!Synthetic data only — no PHI.Sample notes are MTSamples-style fabrications. The “Code your own note” form calls the public Gemini API and is not a HIPAA-eligible path. See the architecture page for the BAA-gated production route.

← Dashboard/Outpatient E/M coding · v1

From clinical note to billable codes

Pick a synthetic MTSamples-style note. The assistant proposes CPT and ICD-10 codes with the exact note span that justifies each one, surfaces NCCI and documentation flags, and asks you to accept, reject, or edit before pushing back to a (simulated) EHR.

Demo runs on a hardcoded mapping — no LLM call, no PHI. The production path (Bedrock / Azure OpenAI under BAA) is described on the architecture page.

Pick a note

Established patient — diabetes follow-up

Outpatient internal medicine · Synthetic, MTSamples-style

hover a code to see evidence

CHIEF COMPLAINT: Diabetes follow-up. A1c review.

HPI: 58-year-old established patient with type 2 diabetes mellitus and hyperlipidemia returns for routine 3-month follow-up. Reports adherence to metformin 1000 mg BID. Home glucose log shows fasting values 130–160 range, post-prandial 180–220. Occasional missed evening dose. Diet has slipped over the holidays. No polyuria, polydipsia, no episodes of hypoglycemia. Vision stable. No foot lesions. Mild paresthesias in toes bilaterally, unchanged from prior visit.

ROS: Endocrine - as per HPI. Neuro - bilateral toe paresthesias, no progression. Cardio - no chest pain, no SOB. All other systems reviewed and negative.

PMH: Type 2 DM (8 years), hyperlipidemia, mild diabetic peripheral neuropathy.
Meds: Metformin 1000 mg BID, atorvastatin 40 mg QHS, gabapentin 300 mg QHS.

EXAM: BP 138/82, HR 76, BMI 31.4. General: well-appearing. Foot exam: pulses 2+, monofilament intact at all sites, no ulceration. Cardio: RRR, no murmurs. Neuro: decreased vibratory sense bilateral great toes, otherwise intact.

LABS REVIEWED: A1c 8.2 (up from 7.6 three months ago). LDL 96. eGFR 78. UACR 24 (normal).

ASSESSMENT/PLAN:
1. Type 2 DM with neuropathy, suboptimal control. Adding empagliflozin 10 mg daily. Reviewed CV/renal benefits and risks (volume depletion, GU infection, DKA awareness). Will reassess A1c in 3 months.
2. Diabetic peripheral neuropathy - stable. Continue gabapentin.
3. Hyperlipidemia - LDL at goal on atorvastatin, continue.
4. Lifestyle: referred to dietitian, encouraged 30 min walking 5x/week.

Time spent: 28 minutes total including chart review and order entry. MDM moderate-high.

Suggested codes

4 candidates · review each

accept · reject · edit

CPT
9921483%
Office/outpatient visit, established patient, moderate MDM, 30–39 min total time
Established patient, 2+ chronic conditions one of which is poorly controlled (DM A1c 8.2 trending up), prescription drug management with new SGLT2 inhibitor → moderate MDM = 99214. Total time documented at 28 min is just under the 30-min threshold; MDM-based selection is the stronger basis.
- documentationTime documented as 28 min (below 30-min 99214 threshold). Bill on MDM, not time. Confirm provider intent.
ICD-10-CM
E11.4292%
Type 2 diabetes mellitus with diabetic polyneuropathy
Combination code for T2DM with diabetic polyneuropathy. Replaces both E11.9 and a separate neuropathy code per ICD-10-CM combination-coding rules.
- ncciDo NOT additionally code E11.9 (T2DM without complications) — combination code E11.42 captures both. Reject any E11.9 suggestion alongside this.
ICD-10-CM
E78.588%
Hyperlipidemia, unspecified
Active condition addressed in the plan (continue atorvastatin). Codeable per ICD-10-CM outpatient guidelines I.B.4.
ICD-10-CM
E66.955%
Obesity, unspecified
BMI > 30 documented and provider gave lifestyle counseling — supports E66.9 + Z68.31 (BMI 31.0–31.9). Some auditors require explicit 'obesity' diagnosis in the assessment to code, which is not present here.
- documentationObesity not explicitly listed in assessment. Coder may need provider clarification before adding.

Accepted: 0/4
Edited: 0/4
Rejected: 0/4
Pending: 4/4