The problem
The note and the billed level do not always match.
In a retrospective review, many level-3 visits had documentation that supported a higher level. That shows where coding review could help. It does not mean those visits should have been billed differently.
How it works
Prepared by OpAgent. Decided by your team.
- 01
What OpAgent prepares
A proposed E/M level and diagnosis codes, each linked to the supporting text in the signed note.
- 02
What the physician reviews
The physician confirms or changes the codes. CodeIQ Visit does not submit claims.
- 03
Where approved work goes
Confirmed codes would be saved to the encounter in athenaOne. This workflow is not offered to practices yet.
Availability
In developmentBeing built or evaluated. Not offered to practices yet.
Evidence
What has been measured
Measured
52.3%
Level-3 established visits whose signed note supported level 4
- Population
- Established-patient visits billed as 99213 at one participating orthopedic practice
- Sample
- 3,985 graded visits
- Period
- Retrospective sample, August 2026 benchmark
- Compared with
- The visit level that was billed
Limitation: Shows where to audit, not that every visit should have been billed higher. No encounter was re-billed.
How this was measured →
Detailed methods →
Related workflows
How it connects