Currently, Heidi includes ICD-10 (DIAGNOSIS) codes to support documentation, but it does NOT, to my knowledge, include CPT (PROCEDURE CODE), or, more precisely, E&M (Evaluation & Management) coding + add on coding (such as G2211, G2212, 99483, etc) support. It would be super helpful if it did, and provided rationales in certain sections, as desired. It would be even more helpful if it automatically entered those CPT codes into my EMR (ecw) for that progress note. For example: Outpatient E/M (based on 25.1m audio duration + 20% prep time): 99214 Outpatient E/M (based on MDM): 99214 Level of MDM: Moderate Visit type: Follow up Problem complexity: High Amount of Data reviewed: Low Risk of complications: Moderate Rationale for Problem complexity: The patient presents with multiple chronic conditions including chronic migraine, vestibular migraine, Hashimoto's disease, empty sella, and possible idiopathic intracranial hypertension (IIH). The IIH is currently not well-controlled, and the patient experienced significant side effects from the prescribed medication (acetazolamide), leading to an ER visit for dehydration. The patient also has a history of multiple mild concussions and other chronic conditions. Rationale for Amount of Data reviewed: New laboratory studies were ordered for cognitive concerns. The physician reviewed prior notes from the ER visit at Baptist Health Emergency Care. Rationale for Risk of complications: The patient is being managed for possible IIH with medication adjustments, which includes restarting acetazolamide at a lower dose and monitoring for side effects. There is a moderate risk due to the potential for significant side effects from the medication and the need for close monitoring. Add-on code: G2211 Rationale for Add-on code: The physician and patient discuss a detailed plan for managing the patient's symptoms and medications, indicating a continued care relationship. The patient also mentions follow-up visits and ongoing management of her condition.
