1. Purpose and Scope
This policy governs the use of CarePilot's CodingAssist product offering ("CodingAssist," "we," "our"). It supplements in-product disclaimers and applies to every clinician or authorized staff member who enables the feature. Nothing herein is legal, coding, or compliance advice; each organization should consult its own counsel and compliance team.
CodingAssist supports two capabilities:
ICD-10-CM Diagnosis Assistant — identifies documented problems and diagnoses with supported ICD-10-CM codes.
E/M Coding Assistant — provides AMA CPT® E/M code suggestions with rationale based on MDM or time, as applicable. AMA CPT content is used under license; see §9 for required notices and restrictions.
2. Best-Effort Suggestions
CodingAssist is a drafting-support tool, not a coding authority. Every output is a best-effort suggestion generated from the context available in the visit — such as the encounter transcript and the chart data CodingAssist can see at the time of the request.
This has practical consequences you should expect:
CodingAssist can be wrong. Suggestions may be inaccurate, incomplete, overly specific, insufficiently specific, or simply not applicable to the encounter.
CodingAssist only knows what it can see. Clinical detail that was discussed but not captured, documented elsewhere in the record, held in a prior encounter, or communicated outside the visit will not be reflected in its suggestions. Absence of a suggestion is not evidence that a condition or service is absent.
Transcript quality affects output. Recording conditions, accents, background noise, crosstalk, specialty vocabulary, and EHR configuration all influence what CodingAssist can extract.
Coding requires judgment CodingAssist does not have. Medical necessity, payer policy, and the completeness of your own documentation are determinations only the clinician and their organization can make.
Treat every suggestion as a prompt to review, never as a conclusion. Features, performance, and availability may change over time, and access may be modified or revoked for misuse or non-compliance. Please report anomalies and incorrect suggestions through the in-app feedback channel; that feedback is how the tool improves.
3. What CodingAssist Does
CodingAssist analyzes the encounter transcript and existing chart, surfaces clinically supported diagnoses with ICD-10-CM codes, and, for visits where E/M coding applies, suggests a candidate CPT® E/M level with a compact rationale (for example, MDM elements and/or total time on the date of service). Accepted items can be synced to your EHR as discrete structured data, not free text. E/M selection observes the current AMA E/M framework (MDM or time, as applicable).
4. How the CodingAssist AI Works
CodingAssist uses prompt-instructed large-language-model components. No protected health information (PHI) is used to train or fine-tune these models.
The system is instructed to:
Stay source-bound — do not infer facts not present in the visit documentation.
Suggest no more than three potential refinements per axis (diagnosis or E/M), and only when supported by the source materials.
Provide a short, specific justification citing concrete chart data for every suggestion.
Ignore revenue incentives (for example, RAF, MCC/CC, wRVU impact) when selecting diagnosis refinements or E/M levels.
For E/M, show how a suggested level is supported — either by MDM (problems, data, risk) or by time, consistent with AMA guidance. Where time-based selection is not applicable (for example, ED visits), the system defaults to MDM-based rationale.
These are instructions, not guarantees. As with any AI system, CodingAssist may not follow them perfectly in every case, which is why clinician review is required.
5. Draft Status and Human Oversight
All codes and refinements are produced as Draft. A licensed clinician must accept, reject, or modify each suggestion prior to signature. Consistent with the AMA's Augmented-Intelligence principles, ultimate diagnostic and coding authority rests with the clinician. CodingAssist does not submit, finalize, or bill anything on its own.
6. Provider Responsibilities
The treating clinician remains solely responsible for:
Verifying that each accepted diagnosis and E/M level is supported by the visit and the medical record, and meets medical-necessity requirements.
Ensuring documentation complies with payer, CMS, and specialty-society rules, including global surgical package rules, split/shared visit rules, teaching physician rules, and telehealth requirements.
Maintaining an auditable record of review and sign-off, including any time attestation used for E/M selection.
Complying with all applicable federal and state laws and with any AMA CPT license obligations applicable to your organization's use of CPT content.
7. Coding Integrity
CodingAssist's objective is transparency and accuracy, not revenue enhancement. Using it to inflate acuity, "game" E/M leveling, add unsupported modifiers, or misrepresent services is prohibited and may expose providers to civil or criminal liability. The E/M assistant produces best-effort suggestions only; it must never be used to justify a level that the documentation does not support.
8. Auditability and Documentation Standards
For every suggested diagnosis or E/M level, CodingAssist surfaces a justification — a concise reasoning trace that:
Quotes or summarizes the chart element, transcript line, or other datum that triggered the recommendation; and
Explains, in one or two sentences, how that datum supports the proposed code.
E/M rationales indicate whether selection is MDM-based (with a summary of problems addressed, data reviewed or ordered, and risk of management) or time-based (with total clinician time on the date of service and examples of included activities consistent with AMA guidance). Some visit types are not time-selectable (for example, ED), in which case CodingAssist shows MDM support only.
A justification explains why CodingAssist made a suggestion. It is not itself documentation, and it is not a compliance opinion. Your documentation must independently meet all AMA and CMS requirements.
Retention: CarePilot does not retain justifications beyond your organization's designated document-retention period; preserving them is your organization's responsibility.
9. Data Privacy and Security
CarePilot encrypts data in transit and at rest, stores PHI exclusively in U.S. AWS data centers, and operates under a HIPAA-compliant Business Associate Agreement. PHI is never used to retrain or fine-tune the underlying models.
10. AMA CPT® and E/M Licensing
CPT® content and E/M guidelines are the copyrighted property of the American Medical Association (AMA). CPT is a registered trademark of the AMA. Use of CPT content requires a license from the AMA. CodingAssist displays and uses CPT content under license; nothing in this policy grants you rights in CPT beyond use within CodingAssist.
Restrictions: Users may not copy, download, store, publish, transmit, or distribute CPT content outside CodingAssist, nor create derivative works, except as allowed by the AMA license applicable to your organization. Applicable FARS/DFARS restrictions apply to government use. For licensing information and required notices, see AMA/CMS license statements.
Authoritative sources: Where CodingAssist shows excerpts or summaries related to E/M, the current AMA CPT code set and E/M guidance remain authoritative in the event of any discrepancy.
11. E/M Assistant Boundaries and Known Exclusions
The E/M assistant:
Suggests candidate levels using either MDM or total time on the date of service, consistent with AMA guidance. History and exam are required only as medically appropriate and do not in themselves determine level.
Does not adjudicate payer-specific edits or bundling rules (for example, global surgery periods, post-op care inclusion, or NCCI edits), split/shared visit nuances, or teaching physician attestations. It may flag potential issues, but the final determination is yours.
Recognizes that some services are not selected by time (for example, ED visits) and presents MDM-only rationales in those cases.
May not capture local policy variation (for example, MAC or commercial payer rules, telehealth waivers, or prolonged services code selection thresholds). Always verify against the current AMA CPT code set and payer policies.
12. AI Model Limitations
Prompt-instructed AI can generate inaccurate, incomplete, or over-specified outputs, and can occasionally produce a code or rationale that looks plausible but is not supported by the encounter. Performance may vary by specialty, accent, background noise, documentation style, or EHR configuration. Consistent with AMA Augmented-Intelligence principles, clinicians must independently validate all outputs before signature.
13. No Warranties; Limitation of Liability
CodingAssist is provided "as-is" and "as-available," without warranties of any kind, express or implied, including fitness for a particular purpose, non-infringement, accuracy, completeness, or uninterrupted availability. CarePilot and its affiliates shall not be liable for indirect, incidental, special, consequential, or punitive damages, including claim denials, audits, penalties, lost revenues, or lost data, arising out of or related to your use of CodingAssist.
14. Acceptance of Terms
By enabling or continuing to use CodingAssist, you attest that you:
Have read, understood, and agree to this policy;
Understand that CodingAssist provides best-effort suggestions based on the context available in the visit, and that those suggestions can be incorrect or incomplete;
Will review every generated ICD-10-CM and E/M suggestion before finalizing the encounter;
Assume full responsibility for the clinical and billing accuracy of accepted items;
Will not use CodingAssist for up-coding, inappropriate E/M leveling, or other non-compliant purposes; and
Understand that CodingAssist is a supplemental tool that does not replace your existing clinical or coding processes.
Appendix A — Definitions
MDM: Number and complexity of problems, amount and complexity of data, and risk of management; used to support an E/M level where time is not used.
Time-based E/M: Total clinician time on the date of the encounter, when allowed by CPT for the service type.