Inside the coding agent: E/M and CPT suggestions at signature

Under-coding rarely looks like a mistake. It looks like a busy clinician picking the code they remember instead of the code the note supports. The coding agent closes that gap at the moment of signature.

What the agent reads

By the time you're ready to sign, the AI scribe for wound care has drafted the SOAP note, and imaging has attached staging, tissue type, and measurements. The coding agent parses all of it — HPI complexity, exam findings, debridement depth and surface area, applications, offloading, supplies — and produces:

• The supported E/M level with the data points that justify it
• Every CPT the visit supports (debridement by depth, application codes, ultrasound, etc.)
• Matching ICD-10s, including laterality and Wagner/stage detail
• A payer-aware recheck that flags missing components before submission

The full walk-through is in Inside the Coding Agent: E/M and CPT Suggestions at Signature, and the payer logic is broken down in the payer-aware recheck deep dive.

Where under-coding usually hides

• Debridement documented as "sharp debridement" without depth or square centimeters
• Multiple wounds treated but only one billed
• Application of skin substitutes without the graft size and waste captured
• E/M dropped a level because time and MDM weren't recorded

Each of these is a code the note already supports. The agent surfaces them as suggestions, with a citation back to the line in the note, so you accept or reject with one tap.

Compliance is a side effect

Because suggestions are drawn from documented facts — not templates — the resulting claim is defensible. Claims and audit trails run through WISER claims and compliance, and the coding agent works inside the AI-powered EMR for wound care so nothing has to be exported or re-entered.

See what your last ten visits should have coded to — start at WoundScribe AI.