E/M Coding: How It Works

Nabla now surfaces an E/M code suggestion directly within the encounter, based on the note Nabla generates. After the note is ready, an E/M tab appears on the encounter. It shows a suggested CPT or HCPCS code alongside a full Medical Decision Making (MDM) breakdown, the same framework a payer uses to evaluate a visit. You review it, adjust the context if needed, and copy the code to your EHR. Nothing is submitted automatically.

The E/M tab is available to providers in outpatient settings in the following specialties:

• Family Medicine

• General Medicine

• Internal Medicine

• Pediatrics

If your specialty is not listed above, or if you work in an inpatient setting, you will not see the E/M tab. In organizations with mixed specialties, only eligible providers see it.

The E/M suggestion is based on what is in the note Nabla generated — nothing more. Information in your EHR that is not referenced in the note does not affect the suggestion. This mirrors the standard a payer auditor applies: only what is documented counts.

Step 1 — Open the E/M tab

After the encounter note is generated, navigate to the E/M tab in the encounter. The tab displays the visit type, MDM level, suggested code, modality, and patient type.

Step 2 — Confirm visit type and context

The visit type, modality, and patient type are pre-filled from your EHR or inferred from the note. You can change any field — the code suggestion updates immediately.

Step 3 — Review the MDM breakdown

For sick visits, click See details to view the predicted MDM level across three categories: Problems Addressed, Data Reviewed and Analyzed, and Risk of Complications. Each category includes a plain-language explanation tied to applicable E/M coding criteria. The MDM level is read-only — it reflects what is documented in the note. If you believe the note should reflect a different level, update the note first, then refresh the suggestion from the E/M tab.

If the engine flags potential ambiguity, a confidence indicator will appear with a short explanation. This is a prompt to review the case more carefully — not an error. A code is still shown.

Step 4 — Copy the code to your EHR

The suggested CPT or HCPCS code appears as a copy-ready pill in the Codes card. Use the copy button and enter the code in your EHR as usual.

• Nothing is submitted automatically. The code enters your EHR only if you copy and enter it. The E/M tab is a decision-support tool. The suggestion is a starting point for your review, not an automatic determination.

• Nabla codes from the generated note only. EHR information not referenced in the note will not affect the suggestion.

• Time-based coding is not supported in this version. MDM-based coding only.

• This feature is for outpatient encounters only. Inpatient providers will not see the E/M tab.