Code suggester at sign-off
Code suggester at sign-off
When a provider signs off an encounter, Pollen8 proposes E/M level
- ICD-10 Dx + CPT procedure codes from the SOAP body. Pairs with AI charge capture, but runs during sign-off, not after.
What it suggests
- E/M level — 99202-99205 (new patient) / 99212-99215 (established) / 99221-99223 (initial inpatient) / etc. Based on MDM complexity inferred from the SOAP problems + data review + risk.
- ICD-10 Dx codes — pulled from the assessment / plan section with severity + acuity modifiers (acute / chronic / improving / worsening).
- CPT procedure codes — for procedures documented in the plan (joint injection, biopsy, suturing, splinting, etc.).
Each code rationale links back to the supporting SOAP text span. Pairs with audio-span citations for the full audio → SOAP → code chain.
How it differs from charge capture
| Code suggester | Charge capture | |
|---|---|---|
| When | During sign-off | After sign-off |
| Catches | Under-coded encounter | Missed line-item charges |
| Output | E/M + Dx + primary CPTs | Additional billable CPTs the provider didn’t code |
| Loop | Provider accepts inline | Coder reviews in worklist |
Both feed the 837 builder.
Provider experience
At sign-off, the provider sees the suggested codes inline. Default behavior is accept-all-and-sign (with the option to reject any individual code). Reasonable defaults so the provider isn’t slowed down — but anything they reject doesn’t enter the chart or the claim.
Audit
Every suggestion + accept / reject decision persists on the
encounter as Procedure.note and Condition.note for audit.