Coding & extraction

The heart of Synaipse is what happens between receiving a note and handing it to billing. This page explains how a free-text operative note becomes structured, coded, claim-ready data — and how you stay in control of the result.

Reading the note

Synaipse reads the full operative note the way an experienced coder does — start to finish, in context. It distinguishes the procedure actually performed from planned or considered approaches, recognizes anatomical detail and laterality, and picks up the findings, devices, and specimens that affect coding.

Handwriting, dictation artifacts, and inconsistent formatting are expected and handled. The original document is always preserved alongside the structured result.

From narrative to codes

For each note, Synaipse produces:

  • Name
    procedures
    Type
    list
    Description

    Each distinct procedure performed, in the order documented.

  • Name
    cpt_codes
    Type
    list
    Description

    Suggested CPT codes for each procedure, each with a confidence score.

  • Name
    icd10_codes
    Type
    list
    Description

    Diagnosis codes drawn from the pre- and post-operative diagnoses.

  • Name
    modifiers
    Type
    list
    Description

    Modifiers for laterality, multiple or bilateral procedures, staged work, and more.

  • Name
    evidence
    Type
    text
    Description

    The exact passage from the note supporting each suggested code.

Every code Synaipse suggests is linked to the language in the note that supports it. When you review a case, you can see why a code was chosen without re-reading the whole document — and that same evidence trail supports audits and appeals.

Confidence and routing

Not every note is equally clear. Synaipse attaches a confidence score to its results and uses it to decide what needs a human:

  • High confidence cases are released to billing automatically.
  • Lower confidence or ambiguous cases are routed to your worklist for a quick check.

You set the threshold. A practice that wants every case reviewed can route everything to the worklist; one that trusts automation for routine procedures can let those flow straight through. Adjust it under Settings → Coding.

Staying in control

Synaipse proposes; your team decides. Suggested codes can always be accepted, edited, or rejected, and the platform learns from the corrections your coders make over time. Nothing reaches a payer that your organization hasn’t configured Synaipse to release.

See how review works