Key Features

• Smart Code Suggestions

AI analyzes your completed note and recommends the appropriate E/M level based on your documentation, no manual code matching required.

• Compliance Justification

Displays a detailed breakdown of how the note meets requirements across HPI, ROS, Exam, and MDM components.

• Guidance to the Next Level

Shows what additional documentation would be needed to justify a higher E/M code—helping providers fine-tune notes for full reimbursement.

• Manual Trigger Control

Providers initiate the review when ready, ensuring feedback is based on the complete clinical picture.

• Uninterrupted Workflow Integration

Built directly into the existing documentation environment for quick, in-context insights. No extra clicks, screens, or tools.

This AI-driven tool removes the guesswork by ensuring coding accuracy, reducing compliance risks, saving time spent on post-visit reviews, and supporting appropriate reimbursement for work performed.

How to Use the Feature

1. Complete the patient note as usual.

2. In the Orders and Procedures page, click the Get E/M Recommendations button.

3. The system analyzes your documentation and:

• suggests an E/M level
• provide the level of Medical Decision Making (MDM) that supports the recommendation
• breaks down the problems addressed (with complexity level), data reviewed and analyzed (labs, imaging, documentation), and risk assessment 

4. Use the feedback to make informed adjustments or finalize your note.

Note: This tool is only enabled manually, giving you full control over when suggestions are made.

To learn more about how to use the E/M Coding Recommendations, refer to the E/M Coding Recommendations User Guide.

Getting Started

The feature is available now and can be enabled within your provider documentation settings. Contact your account manager to schedule a walkthrough.