Skip to main content
Smart Charge Capture lets you document an in-office procedure once and bill for it in the same step. A provider records an injection, an aspiration, or a DME fitting in the visit note, and the matching CPT/HCPCS codes land in the note’s Services section, along with any orders and ICD-10 codes the procedure calls for. Without Smart Charge Capture, a procedure-heavy practice — orthopedics, sports medicine, wound care, dermatology, podiatry, or DME fitting — enters the same procedure up to three times. The provider documents it in the note, someone re-enters the CPT code in Services, and a staff member enters it again as an order. Every extra entry is a chance to miss a charge or to bill a code the note doesn’t support, and every provider has to remember the right codes and modifiers.
Smart Charge Capture is in beta. Order Sets, dynamic text snippets for Air Scribe, and Smart Charge Capture must all be enabled for your site, and you need permission to edit chart notes. If you don’t see Text Snippets or Order Sets in Preferences, contact your account manager for access.

​
How it works

An admin builds each procedure once as a Smart Charge Capture snippet: a text snippet that carries the procedure’s codes and orders along with its documentation. A snippet can include: When a provider inserts the snippet, either by saying its name while Air Scribe records or by typing it, the documentation goes into the note, the codes go into Services, and the orders are added as drafts.

​
Set up a Smart Charge Capture snippet

Admins set up each snippet once in Preferences.
  1. Open Preferences from the EHR menu, choose Text Snippets under Clinical, and click Add Text Snippet.
The Text Snippets list in Preferences, showing a hip injection snippet and the Add Text Snippet button
  1. In Phrase / Trigger Word, enter the name providers will say or type to insert the snippet. To limit the snippet to certain parts of the note, choose them in Available Sections of Visit Note.
✨Smart Tip: Pick a name that is easy to remember, easy to say, and unlikely to come up in normal conversation, so Air Scribe doesn’t insert the snippet by accident. “Insert large joint injection methylprednisolone” works well. “Methylprednisolone injection” is too likely to be said in passing.
  1. Under Documentation, write the procedure text. For each detail that changes from visit to visit, click Alternate Word to add a dropdown and list its options, such as hip, shoulder, and knee. Air Scribe fills each dropdown from the visit transcript, and providers can also pick an option by hand. See Alternate Word Dropdowns.
An alternate word dropdown in the Documentation editor, with hip, shoulder, and knee as its options
  1. Under Orders & Order Sets, click Add Order to attach an order set. Under Services, click Add Services to add each CPT/HCPCS code with its ICD-10 codes and units. Codes that come from the attached orders are listed separately, under Services from Orders on Completion: they are added to the note only when the order is completed.
The snippet editor with its documentation, an attached hip injection order set, and the services that come from its orders
  1. Under Optional Features, set who can use the snippet and how Air Scribe treats it:
    • Category & Access: add the snippet to a group and choose the providers who can use it in Which users should have access to this? Leave that field empty to share the snippet with everyone on the site.
    • Scribe Functionality: turn on Enable this snippet for EHR Scribe so providers can insert the snippet by saying its name. How should this be used with Scribe? sets the macro type (see Understanding Macro Types), and What appointment types can this be used in? limits the snippet to the appointment types you choose.
Optional Features, with the Category & Access and Scribe Functionality settings
  1. Click Save Text Snippet, or click Save & Create Another to start the next snippet.
You can edit or delete a snippet at any time from the Text Snippets list.

​
Add a procedure during a visit

There are two ways to insert a snippet into the visit note.
  1. While Air Scribe is recording, say the snippet’s trigger phrase.
  2. On the Scribe Application Page, review what Air Scribe added from the snippet.
The procedure documentation is highlighted in its note section. The Scribe Notes tab, with the snippet's procedure documentation highlighted in the physical exam section The codes appear under Services. The Services section of the Scribe preview, with CPT code 20610 selected The orders appear under Order Sets. The Order Sets section of the Scribe preview, with the hip injection order set selected
  1. Check the parts you want to keep and click Apply Scribe. See Apply Scribe.
The procedure documentation goes into the visit note. Here the provider said the injection was for the hip, so Air Scribe chose hip in the alternate word dropdown. The procedure documentation in the visit note, with hip selected in the alternate word dropdown The codes go into Services with their ICD-10 codes and units. The Services section with CPT 20610 and HCPCS J1010, each linked to two ICD-10 codes The orders are added to Orders as drafts, ready for you to review and submit. A draft procedure order for a methylprednisolone injection in the Orders section, created from the hip injection order set

​
By typing the trigger

  1. In any note section where the snippet is available, type your trigger character followed by part of the snippet’s name, such as .insert plan. You choose the trigger character in Profile → Preferences → General (see Set Your Trigger Character).
  2. Press Enter or click the snippet in the search results.
Typing .insert plan in the Assessment/Plan section, with the matching snippet in the search results The procedure documentation goes into the section you typed in. The snippet's procedure documentation in the Assessment/Plan section The codes go into Services, with any modifiers the snippet includes. The Services section with CPT 20610 under Surgery and HCPCS J1010 under HCPCS Level II If the snippet includes orders, they go into Orders and show as Sent once you submit them. If it includes ICD-10 codes, those are added as well. Two procedure orders from the hip injection order set in the Orders section, both sent

​
Finish the details

A snippet can’t know everything about a visit in advance, so complete what it leaves open:
  • The order details, such as the lot number, NDC, and procedure location.
  • More specific ICD-10 codes.
  • Any modifiers the snippet doesn’t include.
Then submit the orders. See Sign and Submit.

​
FAQ

Nothing is duplicated. Applying a snippet again skips the procedures and order lines already on the note. ICD-10 codes are only added, never removed, so new codes join the ones already there. To change a code, edit it directly in Services.
A code that comes from an order is added to Services only once the order is completed, so draft orders don’t fill Services with codes you may not bill. Codes attached directly to the snippet appear as soon as you insert it.
Yes. Delete the row in Services, and the procedure documentation stays in the note.
An order item whose CPT code isn’t in your site’s treatments list is left out of Services instead of causing an error. To bill the code, add it in Settings → My Practice → Treatments. See Treatments.
No. Your changes apply the next time the snippet is inserted.
Want a snippet built for your specialty? Contact your account manager.