End E/M Coding Anxiety
Leverage our AI-powered engine to assign the most accurate and defensible Evaluation and Management (E/M) code, every time.
See it in action — paste a note, get a real audit
Add the provider's submitted CPTs and ICDs, run a real audit with deterministic CMS-rule checks. Free, first audit takes ~15 seconds.
An AI-Powered, Rule-Driven Process
1. Document Validation
The AI first confirms the document qualifies for E/M coding, ensuring it contains provider cognitive work and isn't a simple report or note.
2. Choose Best Coding Basis
The system automatically determines whether to code based on Medical Decision Making (MDM) or Total Time, selecting the level the documentation supports.
3. Rigorous MDM Analysis
Using the 3-element matrix (Problems, Data, Risk) and the strict '2-of-3' rule, the AI assigns the most accurate, defensible MDM level.
For Coders
Eliminate Guesswork
Get a clear, AI-driven recommendation for the most defensible E/M code, removing ambiguity from complex encounters.
Focus on High-Value Work
Let the AI handle the initial analysis of MDM and Time, freeing you to focus on complex cases and documentation review.
Instant Justification
Every code comes with a complete justification, including exact snippets from the source document, making your work instantly auditable.
For Compliance Teams
Enforce Guardrails Automatically
Our 'Anti-Overcoding Guardrails' are applied to every analysis, preventing upcoding and ensuring adherence to CMS guidelines.
Identify Denial Risks
The AI proactively flags documentation weaknesses and potential denial risks, providing clear mitigation recommendations.
Build a Defensible Audit Trail
Create a permanent, defensible record for every coding decision, linking the final code to the provider, evidence, and AI analysis.
How E/M coding works
Since 2021, an office visit's level depends on medical decision making or total time, not on how much history and examination was documented. Here is the short version; the full guide covers each rule with its AMA and CMS sources.
Medical decision making
Three elements: the problems addressed, the data reviewed, and the risk of management. A level is met when two of the three elements reach it.
Total time
All of the practitioner's time on the date of the encounter, face-to-face or not, as long as it is not billed separately. Each code has a minimum.
Add-on codes
99417 (CPT) or G2212 (Medicare) for time beyond the highest level; G2211 for Medicare visits where the practitioner is the patient's continuing focal point.
From note to level
An illustrative established-patient note, read the way the audit reads it.
Follow-up for type 2 diabetes. Neuropathic pain in both feet is worse since the last visit despite gabapentin. Increased gabapentin; continue metformin. A1c reviewed.
- Problems
- A chronic illness with progression → Moderate
- Risk
- Prescription drug management → Moderate
- Data
- One test reviewed → below Moderate, and not needed: two elements already meet it
✓ 2 of 3 at Moderate99214
Office and outpatient codes
MDM level and minimum total time on the date of the encounter.
42%
of Medicare E/M claims were incorrectly coded in the HHS Office of Inspector General's nationwide review of 2010 claims, published in 2014. Level selection is a judgment applied to documentation, which is why it gets audited.
E/M coding questions
Code with Confidence. Bill with Accuracy.
The future of E/M coding is not about working harder; it's about getting the most accurate, defensible result, every single time. Let our AI be your safety net.
Schedule Your Live Demo
See our AI on your charts in a focused 30-minute working session — no commitment. We'll show your RAF & revenue lift, the claim-to-evidence audit trail, and how fast you go live.
✓ 30 minutes✓ No commitment✓ See your own numbers
