape. Review a pilot batch with your coding team first.

The autocoder sends each claim to an automated validation service. By default, the service judges every claim by Medicare-derived rules. This feature sends two optional context objects with each claim so the service can judge the claim by the correct rules:

• Payer context: the payer name from the claim's primary insurance, and an optional explicit program (for example commercial or medicaid). The service resolves the program from the payer name when you do not declare one.
• Facility location: your facility's real service location (ZIP code, state, county). The service uses it to select the correct Medicare contractor for coverage checks. Without a declared location, coverage checks fall back to the addresses in the record and can run against the wrong region.

With a declared commercial or medicaid program, Medicare-only automatic corrections stop applying to those claims. This is usually correct, and it changes what the validation step returns. Pilot first.

JSON setting:

Declare program only when you know it with certainty (valid values: medicare, medicare_advantage, medicaid, commercial, workers_comp, self_pay). All values must be real JSON types: enabled is a boolean, not the string "true", and every facility value is a quoted string (unquoted numbers are ignored).

One location per configuration. The facility location applies to every claim under this facility configuration. Declare it only when the configuration maps to ONE service location. A group that bills several hospitals or surgery centers under one configuration must not declare a single location for all of them.

Appendix A: Practice type comparison

This table compares the four built-in practice types. Select the one closest to your staffing model, then change individual settings as you need.

Key differences: standard direction is the typical MD and CRNA group. A teaching hospital adds stricter controls, so a CRNA-alone case alerts and more notes are required. CRNA independent suits an opt-out state where CRNAs practice without MD direction. MD only suits a solo-MD practice, where a CRNA or AA in the data shows an extraction error.

Appendix B: Frequent questions

What if I leave everything at default?

The autocoder works with sensible defaults. Medical direction is on, all 7 TEFRA requirements apply, the standard confidence thresholds apply, and the basic patient fields are required. Most facilities change only a few settings.

Can I change settings after go-live?

Yes. Your Hank representative can update your configuration at any time. A change takes effect on the next claim. It does not affect a claim already processed.

What if the autocoder codes something wrong?

Every code carries a confidence score. A low-confidence code raises a review alert, so a coder can verify it. You can also add a custom coding instruction, as Section 12 explains, to prevent a specific error. Report a systematic problem to your Hank representative, who can update the base coding rules.

How does the autocoder handle a code it has not seen before?

The autocoder works from the complete CPT and ICD code sets. It can select any valid code within its supported specialties. For an unusual or rare code the confidence score is often lower, which raises a review alert.

What is the difference between a HARDSTOP alert and a COMPLIANCE alert?

A HARDSTOP alert marks something missing or conflicting that a person must resolve. A COMPLIANCE alert marks a regulatory or audit concern for your compliance process. Read the alert reference for your specialty for the complete type reference.

What happens when I disable an alert?

The autocoder stops raising that alert. Nothing appears in your review queue for it. The underlying condition still exists, and the autocoder no longer surfaces it. Your configuration change is logged for audit.

Can I suppress one alert at my facility without disabling it everywhere?

Yes. Ask your Hank representative to add the alert id to claimValidation.suppressedHreIds in your facility configuration. A suppressed alert is downgraded to INFORMATIONAL, not removed. It still appears in the audit trail. The alert reference lists the id for each alert.

How does the autocoder handle a case that spans midnight?

The autocoder detects an overnight case and uses the earliest date as the date of service. If an epidural goes in late one evening and the cesarean delivery starts in the early hours of the next day, the date of service is the earlier day.

Can two facilities in one organization use different settings?

Yes. Each facility gets its own configuration. A facility setting overrides the base specialty default. One facility can use one set of rules while another uses a completely different set.

What is an add-on-only code?

Some codes, such as 99100 and 99140, are qualifying circumstance codes. They can appear only with a primary code. A claim with only these codes and no primary procedure is an error. The "at least one billable code" check excludes an add-on-only code when it decides whether the claim carries a valid primary service.

How these alerts reach you

What happens next depends on how your organization consumes HANK CODES. In HANK Claim Maker, a HARDSTOP alert places the claim in the review queue your administrators configured for it. Organizations that consume the coding API directly decide in their own workflow which alerts pause a claim, who reviews them, and when a claim is released.