We're rolling out CodingAssist to all CarePilot users as part of our full product suite. This guide walks you through what CodingAssist does, how it fits into your existing workflow, and how to get the most out of it starting from your very next visit.
Video Demonstration
What is CodingAssist?
CodingAssist is CarePilot's AI coding module that reads your clinical notes in real time and connects the diagnoses you document to the right ICD-10 codes and E/M levels. Instead of manually looking up codes or second-guessing specificity, CodingAssist surfaces the most accurate codes directly in your workflow — with the clinical reasoning to back them up.
How It Works in Your Workflow
CodingAssist runs alongside CarePilot in three steps during each visit. Here's what happens under the hood — and what you'll see in the Diagnoses & Orders and Billing tab:
Step 1: Identify & Surface Missing Diagnoses
As you document your visit, CarePilot scans the note and your existing chart to flag any relevant conditions you may have missed. You'll see suggested diagnoses appear in the Diagnoses & Orders tab — including both missing ones and possible updates to what's already documented. This happens automatically; you don't need to do anything to trigger it.
Step 2: Draft Precise ICD-10 and E/M Codes
Once diagnoses are surfaced, CodingAssist pairs each one with the most specific ICD-10 code it can support based on your note. It also proposes an E/M level based on both time-based and medical decision-making (MDM) criteria, and links the E/M to your problem list. Each suggestion includes a clear rationale so you understand exactly why it was proposed before you accept or adjust it.
Step 3: Review, Refine, and Sync to Your EHR
Before you sign off, you can review each AI-suggested refinement, modifier, or specificity upgrade. Accept what works, adjust what doesn't. Once approved, CodingAssist writes the structured diagnosis and coding data directly into the correct fields in your EHR — no copy-pasting required.
Key Features at a Glance
Here's a quick summary of what CodingAssist does for you during every visit:
Links visit diagnoses to existing problems and adds new ones when appropriate
Surfaces evidence-based ICD-10 refinements and specificity upgrades automatically
Generates an audit trail explaining every suggested code with clinical context from your note
Drafts E/M codes using both time and MDM, linked to your problem list
Pushes accepted diagnoses and codes directly into the right EHR fields
Provides real-time suggestions as you type your note
Fully integrated with your existing CarePilot workflow
What to Expect When You Start Using It
CodingAssist is ready to be activated in your account, by toggling it on in your user settings – no additional setup needed. The next time you start a visit and open your note, you'll see AI coding suggestions appear automatically in the Diagnoses & Ordesr tab. You can accept, edit, or dismiss any suggestion at any time; nothing is applied without your approval.
If you run into any questions or want to walk through the feature with a member of our team, reach out at any time through the Help Center or chat below. We're here to make sure the transition to the full CarePilot suite is as smooth as possible for you and your team.