computer assisted coding - code suggestion tool for provider/encounter notes

Turn provider notes into codes using Code-A-Note™.

This feature is currently unavailable for online purchase. For more information, please call 801-770-4203 or Contact Us.

SAMPLE: (buttons are disabled)

Patient Information

Notes/EMR  (Paste notes here.)

ASSESSMENT: Chest pain.ASSESSMENT: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".ASSESSMENT: The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck and left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath and diaphoresis. He states that he has had nausea and 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour. Acute Inferior Myocardial Infarction.ASSESSMENT: The patient is moderately obese but he is otherwise well developed and well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.Normocephalic / atraumatic head. Pupils are 2.5 mm, equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. External auditory canals are clear bilaterally. Tympanic membranes are clear and intact bilaterally.Neck: No JVD. Neck is supple. There is free range of motion and no tenderness, thyromegaly or lymphadenopathy noted.Pharynx: Clear, no erythema, exudates or tonsillar enlargement.Chest: No chest wall tenderness to palpation. Lungs: Clear to auscultation bilaterally. Heart: irregularly-irregular rate and rhythm no murmurs gallops or rubs. Normal PMIAbdomen: Soft, non-distended. No tenderness noted. No CVAT.Skin: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.Extremities: No gross visible deformity, free range of motion. No edema or cyanosis. No calf / thigh tenderness or swelling.ASSESSMENT:The patient's chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug / Minute. He tolerated the TPA well. He was transferred to the CCU in a stable condition


Recommendations  (Click on a code to Choose it.)

E11.9 - Type 2 diabetes mellitus without complicationsView Code Info
E66.8 - Other obesityView Code Info
F48.8 - Other specified nonpsychotic mental disordersView Code Info
M54.2 - CervicalgiaView Code Info
M79.602 - Pain in left armView Code Info
N64.4 - MastodyniaView Code Info
O90.89 - Oth complications of the puerperium, NECView Code Info
P92.1 - Regurgitation and rumination of newbornView Code Info
P96.8 - Other specified conditions originating in the perinatal periodView Code Info
R00.8 - Other abnormalities of heart beatView Code Info
R06.02 - Shortness of breathView Code Info
R07.89 - Other chest painView Code Info
R07.9 - Chest pain, unspecifiedView Code Info
R10.2 - Pelvic and perineal painView Code Info
R11.10 - Vomiting, unspecifiedView Code Info
R50.81 - Fever presenting with conditions classified elsewhereView Code Info
R50.9 - Fever, unspecifiedView Code Info
R52 - Pain, unspecifiedView Code Info
R53.81 - Other malaiseView Code Info
R54 - Age-related physical debilityView Code Info
R61 - Generalized hyperhidrosisView Code Info
R69 - Illness, unspecifiedView Code Info
Z86.7 - Personal history of diseases of the circulatory systemView Code Info
Z91.14 - Patient's other noncompliance with medication regimenView Code Info
  Non-specific Code    View Code Info    Remove Code

Chosen Codes

Code Checker

About Code-A-Note™

Code-A-Note's Clinical Code Extractor incorporates an advanced clinical domain Natural Language Processing (NLP) solution to harvest clinical information from unstructured text, and then applies additional filter and data resources from Find-A-Code's digital coding library. The system increases coder accuracy and efficiency, saving you both time and money.

The Clinical Code Extractor implements semantically broad Clinical Ontologies based on trusted health community resources including U.S. National Library of Medicine (NLM) Unified Medical Language System (UMLS), Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), National Center for Health Statistics (NCHS), American Medical Association (AMA) and NLM clinical resources, enriching terminology variance. A four stage term correlation processor provides high throughput performance across these very large Clinical Ontologies. Other special, advanced clinical NLP techniques to optimize Precision and Recall performance involves: canonicalization and Clinical Synonyms Expansion (CSE); Clinical Semantic Compression (CSC); and section, negation, experiencer and temporality context-aware.

The professional coder selects appropriate codes from the candidate extracted codes. Selected codes can then be validated using Find-A-Code's up-to-date code validation tools. The "Check Codes" button validates the selected codes for Medical Necessity, NCCI Edits, MUE Edits (gender, age, pregnancy, etc.), active/inactive codes, and proper Place of Service values.

Code-A-Note's automatic, thorough analysis of the medical record results and code selection decision aids provides a high quality claim compliance and accuracy while improving the overall coding workflow efficiency and throughput, and minimizing user fatigue errors. Code-A-Note greatly reduces the number of claims rejected, denied, or suspended. Code-A-Note puts your clinic or office on the fast track for coding and claims processing.

request yours today
start today
free subscription

Thank you for choosing Find-A-Code, please Sign In to remove ads.