Skip to content
Brightcore AI
Code-Sense

The right E/M level,
with the rationale to defend it.

Physician-led E/M decision support that compares Time vs. Medical Decision Making, verifies ICD-10 medical necessity, and produces an EHR-ready coding rationale.

  • Calculates the highest justified level by Time or MDM
  • Applies the 2-out-of-3 MDM rule with visible reasoning
  • Flags ICD-10 support, contradictions, CDI gaps, and audit risk
Try the sample case View product info
Hospital progress note Encounter

Subsequent hospital care. Total time entered: 25 minutes.

Clinical summary

ETOH withdrawal improving. CK and creatinine improving. Case discussed with addiction medicine. IV Ativan managed.

Question

Should this be coded by time or by medical decision making?

Analysis complete 99233
By time 99231

25 minutes

By MDM 99233

High complexity

ProblemsModerate DataHigh RiskHigh
Coding rationale

Data and Risk meet High. Because MDM supports the higher code, 99233 is recommended.

The actual workflow, from patient note to coded rationale.

Code-Sense starts with a familiar encounter form, then returns the code, ICD-10 medical necessity, MDM breakdown, risk flags, and CDI guidance in one reviewable output.

E/M Code-Sense AI Enterprise Volume Edition

Select encounter type, enter time, then paste the clinical note. Code-Sense calculates the correct level of care.

Enterprise License: 1 / 1,000 Charts Used
Result

99233 Level of Care

  • Reimbursement: $106.88
  • Utilization: 42.68%
  • Basis: Medical Decision Making

ICD-10 Diagnoses & Medical Necessity

F10.239 Alcohol withdrawal, uncomplicated M62.82 Rhabdomyolysis N17.9 Acute kidney failure, unspecified

Medical Decision-Making

E/M Service Code: 99233
Basis for Code Selection: MDM of High complexity.

Problems Level: Moderate
- ETOH withdrawal, rhabdomyolysis, AKI improving

Data Level: High
- BMP, CK, CBC reviewed and repeated
- Case discussed with addiction medicine

Risk Level: High
- IV Ativan discontinued, PO Ativan CIWA started
- Vivitrol planned prior to discharge

Recommended by 2-out-of-3 MDM criteria.
Audit risk flags

No encounter mismatch detected

Encounter type, MDM support, and documentation align for the selected E/M level.

Documentation Improvement (CDI)

Data and risk drive the code

Document labs reviewed, repeat testing ordered, addiction medicine discussion, and medication-management risk.

Print / Save PDFAnalyze another patient

Complex coding logic, reduced to four decisions.

Code-Sense follows the same thinking pattern a strong auditor uses: encounter type, time, note content, then the highest supported code with rationale.

01

Select encounter

Choose the visit type, from hospital care to office visits and emergency department encounters.

02

Enter time

Add total time when available so the engine can compare time-based coding against MDM.

03

Paste the note

Drop in raw clinical documentation, HPI, or a concise summary for auditor-style review.

04

Get the code

Receive the recommended CPT code, ICD-10 support, risk flags, and a clear explanation.

Interactive review

Walk the decision before you accept the code.

Select each step to see how Code-Sense moves from chart details to the final recommendation.

Step 1

Time check

99231

25 minutes supports a lower time-based level.

Step 2

MDM check

99233

Data and Risk meet the High threshold.

Step 3

Defense

Ready

The rationale explains why MDM beats time.

MDM is scored in the open.

The 2-out-of-3 rule is visible, so coders and clinicians can see which elements actually carry the encounter.

Problems addressed Moderate

Multiple improving or resolving conditions, mapped conservatively.

Data reviewed High

Tests ordered or reviewed plus discussion with an external clinician.

Risk of complications High

Drug therapy or hospitalization decisions create high-risk management.

ICD-10 medical necessity Supported

Diagnosis support is checked against the selected level and clinical rationale.

Rationale output

A coding explanation ready for review.

Code-Sense does more than return a CPT code. It explains the decision, identifies risk drivers, and gives teams a concise narrative they can use in coding review workflows.

EHR-ready coding rationale

Time: 25 minutes supports 99231.

MDM: High, with Data and Risk meeting the threshold.

Because MDM is the higher supported method, 99233 is selected.

Built for revenue and compliance.

Code-Sense gives clinicians, coders, and revenue teams the same evidence trail for E/M level selection.

Clinicians

  • See why the code is supported
  • Improve documentation before repeat errors spread
  • Use concise rationale in review conversations

Revenue-cycle teams

  • Reduce undercoding from time-only assumptions
  • Catch risk before claims are submitted
  • Protect reimbursement with documented support

Credentialed coders

  • Audit MDM and time side by side
  • Review ICD-10 medical necessity
  • Escalate contradictions with clear evidence

Stop guessing. Start coding with confidence.

Test the sample case, review the product details, or talk with Brightcore about deploying Code-Sense across your workflow.

Try the sample case Contact enterprise solutions