Video Demonstration
What is BillingAssist?
BillingAssist is CarePilot's AI coding module that reads your clinical notes in real time and connects the diagnoses you document to the right E/M levels and billing codes. Instead of manually looking up codes or second-guessing specificity, BillingAssist surfaces the most accurate codes directly in your workflow — with the clinical reasoning to back them up.
How It Works in Your Workflow
BillingAssist runs alongside CarePilot during each visit. Here's what happens under the hood — and what you'll see in the Billing tab:
Step 1: Draft Precise E/M and Billing Codes
BillingAssist 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. It also suggests other billable services documented in your note, such as preventive visits, screenings, procedures, and add-on codes. Each suggestion includes a clear rationale so you understand exactly why it was proposed before you accept or adjust it.
Step 2: Review and Sync to Your EHR
Once approved, BillingAssist writes the structured coding data directly into the correct fields in your EHR — no copy-pasting required.
Codes BillingAssist Suggests
Below are the billing codes BillingAssist can currently suggest.
Tip: document your time. For time-based codes (like counseling, screenings, prolonged services, and time-based E/M), the time spent must be written in your note. If the time isn't documented, BillingAssist won't suggest the code.
Office Visits (E/M)
Code | Description |
99202–99205 | New patient office visit, levels 2–5 (straightforward → high MDM / 15–74 min) |
99211 | Established patient office visit, may not require physician presence |
99212–99215 | Established patient office visit, levels 2–5 (straightforward → high MDM / 10–54 min) |
Home Visits
Code | Description |
99344, 99345 | New patient home visit, moderate / high MDM |
99347–99350 | Established patient home visit, straightforward → high MDM |
Preventive & Wellness Visits
Code | Description |
99381–99387 | Preventive visit, new patient, by age band (<1, 1–4, 5–11, 12–17, 18–39, 40–64, 65+) |
99391–99397 | Preventive visit, established patient, same age bands |
G0402 | Welcome to Medicare visit (IPPE) |
G0438 | Annual Wellness Visit, initial |
G0439 | Annual Wellness Visit, subsequent |
Screening & Counseling
Code | Description |
96127 | Brief emotional/behavioral assessment, per standardized instrument, scored |
G0442 | Annual alcohol misuse screening, 5–15 min (Medicare) |
G0443 | Brief alcohol misuse counseling, 15 min, only after a positive screen (Medicare) |
G0444 | Annual depression screening, 5–15 min (Medicare) |
99406 | Tobacco cessation counseling, >3–10 min |
99407 | Tobacco cessation counseling, >10 min |
99408, 99409 | Alcohol/substance screening and brief intervention (SBIRT), 15–30 min / >30 min (commercial) |
G0396, G0397 | Alcohol/substance screening and brief intervention (SBIRT), 15–30 min / >30 min (Medicare) |
Procedures (ENT)
Code | Description |
31231 | Nasal endoscopy, diagnostic |
31237 | Nasal/sinus endoscopy with biopsy, polypectomy or debridement |
31575 | Flexible laryngoscopy, diagnostic |
69209 | Earwax removal by irrigation, one ear |
69210 | Earwax removal with instruments, one ear |
Transitional Care Management
Code | Description |
99495 | Transitional care management, moderate complexity, face-to-face visit within 14 days |
99496 | Transitional care management, high complexity, face-to-face visit within 7 days |
Add-On Codes
Code | Description |
G2211 | Visit complexity add-on for ongoing care (Medicare only) |
99417 | Prolonged office visit add-on (non-Medicare) |
G2212 | Prolonged office visit add-on (Medicare) |
G0136 | Assessment add-on, 5–15 min, at most once every 6 months (social needs in 2024–2025; physical activity and nutrition from 2026) |
BillingAssist suggestions are best-effort drafts. Always confirm the code is supported by your documentation and meets payer requirements before accepting. See the CarePilot Coding Suggestions Usage Policy & Provider Terms for details.
Key Features at a Glance
Here's a quick summary of what BillingAssist does for you during every visit:
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
Suggests preventive, screening, procedure, care management, and add-on codes when documented
Pushes accepted 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
BillingAssist 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 Billing tab. You can accept or reject the codes; 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.