!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

New patient — knee pain after fall

Outpatient orthopedic urgent care · Synthetic, MTSamples-style

hover a code to see evidence

CHIEF COMPLAINT: Right knee pain after a fall 2 days ago.

HPI: 34-year-old new patient slipped on icy steps and landed on flexed right knee. Reports immediate pain, mild swelling that night, and difficulty bearing full weight today. Denies hearing a pop. No prior knee injuries. Able to walk with limp. No numbness or tingling distally.

ROS: MSK - right knee pain and stiffness. Constitutional - no fever. Neuro - no numbness, no weakness. All other systems negative.

PMH: None. PSH: None. Meds: ibuprofen PRN. NKDA.

EXAM: BP 122/74, HR 68. Right knee with mild effusion, tender along medial joint line. Full extension, flexion limited to 110 degrees by pain. Negative anterior drawer, negative Lachman. McMurray equivocal medially. Distal pulses 2+, sensation intact, capillary refill brisk. Skin intact, no abrasions.

IMAGING: Right knee 3-view X-ray obtained in office: no acute fracture, no effusion-related joint widening, alignment preserved.

ASSESSMENT/PLAN:
1. Right knee contusion with possible medial meniscus strain. RICE, knee sleeve, weight-bearing as tolerated. NSAIDs continued.
2. Will obtain MRI if not improving in 2 weeks.
3. Return precautions discussed.

Time spent: 32 minutes face-to-face. New patient, MDM moderate.

Suggested codes

4 candidates · review each

accept · reject · edit

CPT
9920386%
Office/outpatient visit, new patient, low MDM, 30–44 min total time
New patient, total time 32 min in the 30–44 min band; one undiagnosed new problem with uncertain prognosis (low-moderate MDM) supports 99203. 99204 possible if MDM judged moderate with extended review.
- documentationProvider documented MDM as 'moderate' but data reviewed appears limited (X-ray only). Verify before upcoding to 99204.
CPT
7356294%
Radiologic exam, knee; 3 views
In-office 3-view knee X-ray is separately reportable. Append modifier 26 if professional component only; TC if technical only.
- modifierVerify global vs. split billing. If radiologist reads externally, append -TC here and -26 on radiologist's claim.
ICD-10-CM
S80.011A90%
Contusion of right knee, initial encounter
Right knee contusion, initial encounter (7th character A). Laterality and encounter type both documented.
ICD-10-CM
W00.0XXA83%
Fall on same level due to ice and snow, initial encounter
External cause code for fall on ice. Required by some payers and for workers' comp / liability cases.
- lcdExternal cause codes are payer-discretionary in most outpatient settings. Verify whether this practice's payer mix requires them.

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