Encounter Billing and Codes Selection

Billing-code selection in WoundScribe solves three problems at once: compliance through linked diagnoses, revenue through complete coding, and audit-readiness through a documented superbill. This walkthrough shows how the coding agent turns a finished encounter into a clean, defensible claim.

1. Review AI suggestions. Open the Billing handoff and check the amber suggestion bar. WoundScribe reads the encounter and proposes an E/M level (for example, 99213) alongside procedure CPTs such as 97597 and 97606. Click any pill to add it — nothing is committed until you confirm.

1. Accept the E/M. Accepting 99213 drops it into place, auto-applies modifier 25 for the separately identifiable problem, and links the diabetic foot ulcer diagnoses that justify the level. The linked-diagnoses bar enforces that every code carries the ICD-10 codes it needs to support it.

1. Code the procedures. Whether you accept a suggestion or add one manually, the same dialog opens. Click Add CPT manually, type a few digits, and WoundScribe surfaces matching wound-care codes with their official descriptions from an admin-maintained, payer-current library.

1. Confirm procedure details. Choose 97606 for negative-pressure therapy and the dialog prefills the indication, anesthesia note, and required-field chips, then auto-applies the RT modifier for the right heel. The procedure floats below the E/M as its own card, each tied to the diagnoses that support it.

1. Print the superbill. Click Print or Save PDF and WoundScribe assembles the superbill — demographics, diagnoses, charges with modifiers, and the signed provider attestation. The result is coding that defends itself on every visit.

For mobile teams, see how auto-suggested E/M and CPT codes work at the bedside, or review the full AI-powered EMR for wound care.