Clinical documentation and coding

Documentation and coding, rebuilt for AI.

Hospitals lose revenue to incomplete documentation and miscoded encounters. Qinova builds the AI layer that completes the note, finds the codes, and turns every patient encounter into clean, structured data. Ready for billing today. Ready to feed your analytics, quality reporting, and value-based contracts as the dataset grows.

Coding Standards
ICD-10-CM, ICD-10-AM
Languages
English, Arabic
Deployment
Cloud or on-prem
Compliance
HIPAA, NCA, APP
The Problem

Documentation breaks. Coding breaks. Revenue and data break with them.

Hospitals run on coded data. The workflow that produces it (clinician documentation flowing to human coders flowing to billable claims) is buckling under volume, complexity, and a workforce that cannot grow fast enough. Two numbers tell the story.

$25.7B

administrative cost of working claim denials across U.S. providers in 2023, up 23% year over year. About 70% of denials are overturned on appeal, meaning most of that spend was preventable.

Premier Inc. Claims Adjudication Survey, Feb 2025 (n=280 hospitals)
3 in 100

For some routine diagnoses, only 3 of every 100 cases that actually happened were captured in the coded record in 2022. Twenty years earlier the number was 40 in 100. The data layer medical AI inherits is going backwards.

Pan et al., BMJ Health & Care Inform, 2025 (16,000 audited charts)
The Suite · two ways to code

One note, two coding products, one dataset.

Each product fixes one stage of the documentation-to-coding pipeline. Used together, they compound: better notes make better codes; better codes make better claims; better claims mean revenue your team has already earned. Complex cases go through AI-Aided Coding with a coder in real time. Routine cases get pre-coded by AI Auto-Coding for batch coder review. Both feed the same clean coded dataset.

01 / DocumentAI Dictation
dictation · live
62 y/o M, day 3 post-CABG, new-onset palpitations overnight, rate 140s

Captures the spoken encounter into a structured SOAP note.

02a / Code · assistedAI-Aided Coding
aided-coding · #4017
post-op atrial fibrillation w/ RVR
I48.91Atrial fibrillation, unspec.
I97.190Post-CABG cardiac
R00.0Tachycardia, unspec.

Coder works the case. AI surfaces document-grounded suggestions in real time.

02b / Code · automaticAI Auto-Coding
auto-coding · live
245 encounters / hour

AI pre-codes routine cases. Coder reviews and approves in batch.

Chapter 01 · search, suggest

AI-Aided Coding

Coders stay in control. AI reads the full chart and surfaces the codes that drive the right reimbursement: fewer missed severity diagnoses, fewer denials, less time per encounter.

39%

of hospitals in a peer-reviewed multicenter study (89 of 230) systematically under-captured CC/MCCs against their expected case mix in their vascular admissions, a documented pattern of revenue leakage from missed complications and comorbidities.

J Vasc Surg, 2025 (230 hospitals, 40,000+ admissions)
  • Reads the full encounter, not just the chief complaint, and surfaces the codes you would otherwise miss.
  • Built around how your coders actually work. AI suggests, the coder decides. Every suggestion links back to the supporting text.
  • Bring a case your team has struggled to code. We will walk it through the product, click by click.
qinova / aided-coding · case #4017
post-op atrial fibrillation with rapid ventricular response
I48.91Atrial fibrillation, unspecified98%
I97.190Postoperative cardiac (post-CABG)91%
R00.0Tachycardia, unspecified62%
I50.9Heart failure, unspecified41%
Chapter 02 · speak, structure

AI Dictation

Speak the encounter. Get a structured SOAP note, discharge summary, or referral letter, ready for coding and analytics.

49 / 27

Physicians spend 49% of office time on EHR and desk work, against 27% with patients, plus 1 to 2 hours of unpaid documentation each night.

Sinsky et al., Ann Intern Med, 2016
  • Real-time speech to structured document. SOAP, discharge summary, or referral letter, generated as the clinician dictates.
  • Multilingual at launch (English and Arabic). The structured output drops directly into the coding workflow. Nothing falls through the gap.
  • Fifteen minutes of dictation in your specialty shows more than this page can. Bring an encounter type that bites your team most.
qinova / dictation · live
62-year-old male, day three post-CABG, new-onset palpitations overnight, rate 140s, started on diltiazem drip
ANew-onset post-op atrial fibrillation with RVR, hemodynamically stable.
Chapter 03 · draft, review

AI Auto-Coding

AI pre-codes routine encounters; your coders review them in batch and focus their attention on the complex cases. Throughput up, oversight intact.

25-75%

Computer-assisted coding lifts coder productivity 25-75% depending on case complexity. Same workforce, more encounters cleared, lower cost per chart.

AHIMA, Computer-Assisted Coding Toolkit
  • Pre-codes routine ICD-10-CM and ICD-10-AM encounters where documentation is clean and the path is clear. Ready for fast coder review.
  • Configurable confidence threshold and complexity routing. You decide what queues for expedited review and what gets the full coder work-up.
  • Bring your ED and outpatient case mix to a demo. We will show you what gets drafted, what gets routed, and why.
qinova / auto-coding · live
running
The Infrastructure

PHI stays in your perimeter. Or does not move at all.

Healthcare buyers do not accept "trust us." Qinova ships with on-premises deployment as a first-class option, end-to-end audit trails, and AI behavior you can inspect, because the model lives inside your boundary.

70%

of Medicare Advantage diagnoses that government auditors examined had no supporting documentation in the medical record. Whichever side of audit you are on, undercoding or overcoding, auditors want source text. Qinova attaches it to every code it suggests.

OIG Toolkit on Medicare Advantage, November 2023
01

Designed for HIPAA, NCA, APP

Encryption in transit and at rest. Role-based access controls, audit logging, and documented access reviews. BAA (US) or DPA (KSA, ANZ) signed on request.

02

On-premises option

Run Qinova inside your data center, fully air-gapped if required. Models and PHI never traverse the public internet.

03

Audit trails included

Every AI suggestion, every coder action, every model version, logged with source-text provenance. Your compliance team has the artifact they need.

04

Multi-region, multi-standard

English and Arabic at launch. ICD-10-CM for the United States, ICD-10-AM for Saudi Arabia, Australia, and New Zealand. Data residency configurable per jurisdiction.

The Demo

Bring Qinova to your team.

Fifteen minutes with a founder. Bring a coding workflow you would like fixed, a documentation pain you would like to close, or a question about the suite.