Billing Education

Once the MDM finishes, open the Billing Education tab. It reads the finished chart and shows the level it supports, why, and anything billable you haven’t captured.

Reading the level

The code and level are at the top. Problems, Data and Risk each get a rating and the part of your note that earned it. Two of the three set the level, and the rationale says which two.

Want to know what would move it? Ask in the chat. Coaching answers in plain terms:

Additional billable services

Below the level, Encounter lists services you could bill separately. Which ones are yours depends on your site: an ECG interpretation is typically billed by the ED physician, while an imaging read is most often billed by radiology. In Settings you can turn off anything your group doesn’t bill separately. Each service is in one of three states.

Captured

You documented it, so it counts. Nothing to do.

Applied to level

The same documentation was used to support your E/M level instead. A service can raise the level or bill on its own, never both.

Opportunity

Billable if you add the missing documentation. The row tells you what to add.

Suggestions beside the note

You don’t have to open the tab to catch an opportunity. Uncaptured services also appear as a Billable service card beside the note, one at a time, with arrows when there is more than one. It names the service, its CPT code and wRVU, and the one thing to document.