Coding appears twice. In Assessment & Plan the Coding tab is a preview — Suggested only — preview. Attest at sign-off; nothing is billed automatically. The decisions happen at sign-off.
The card
At sign-off: Draft coding (attestation required — drives automatic billing).
The line under the heading is worth reading once, properly: Clinician attests codes. On Sign & Finalize the system will capture charges, generate a correct X12 837P (professional claim format), and submit via clearinghouse abstraction to the patient's payer.
The table is Attest, Type, Code, Description, Fee $ (editable), Source, Documentation.
Screenshot pending capture
Fees prefill from Admin → Billing configuration → Fee schedule where the code has an active entry. The amount shown is what gets billed, and you can edit it before finalizing.
The E/M row
The E/M row is a choice between exactly two codes, and the recommended one is marked with ✦:
Code Description Time 99203 Office visit, new patient — low MDM 30–44 minutes total on the date of the encounter 99204 Office visit, new patient — moderate MDM 45–59 minutes 99213 Office visit, established patient — low MDM 20–29 minutes 99214 Office visit, established patient — moderate MDM 30–39 minutes You see the new pair or the established pair, never all four.
Screenshot pending capture
Under the description, two lines do the explaining.
The class line says which pair you're being shown and why — for example Booked as a follow-up; last visit 2026-03-14. Beside it is a link to switch: Use new-patient codes instead / Use follow-up codes instead.
The basis line is at its most useful when the booking was wrong:
Booked as a follow-up, but no visit with this practice in the last 3 years is on file — by the CMS 3-year rule this would be a NEW patient.
Booked as a new-patient visit, but the chart shows a visit on 2025-11-02 — within 3 years, which would make this established.
The rationale line, prefixed ✦, is why this level:
Moderate MDM: 2 of 3 elements met — prescription drug management; 2 stable chronic illnesses addressed.
Low MDM: only the risk element reaches moderate (prescription drug management) — 2 of 3 are required for level 4. Raise the level if your note supports it.
Why it suggests the lower level
The recommendation defaults down on purpose. The reasoning, from the code that produces it: an under-coded draft is corrected in ten seconds at sign-off; an over-coded one is a compliance problem.
So the system is not trying to guess your billing — it is trying to be wrong in the safe direction, and to hand you the reasoning so you can correct it. Which means you should expect to raise the level sometimes, and that doing so is normal.
What each level requires expands into the actual criteria: level is set by medical decision making — 2 of the 3 elements must meet or exceed it — or by total time on the date of the encounter, with the Problems, Data and Risk definitions written out.
Attesting
Tick Attest against each code you accept. If you finalize with none attested you get a blocking message: Please attest at least one code (check the boxes in Draft coding) before finalizing.
What usually goes wrong
Accepting the ✦ because it is marked. It is the safe default, not an assessment of your documentation. Read the rationale and decide.
Missing a wrong new-versus-established call. It changes the code pair entirely, and the booking is not always right. The basis line tells you when to look.
Editing a fee without knowing the schedule. The amount shown is what gets billed. If it looks wrong, check Admin → Billing configuration rather than typing over it.
Treating attestation as paperwork. It generates a claim.