!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 — sinusitis follow-up

Outpatient family medicine · Synthetic, MTSamples-style

hover a code to see evidence

CHIEF COMPLAINT: Sinus congestion and facial pressure x 6 days.

HPI: 42-year-old established patient returns for follow-up of acute sinusitis. Reports persistent maxillary pressure, purulent nasal discharge, and post-nasal drip despite a 5-day course of amoxicillin started by urgent care last week. No fever today. No tooth pain. No vision changes. Sleep disrupted by nasal congestion.

ROS: Constitutional - no fever, no chills. ENT - maxillary tenderness, congestion, post-nasal drip. Resp - mild cough, no SOB. All other systems negative.

PMH: Hypertension, well-controlled on lisinopril.

EXAM: BP 128/78, HR 72, T 98.4F. General: NAD. HEENT: tenderness over bilateral maxillary sinuses. Nares with erythematous mucosa and purulent discharge. Oropharynx clear. Neck supple. Lungs clear bilaterally.

ASSESSMENT/PLAN:
1. Acute bacterial sinusitis, not improving on first-line antibiotic. Switching to amoxicillin-clavulanate 875/125 BID x 10 days. Discussed warning signs.
2. Hypertension - stable, continue lisinopril.
Patient instructed to return or call if symptoms worsen, fever develops, or vision changes occur.

Time spent: 18 minutes face-to-face, MDM moderate complexity.

Suggested codes

4 candidates · review each

accept · reject · edit

CPT
9921391%
Office/outpatient visit, established patient, low-to-moderate MDM, 20–29 min total time
Established patient, single acute uncomplicated illness with prescription drug management; documented total time 18 min and moderate MDM supports 99213 (could justify 99214 if total time includes pre/post review).
- documentationIf total time including chart review/orders ≥ 20 min, 99214 may be supportable. Confirm with provider.
ICD-10-CM
J01.0088%
Acute maxillary sinusitis, unspecified
Documentation specifies acute sinusitis localized to bilateral maxillary sinuses; J01.00 used because laterality not separately coded for maxillary sinusitis in ICD-10-CM.
ICD-10-CM
I1095%
Essential (primary) hypertension
Active comorbidity addressed in the assessment/plan; codeable as it influenced today's MDM (medication continuation).
ICD-10-CM
Z79.89942%
Other long term (current) drug therapy
Optional add-on for long-term ACE inhibitor use. Some payers require it; many do not. Low confidence — recommend reject unless payer-specific guideline applies.
- lcdPayer-specific. Reject by default unless contractor LCD requires Z79.x.

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