Codes arrive
with the chart.
The note lands. ICD-10 and CPT follow. The problem list updates with them.
- Assessment / Plan 9:40a Note complete. Three diagnoses. 52F · fatigue, polyuria × 3 weeks
- Diagnosis lines ICD-10 Type 2 diabetes mellitus with hyperglycemia · E11.65
- ICD-10 Hypertension, essential · I10
- ICD-10 Hyperlipidemia, mixed · E78.2
- Visit record CPT Office visit, established patient · moderate MDM · 99214
- Problem list + Hyperlipidemia, mixed · added
- ~ Type 2 diabetes · marked with hyperglycemia
The chart closes.
The codes are in.
The finalized
note.
Scribe writes it, Coder reads it. Coder starts the moment the note is complete: no separate capture step, no second workflow for the clinician.
Existing athenaOne notes also qualify. Practices onboarding Coder without Scribe can start coding from their current documentation workflow. No new note-taking behavior required.
Real-time coding
from the narrative.
ICD-10 codes map from the Assessment field and tie to the right diagnosis lines. CPT codes draw from the encounter's documented work: E/M level, procedures performed, modifiers when the documentation supports them.
The problem list updates as a first-class artifact: new diagnoses added with supporting language, existing conditions marked current or resolved, duplicates collapsed. HCC and RAF capture runs in the same pass. Risk-adjustment codes land during the visit, not after the claim files.
Discrete fields,
coded at close.
Diagnosis codes on the problem list. Procedure codes on the encounter. Risk-adjustment codes where athenaOne expects them.
By the time the chart closes, the codes are placed and clinician-signed. The biller opens an encounter that's already coded. Their job is checking, not coding.
Signed today. Submitted today.
A 32% lift in same-day claim submissions. Measured in the practices already running CarePilot.
lift in same-day claim submissions.
Measured across CarePilot customer practices
The coding is right before I hit sign. I stopped rewriting notes to fit the codes.
Where Coder
writes.
Every Coder output lands in a discrete athenaOne field: ICD-10 on the diagnosis lines, CPT on the visit record. Finished codes, not suggestions waiting for triage.
ICD-10 codes attach to the problem list and to the diagnosis lines of the encounter. CPT codes attach to the encounter itself: E/M level on the visit record, procedure codes on the procedures performed, modifiers where the documentation supports them. The encounter is coded and clinician-signed when the chart closes. The billing pass starts from finished codes, not a blank claim.
New diagnoses added with the supporting clinical language attached. Chronic conditions reviewed at every relevant visit and marked stable or changed. Duplicates and orphan codes cleaned. The problem list athenaOne carries forward to the next visit is the problem list the clinician actually wants to see.
For practices with Medicare Advantage or value-based populations, the risk-adjustment codes that drive capitation and quality bonuses land on the encounter alongside the primary coding. No separate risk-adjustment workflow. No retrospective chart sweep at year's end.