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E-Newsletter • October 2026 |
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Editor's E-Note
Add clinical documentation integrity (CDI) to the list of medical tasks that are being changed by AI.
Although AI is often touted as an aid to workflow, it also comes with a learning curve. This is causing a shift in how CDI is performed.
As new AI tools become eligible for reimbursement and health care providers increase the use of AI in a variety of processes, CDI professionals are tasked with determining whether the organization’s coding accurately reflects how AI was used and whether it is billable. They must now adjust their workflows to meet granular requirements, new documentation rules, and compliance oversight requirements.
Another concern with AI is that it may add extraneous information to patient reports because it is focusing on completeness rather than essential details. Read on for an in-depth look at how AI is affecting CDI.
In addition to reading our e-newsletter, be sure to visit For The Record’s website at www.fortherecordmag.com. We welcome your feedback at edit@gvpub.com. Follow For The Record on Facebook and X, formerly known as Twitter, too.
— Dave Yeager, editor |
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The Impact of Standardized AI Taxonomy on CDI
By Elizabeth S. Goar
In June 2026, the American Medical Association (AMA) CPT Editorial Panel revised Appendix S: AI Taxonomy for Medical Services and Procedures to improve AI reporting while preserving the framework’s core 2022 structure. Alongside temporary Category III CPT codes, the revisions created fundamental shifts in clinical documentation integrity (CDI) by reframing AI from an EHR tool to distinct, trackable clinical services with specific documentation and compliance requirements for billing and audit defense.
“It adds another layer or set of things that CDI needs to evaluate,” says Andrew Ibrahim, MD, MSc, chief clinical officer at Viz.ai. “If it’s potentially influencing care or tied to a billing code, then CDI needs to evaluate and ensure the documentation mirrors the care provided. In the case of AI, it would be both.”
Keeping Pace With AI
As AI capabilities expand and adoption accelerates, consistent terminology has become essential for aligning clinical oversight, payer policy, and regulatory expectations. Appendix S established a technology agnostic, output-based framework for classifying AI enabled medical services to guide how emerging AI innovations, ranging from expert systems and machine learning models to algorithmic services, are described within the CPT code set.
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Senate Passes Bipartisan Health Care Cybersecurity and Resilience Act
The US Senate unanimously passed the Health Care Cybersecurity and Resiliency Act of 2026 (S.3315), which would help small and rural health care providers strengthen their cybersecurity and protect patient data, reports Healthcare IT News. The bill now heads to the House for a vote.
14 Organizations Earn CHIME's Highest Digital Health Most Wired Designation for 2026
The College of Healthcare Information Management Executives (CHIME) announced 14 organizations have achieved Level 10—the highest designation—in the 2026 CHIME Digital Health Most Wired survey, which evaluates whether technology is translating into meaningful progress.
Responsible AI in Release of Information
A Framework for Health Information Leaders
By Angela Rose, MHA, RHIA, CHPS, FAHIMA
AI has quickly moved from an emerging technology to an operational reality across health care. It is reshaping everyday work for HIM teams, and its evolution has only just begun.
Health information (HI) professionals have already experienced rapid AI advancements in departmental operations, particularly across clinical documentation integrity, medical coding, patient access, and revenue cycle workflows. Early successes with robotic process automation and machine learning provide a foundation for what comes next: increasingly intelligent automation that supports the expertise of HI professionals, including release of information (ROI) teams.
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| Have a coding or documentation question? Get an expert answer by sending an email to edit@gvpub.com. |
Oracle Announces New Oncology EHR
The Oracle Health Oncology EHR is built for the distinct demands of cancer care, bringing together oncology-specific workflows, AI-fueled clinical intelligence derived from multiple data sources, and connected information to support patient care from diagnosis through treatment and follow-up. Capabilities include unified cancer-care timelines, connected worklists for nurse navigators, intelligent precision oncology insights, and streamlined regimen planning workflows.
Teladoc Health Expands Solo Connected Care Platform
Teladoc Health announced two new AI-powered capabilities within Solo, its enterprise smart care platform for hospitals and health systems: SoloVitals and SoloScribe. SoloVitals is a vital sign measurement solution that can capture heart rate and respiration rate without physically touching a patient. Using a patient’s smartphone or other camera-equipped device, SoloVitals analyzes subtle facial skin color changes through remote photoplethysmography technology to generate measurements. SoloScribe is an ambient AI documentation scribe that creates structured clinical notes in Solo. It supports both direct-to-patient and telemedicine device-based visits and creates a templated summary that is transferred into the EHR, helping hospitals scale AI-assisted documentation across eligible clinicians, programs, and workflows through one integrated Solo experience. |
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