E/M Coding

Does the E/M code get submitted automatically to a payer?

No. Nabla displays a suggestion. You copy it and enter it in your EHR. Nothing is filed automatically.

What if I disagree with the suggested code?

The MDM level reflects what is documented in the note. If the suggestion doesn't match the complexity of care delivered, check whether the note captures all relevant elements, problems addressed, data reviewed, and risk factors. You can refresh the suggestion after editing the note, or choose a different code in your EHR.

I edited my note after generating it. Will the E/M suggestion update automatically?

Not automatically. Open the E/M tab and use the refresh option to regenerate the suggestion from the updated note.

What does the confidence flag mean?

The engine detected ambiguity, more than one code could be defensible. Review the MDM breakdown carefully before entering a code. The flag is informational; a code is still shown.

Can I use this for time-based billing?

Not in the current version. E/M coding is MDM-based only.

I don't see the E/M tab. Why?

The E/M tab is only available for eligible providers in supported specialties (Family Medicine, General Medicine, Internal Medicine, Pediatrics) in outpatient settings. If you are in one of these specialties and still don't see the tab, contact your administrator or Nabla support.

Is this available for inpatient visits?

No. The E/M tab is currently available for outpatient encounters only.