(Last updated 11 June 2025 — Current release status: Beta)
1. Purpose and Scope
This policy governs the use of DocuCare Inc.’s CarePilot ProblemAssist product offering (“ProblemAssist,” “we,” “our”). It supplements the in-product disclaimers and applies to every clinician or authorized staff member who enables the feature. Nothing herein constitutes legal, coding, or compliance advice; each organization should consult its own counsel and compliance team.
2. Beta Status
ProblemAssist is offered as a Beta Service. Features, performance, and availability may change without notice, and access may be revoked for misuse or non-compliance. Users agree to report anomalies through the in-app feedback channel.
3. What ProblemAssist Does
ProblemAssist analyzes the encounter transcript and existing chart, identifies clinically relevant diagnoses, paired with any associated ICD-10-CM code(s) that the documentation supports, and surfaces optional refinements to increase documentation accuracy. Accepted items can be synced back to the users EHR as discrete structured data, not free text.
4. How the ProblemAssist AI Works
ProblemAssist uses prompt-instructed large-language-model components.
No protected health information (PHI) is used for model training or fine-tuning.
The system is instructed to:
• Stay entirely source-bound—never infer facts not present in the visit
documentation.
• Suggest no more than three potential refinements, and only when fully supported by the source materials.
• Provide a short justification citing concrete chart data for every suggestion.
• Ignore RAF, MCC, CC, or any billing incentives in its selection of possible diagnosis refinements.
5. Draft Status & Human Oversight
All codes and refinements are produced as a “Draft”. A licensed clinician must accept, reject, or modify each suggestion before signature.
6. Provider Responsibilities
The treating clinician remains solely responsible for:
Verifying that each accepted diagnosis is supported by the visit, medical record and
meets medical-necessity requirements.
Ensuring documentation complies with payer, CMS, and specialty-society rules.
Maintaining an auditable record of your review and sign-off.
Complying with all applicable federal and state laws.
7. Coding Integrity—Not an Up-Coding Tool
ProblemAssist’s objective is transparency and accuracy—not revenue enhancement. Using it to inflate acuity, add unsupported modifiers, or misrepresent services is prohibited and may expose providers to civil or criminal liability.
8. Auditability & Documentation Standards
For every suggested diagnosis, or refinement, ProblemAssist surfaces a justification—a concise reasoning trace that
quotes or summarizes the chart element, transcript line, or other datum that triggered the recommendation, and
explains (in one or two sentences) how that datum supports the proposed code.
These justifications enable clinicians, auditors, and payers to trace each suggestion back to its documented source. CarePilot does not retain justifications beyond your organization’s designated document-retention period; preserving them is your organization’s responsibility.
9. Data Privacy & Security
CarePilot encrypts data in transit and at rest, stores PHI exclusively in U.S. AWS data centers, and operates under a HIPAA-compliant Business Associate Agreement. PHI is never used to retrain or fine-tune the underlying models.
10. AI Model Limitations
Prompt-instructed AI can generate inaccurate, incomplete, or over-specified outputs.
Performance may vary by specialty, accent, background noise, or EHR configuration.
Consistent with AMA Augmented-Intelligence Principles, ultimate diagnostic and coding authority rests with the clinician.
11. No Warranties; Limitation of Liability
ProblemAssist (including this Beta release) is provided “as-is” and “as-available,” without warranties of any kind, express or implied—including fitness for a particular purpose, non-infringement, accuracy, or uninterrupted availability. CarePilot and its affiliates shall not be liable for indirect, incidental, special, consequential, or punitive damages—including claim denials, audits, penalties, lost revenues, or lost data—arising out of or related to your use of ProblemAssist.
12. Acceptance of Terms
By enabling or continuing to use ProblemAssist, you attest that you:
Have read, understood, and agree to this policy;
Will review every generated code or refinement before finalizing the encounter;
Assume full responsibility for the clinical and billing accuracy of accepted items;
Will not use ProblemAssist for up-coding or other non-compliant purposes; and
Understand that ProblemAssist is a supplemental Beta tool whose use does not replace your existing clinical or coding processes, and that access may change or terminate at any time.
Questions or Feedback?
Email [email protected] or visit the Help Center for implementation guides, security white papers, and integration resources.