User manual

CodeEvident reads a de-identified clinical note and drafts a complete code set: the principal and secondary ICD-10-CM diagnoses, the CPT and HCPCS procedures with modifiers and units, the office-visit level supported by the documentation, and the denial risks a payer would raise. Every code is then checked against the official tables and edits, challenged by an independent second-opinion pass, and tied to the exact sentence of the note that supports it.

Three principles run through every screen:

• Validated, not just suggested. A code that does not exist in ICD-10-CM or in the CPT/HCPCS table never reaches you. NCCI procedure-to-procedure edits, medically unlikely units (MUE), Excludes1 conflicts and coverage limits are checked deterministically, by rules, not by the model.
• Evidence you can see. Each code cites the phrase in the note that justifies it, highlighted in place. That is what makes the result audit-ready.
• A second opinion built in. An adversarial auditor pass reviews the draft with the official descriptions, instructional notes and guideline passages in front of it, and flags what a coder should look at before billing.

Who it is for

• Small practices that want every encounter checked before it goes to the payer.
• Freelance coders who use it on the hard encounters and as a second opinion.
• Billing companies and multi-provider groups: a shared queue, QA on billed coding, and training by provider.

How to read this manual

Begin with the visual walkthrough above to follow one complete case. The reference chapters follow the order of a working day: sign in, analyze a note, review and decide, close the documentation gaps with the provider, audit what was already billed, and learn from denials. Names in this style are buttons, tabs and fields exactly as they appear on screen. The Reference chapter explains statuses and labels; Privacy and data handling covers data commitments.

Sign in

1. Open app.codeevident.com and press Sign in.
2. Use your email and password, or the single sign-on your organization set up. The first sign-in creates your account.
3. If you were invited to an organization, accept the invitation from the email you received; you land in that organization’s workspace.

Organizations and roles

Everything in CodeEvident belongs to an organization: a practice, a coding team or a billing company. Analyses, decisions, remittances and reports are isolated per organization and never visible to another one. A person can belong to several organizations and switch between them from the organization menu in the header. Without an organization you work in a personal workspace.

Members and roles are managed in the identity provider and mirrored into CodeEvident. The Team card under Settings says so.

The free trial

Every new organization starts on the free trial: five analyses, one time, no credit card. When they are used up the app answers Plan limit reached on the next analysis and points you to Settings to pick a plan. Chapter 9 covers plans and prices.

Finding your way around

The left sidebar has one entry per screen:

Open Analyze. The screen has two tabs: Code a note, covered here, andAudit existing codes, covered in chapter 6.

Enter the encounter

1. Paste the visit note as the provider wrote it into Clinical note of one encounter: history, exam, assessment and plan. One encounter at a time, between 50 and 15,000 characters, and without patient identifiers.
2. Or press Import a PDF. The text read from the file is previewed with its page count; check it, remove anything that identifies the patient, then Use this text orAppend to what I wrote. Scanned PDFs without a text layer cannot be read yet; paste the text instead.
3. If the encounter has more documents (an order, a procedure report, a lab or imaging result), pressAdd another document of this encounter and give each one its type, title, date and text. They are checked against each other and contradictions, such as a side that differs between the order and the report, are flagged before billing.
4. Pick the Specialty. It selects the coding rules and the auditor’s checklist for that field.
5. Optionally set Date of service (coding edits are applied as of that day; a date found in the note is pre-filled for you to confirm), Insurer or payer (turns on that payer’s rules) andEncounter ID (your own encounter or claim id, used later to match the remittance).
6. Press Analyze.

While it runs

A progress bar walks through In queue, Reading the note, Checking the tables,Second opinion and Ready to review. If the analysis fails, nothing is billed, your note is still in the form, and Fix the note and retry sends it again. When the first pass is not ready to bill, a second pass runs on the premium model; the footer of the result says so and why.

Reading the result

The result is one page, top to bottom:

• Summary banner. The status (chapter 11), the coding summary in one paragraph, the auditor’s verdict and a confidence bar. When several coder passes ran, it says whether they agreed on every code.
• Four tiles. Codes checked against the official tables,Corrected by the book (codes the resolver re-selected from the Index and Tabular),To fix before anything is billed, and To check or ask.
• Clinical note. Your note with every supporting phrase highlighted. Click a highlight or a code to pair them. The legend tells principal, secondary, procedure and auditor evidence apart.
• Diagnoses and Procedures and services. One card per code with its description, confidence, the quoted evidence, modifiers and units, and chips for every rule or auditor finding that touches it.
• E/M level, by the table. For office visits, the AMA 2021 medical decision making table applied to what is documented: problems addressed, data reviewed or ordered, and risk of management. The level is deterministic; if you disagree, the question is which element is misclassified, not the arithmetic.
• Second opinion. The auditor’s findings by severity and category, each with the code it targets and the passage behind it.
• Before you bill. The to-do list, most important first: Fix,Check and Ask the provider items. Provider questions can go out as a documentation query from the review screen.

Press Review and decide to continue in the review screen, or New note to start another.

The review queue

Review queue lists every analysis waiting for a decision, most urgent first: needs review, then low confidence, then completed, lowest confidence first within each. Pending andReviewed switch between what is open and what has been decided. Each row shows when it was analyzed, the specialty, your reference, the status, the audit verdict and the confidence; an “audit” tag marks code sets you submitted for audit and “rev 2” marks a re-coded revision. The list refreshes by itself.

The review screen

Open a row. Sections appear in this order:

• The header with the session id, your reference and the revision number.
• Revisions of this encounter, only when the encounter was analyzed more than once (chapter 5).
• A banner when the reference tables changed since the analysis, listing what is newly raised and what is no longer raised. Got it dismisses it.
• Your decision, the panel described below.
• The full result, as on the analyze screen, with per-code actions while the review is pending.
• Payer outcome, when a remittance mentions this claim (chapter 7).
• Claim, the export.
• Ask the provider, the documentation queries (chapter 5).

Editing the code set

What you sign becomes the claim and this organization’s precedent, so the panel lets you shape the code set before signing:

• On any code card: Make principal promotes a secondary diagnosis, Remove takes a code out (the card then reads “removed from your code set”). On an auditor finding, Use 99214 swaps in the code it suggests.
• In the panel, diagnoses carry their box-21 letter, A to L. Add a code with the search box, choosingprincipal, secondary or procedure; procedure-shaped codes are placed as procedures automatically.
• Under Procedures and services · claim lines, each line has Modifiers (separated by spaces, commas or dashes), Units, and the Diagnoses letters that justify it, up to four. With no letter chosen the claim points to the first four diagnoses.

About half a second after every edit the server re-runs its deterministic checks, without the model. The status line reads Checking…, then shows the count if rule errors remain. A line with an error gets a red border and its issues are listed under it: an invalid code, an NCCI edit, a unit above the MUE, a modifier the rules object to, or a diagnosis pointer problem.

Signing the decision

1. Write the reason in Notes: it goes to the audit trail and to the next coder who opens the encounter.
2. Press Submit approved, Submit corrected or Submit rejected. A corrected decision needs a principal diagnosis.
3. The panel then shows the decision, the date, the reviewer and the signed code set. A session accepts one decision.

Exporting the claim

The Claim card shows box 21 (diagnoses) and box 24 (service lines, modifiers, units and diagnosis pointers) ready for your practice-management system or clearinghouse; demographics, payer and charges are added there. A badge says whether the export comes from the approved set, the corrected set or an unreviewed proposal, and your Encounter ID is used as the control number to match the remittance later.

• CSV: one row per service line, for import into billing software.
• Superbill text: a readable claim draft with the CMS-1500 fields.
• JSON: the full structure, for integrations.

Many coding problems are documentation problems: a chronic kidney disease without its stage, a knee without a side, a visit without total time. CodeEvident turns those gaps into queries the provider can answer, and re-codes the encounter with the answer. The cycle lives in the Ask the providercard of the review screen.

Drafting queries

1. Press Draft queries from the gaps. One query is drafted per documentation gap: a title, the clinical indicators quoted from the note, a question, and options that never suggest an answer. The button is disabled when there are no gaps.
2. In state draft, edit the title and the question if you wish. Copy puts the full query on the clipboard, ready to paste into your EHR message or email to the provider.
3. Press Mark as sent. The query moves to sent.

Recording the answer and re-coding

1. When the provider replies, type their words into Provider’s answer and press Record answer. The query is now answered.
2. Press Apply to the record and re-code, then Apply and re-code. Only the provider’s words are added to the note, as a dated addendum; the question itself is never added.
3. The encounter is analyzed again with the addendum. The result is a new revision; the previous one leaves the queue as superseded. A revision does not consume one of your plan’s analyses.
4. Press Open the new revision and review it as in chapter 4.

Revisions

At the top of an encounter with more than one analysis, Revisions of this encounter lists each revision with its date, state (pending review, decided or superseded) and the reason it ran.What changed since revision 1 shows added codes with a plus, removed codes with a minus and moved codes with their old and new role. The latest revision is the one to review and bill; answers always apply to it.

The Audit existing codes tab of Analyze takes a note together with the codes that were assigned to it and checks them: against the note, against the official tables, and against the MDM table for office visits. Nothing is changed without your decision; the output is a review like any other, with the submitted codes as the draft.

One encounter

1. Paste the Clinical note of the encounter (at least 50 characters).
2. Under Diagnoses as coded, search or type the Principal diagnosis and any Secondary ones. The search starts after two characters and reads the ICD-10-CM Index.
3. Under Procedures and services as coded, add each CPT/HCPCS code with its modifiers (for example 25 RT) and units.
4. Set the specialty, and optionally the date of service, the payer and the encounter id.
5. Press Audit these codes. The result appears on Analyze with the badge “audit of submitted codes”. Press Review and decide to open the review screen.

A batch from CSV

The card Audit a batch from CSV audits up to 200 billed encounters in one import and produces a report for the whole batch. Give the audit a name, such as “September, Dr. Ruiz”, and choose the file. Accepted rows are queued and the report fills in as the audits finish; rejected rows are listed with the reason so you can fix them in the file and import again.

Column order does not matter and header names are case-insensitive. Standard CSV quoting applies, so a note with commas or line breaks goes between double quotes; a file saved from Excel works as is.

The audit report

Open Audit reports and the batch, or press Open the report right after the import. The report reads top to bottom and is designed to be handed to a practice:

• Dollars. Under-coded visits: revenue left behind, Over-coded visits: exposure to recoupment and Lines a rule would get denied. Amounts use the Medicare national fee schedule before locality adjustment; commercial payers pay their own rates, so read them as an order of magnitude.
• Four outcome tiles. No changes, Confirmed by the rules (facts about the claim: invalid code, NCCI, Excludes1, MUE, coverage), E/M level differs (the documented MDM supports another level) and Auditor suggests (only the second-opinion model objects; a coder should look). Facts and opinions are kept apart on purpose.
• Office visit levels. Billed levels against the levels the documented MDM supports, as a chart, with the counts of matches, under-coded, over-coded and new/established mix-ups.
• Finding lists. What the rules confirmed and what the auditor suggests, each with how many encounters and an example.
• By provider. Audited encounters, findings, under- and over-coding and the documentation gaps that keep coming up: who to train and in what.
• Encounters. Every row of the import with its result, visit difference in dollars and main finding. Open one to see the evidence and decide, as in chapter 4.
• Rows not audited. The rows refused at import and why.

Print or save as PDF prints the report as a clean document without menus or buttons. That is the deliverable a client takes away.

Import a remittance

1. Download the electronic remittance advice (ERA, X12 835) from your clearinghouse or payer portal.
2. Open Denials and drop the file on Import a remittance (835), or press Choose file. Files ending in .835, .txt, .edi and .era are accepted.
3. The result line reports the payer, how many claims were found, how many matched your analyses, and the denied claims and lines. Claims match analyses by the Encounter ID you gave when analyzing. A file imported twice changes nothing.

The denials dashboard

Pick the Window (30, 90, 180 or 365 days). Three tiles give the service lines, the denied lines with their rate, and the denied charges. Five tabs break them down:

Appeals

On the review screen of a claim that appears in a remittance, the Payer outcome card lists each line as paid or denied with the CO and PI reason codes. For a denied line, Draft appealwrites an appeal letter that argues from the note: every quote is verified against the documentation and the card says how many were. Edit the letter, Copy letter, or Redraft.

Dashboard opens with three tiles that link into the queue: Pending review,Reviewed and Rejected by auditor. The Start card takes you to analyze a note.

Rule changes affecting your pending reviews

CMS publishes new NCCI and MUE tables every quarter and a new ICD-10-CM every October. When a release is loaded, every analysis still under review is checked again against the new tables. Nothing is changed for you; the differences are listed here, per analysis: the versions that changed, what is newly raised and what is no longer raised. Acknowledge clears an item once you have looked. Owners and admins can press Scan now to run the check immediately.

Plan and usage

Current plan shows the plan, its status, the analyses used this period against the allowance, and when the period resets. The bar turns amber at 80 percent and red at the limit. Owners and admins see Manage billing, which opens the billing portal to change the card, download invoices or cancel; members read “Only organization owners and admins can change the plan.”

To change plan, an owner or admin presses Upgrade or Switch on a plan card and completes the secure checkout. The plan updates a few seconds after the payment is confirmed; the notice “Payment received” appears on return. An analysis counts once per encounter; re-coding after a provider’s answer is free.

Coding defaults

Default specialty and Default payer are pre-filled on the analyze form for every coder in the organization; each analysis can still change them. Owners and admins pressSave defaults.

Autonomy, measured on your own reviews

This card answers a question practices ask early: which analyses could go through without review? It is computed from your own decisions. Once a few dozen analyses are reviewed, it shows, for each candidate policy such as “confidence ≥ 90% · no warnings, unanimous”, how many reviews it covers, how often those analyses were approved unchanged, and the share of volume. A policy needs at least 20 reviews with 97 percent approval to be recommended. Nothing is switched on from here; it is the evidence to have before asking for autonomy.

• De-identified notes. The app asks for notes without patient identifiers. Analysis works on the clinical content: history, exam, assessment and plan.
• Isolation per organization. Results, decisions, remittances, reports and the audit trail are kept per organization, isolated from every other tenant. A person switching organizations sees only the one selected.
• Notes at rest. Deployments can keep the clinical note encrypted (envelope encryption with a per-organization key) so the review screen can highlight evidence later and a provider’s answer can re-code from it; notes are purged after the retention period. A deployment configured not to store notes keeps them only in the browser tab that submitted them.
• Model calls. Notes are sent to the model provider for coding and auditing under zero data retention. A Business Associate Agreement is part of onboarding before any protected health information is processed.
• Audit trail. Every analysis, audit, decision and staff action is recorded with who did it and when. The trail holds actions and outcomes, never clinical text.
• Payments. Card data is handled by the payment provider; CodeEvident stores only the plan, its status and the provider’s references. No clinical data reaches the payment provider.

Questions and requests: support@codeevident.com.

Analysis status

Auditor verdict and severities

The second opinion ends in APPROVE, REVISE or REJECT. A high-severity finding always means REJECT. Findings are HIGH when they would change a code, MEDIUM for modifiers and documentation, LOW for advice.

Review state and outcome

An analysis is pending review, decided (approved, corrected or rejected) or superseded when a newer revision replaced it before anyone decided.

Rule labels on code cards

Glossary

Members of the CodeEvident staff organization see a Backoffice entry in the sidebar. It reads metadata, counts and costs across organizations; it never shows clinical text or analysis results.

• Overview. Organizations by plan, monthly recurring revenue at list price, model cost over 30 days with the cost per analysis, and what needs attention. The Needs attention card lists suspensions, past-due subscriptions, trials used up, organizations near their limit and organizations whose cost per analysis is above target. Monthly report (CSV) exports one row per organization for accounting.
• Organization detail. Plan, status, usage, members and roles, spend by model, analyses per day, and the audit log of staff and system events.
• Adjustments. Layered over the payment provider and always time-boxed with a reason that goes to the audit log: Extra analyses adds to the current period (also how a trial is extended), Courtesy plan treats the organization as being on a paid plan without payment until a date, Suspension blocks analyses until a date or until revoked. Every adjustment can be revoked with a reason, and Resync with Stripe re-reads the subscription when a webhook was missed.