E/M Coding Recommendations User Guide

This AI-powered tool assists providers in reviewing their documentation and selecting the appropriate E/M code based on current CPT guidelines. It analyzes the clinical note content and delivers transparent coding advice, including upgrade opportunities.

Step 1: Create a Clinical Note

Complete the patient encounter as you normally would. Document relevant components including:

• HPI (History of Present Illness)
• ROS (Review of Systems)
• Physical Exam
• Procedures & Orders
• Assessment & Plan

Step 2: Click “Get E/M Recommendations”

Once documentation is complete, click the Get E/M Recommendations button in the Orders & Procedures page.

Step 3: View Coding Recommendations

A new tab will open and display a comprehensive summary, including:

• Recommended E/M Code (e.g., 99214 or 99215)
• Level of Medical Decision Making (MDM) that supports the recommendation (e.g., moderate or high)
• Breakdown of Key Elements, such as:
  • Problems Addressed (with complexity level)
  • Data Reviewed and Analyzed (labs, imaging, documentation)
  • Risk Assessment (e.g., prescription changes, diagnostic evaluations)