Changelog

The autocoder now codes Evaluation and Management (E/M) encounters. This covers office visits (99202-99215), hospital inpatient and observation care (99221-99239, including same-date admit and discharge 99234-99236), and emergency department visits (99281-99285).

How E/M leveling works. The level is never picked by the language model. The model extracts the evidence (medical decision making elements, time statements, encounter setting) with citations that are verified against the chart text word for word. A deterministic rule engine then computes the level from the verified evidence, following the AMA MDM table and the CMS time rules. A fabricated or unverifiable quote is discarded like a missing one.

What you will see:

• E/M codes on charts that contain a qualifying visit note.
• A chart with NO qualifying visit note is refused, not guessed. The refusal carries an alert that says why.
• Review alerts when the evidence is thin: insufficient evidence for a level, a disagreement between the time-based and MDM-based level, a level that rests only on an uncorroborated time statement, or a same-day procedure that needs a modifier 25 decision. None of these are decided silently.
• Hospital stays shorter than 8 hours follow the CMS length-of-stay rules: discharge day management is suppressed when the stay provably does not qualify, with an alert.
• Medicare observation-status consultations are directed to office codes, with an alert, per Medicare policy.

What to look out for: E/M encounters that used to go to your coders untouched now arrive coded, with the evidence cited. Held charts carry named alerts that explain the reason. The refusal behavior is deliberate: a chart the system cannot support with cited evidence is left for a human, never guessed.

This change affects only organizations that chose the X modifier set in place of modifier 59.

Modifier 59 stays on the lines CMS excludes. Per CMS guidance (MLN1783722), modifier 59 and its X modifier subsets identify services other than evaluation and management. E/M services use modifier 25 instead. The autocoder no longer converts a 59 into XE or XS on an E/M line, an anesthesia line, or a qualifying circumstance line. A modifier 59 that arrives on one of those lines stays 59.

The catch-all XU rule already worked this way. The XE rule (return to the operating room) and the XS rule (separate structure) now follow the same exclusion.

What to look out for: if your organization uses the X modifier preference, expect 59 to remain on E/M, anesthesia, and qualifying circumstance lines. Other lines still receive the X modifiers as before. Organizations that bill with modifier 59 see no change at all.