Healthcare organizations continue to face mounting pressure from declining reimbursement, growing documentation complexity, and increasing scrutiny around coding accuracy and denied claims.
Zotec Partners has launched ZDI (Zotec Documentation Improvement), a real-time documentation guidance application for the NoteReader CDI category. Using Epic’s NoteReader CDI API, ZDI sends targeted nudges back to Epic as clinicians write — bringing documentation guidance closer to the moment of care.
By prompting clinicians to address potential issues before the note is signed, ZDI helps improve documentation quality upstream, support accurate reimbursement, reduce post-encounter follow-up, and minimize compliance risk.
“The best time to address a potential documentation gap is before the note is signed — while the clinical context is still fresh.”
“Our goal with ZDI is simple: surface documentation guidance in real time, directly within the note-writing process,” said Jimmy Comfort, VP of Product Management at Zotec Partners. “ZDI helps clinicians clarify documentation before the encounter is signed, supporting accurate reimbursement and reducing downstream follow-up.”
Documentation guidance as the note is written
ZDI analyzes provider notes and available encounter context to identify opportunities where additional specificity, clarification, or supporting documentation may be appropriate. The application then returns plain-text nudges through the NoteReader CDI API, giving clinicians context-specific guidance they can choose to incorporate before signature.
Because ZDI can evaluate more than the note text alone, orders, results, vitals, prior notes, and other encounter-level signals can help inform when a nudge is appropriate.
For example, if an EKG is ordered but an independent interpretation is not documented, the note alone may not provide the full picture. Encounter-level context allows ZDI to identify that opportunity while the clinician is still completing the note.
ZDI is designed to support the documentation process already happening in Epic. It does not require clinicians to log into a separate system or learn a parallel workflow, and it can complement existing note-writing approaches, including ambient documentation workflows, by adding targeted guidance before the note is signed.
Focused on high-impact E/M documentation scenarios
ZDI is initially focused on documentation patterns that frequently affect Evaluation and Management coding accuracy and professional billing compliance, including:
Beyond these initial focus areas, ZDI can be configured around each organization’s documentation priorities, including specialty-specific requirements, quality initiatives, internal standards, or other patterns that benefit from real-time clarification.
Every nudge is an opportunity
In Zotec evaluation testing against representative documentation samples, ZDI surfaced documentation improvement opportunities on more than 10% of encounters. The initial nudge library is designed to address documentation patterns associated with more than 80% of common Requests for Information, moving clarification earlier in the process before the note is signed.
Each nudge represents an opportunity to improve documentation integrity — whether by supporting the appropriate E/M level, adding required specificity, strengthening compliance, or reducing the need for downstream follow-up.
By shifting documentation guidance upstream, ZDI helps organizations improve accuracy at the point of documentation while reducing avoidable rework for clinicians, coders, CDI teams, and revenue cycle staff.
“There is valuable documentation work that can happen before the note is signed,” Comfort said. “Real-time, encounter-aware nudges give clinicians a way to address those opportunities when the information is most actionable.”
Available in Toolbox on Epic Showroom
ZDI is available for download on Epic Showroom. The application meets Epic’s recommended practices for the NoteReader CDI category.
For organizations using Epic, ZDI offers a practical way to support documentation integrity at the point of care while fitting into the note-writing process clinicians already use.
Expanding the future of real-time revenue integrity
As healthcare organizations continue to prioritize documentation accuracy, reimbursement integrity, and operational efficiency, Zotec sees real-time documentation guidance as an important shift in how CDI can support clinicians, coders, CDI teams, and revenue cycle leaders.
“CDI has long played an important role in documentation accuracy,” Comfort said. “ZDI extends that work earlier in the process — delivering real-time guidance at the point of documentation to help organizations get credit for the care they deliver while reducing friction across the revenue cycle.”
For organizations already using Epic, ZDI represents a practical way to support documentation integrity at the point of care.
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