✓
Intake
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2
Ambient Capture
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3
SOAP Note
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4
Coding
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5
Claim Prep
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6
EHR Push
MT
Maria Torres
Follow-up · HTN
Dr. R. Chen
Live Transcript
Real-time
MD
Hi Maria, how have you been
feeling since we adjusted the
lisinopril dose last
month?
PT
Mostly better. The swelling in
my ankles has gone down a lot. I
do get some lightheadedness when
I stand up too quickly
though.
MD
Any chest pain or shortness of
breath?
PT
No chest pain. A little short
of breath when I climb stairs
but that's been the same.
AI Observations
Orthostatic hypotension —
possible
Patient reports lightheadedness
on standing · consider BP check
supine + standing
Ankle edema improved — document
response to lisinopril increase
ICD-10 I10 · prior visit
documented bilateral edema
Dyspnea on exertion — stable,
unchanged from prior
No escalation indicated based on
transcript
MT
Maria Torres
Note generated · 4s
SOAP Note — AI Draft
editable · sync on save
S — Subjective
O — Objective
A — Assessment
P — Plan
MT
Maria Torres
3 codes suggested
CPT Codes
99214
Office visit — established
patient, moderate complexity (25
min)
98%
✓
93000
ECG with interpretation and
report (if obtained)
71%
✓
99401
Preventive counseling,
individual (approx 15 min)
64%
✓
ICD-10 Diagnosis Codes
I10
Essential (primary) hypertension
99%
✓
I95.1
Orthostatic hypotension
93%
✓
R06.09
Other forms of dyspnea —
exertional
87%
✓
Payer alert — Aetna requires orthostatic
BP documentation for I95.1
Add to SOAP note before claim submission
to avoid denial · Z71.89 counseling code
may also be billable
MT
Maria Torres
Claim ready · 0 errors
CMS-1500 Claim Preview
| Field | Value | Status |
|---|---|---|
| Patient name | Torres, Maria A. | ✓ verified |
| DOB | 03/14/1978 | ✓ verified |
| Payer | Aetna PPO · Group 8812 | ✓ active |
| Rendering provider | Chen, Raymond MD · NPI 1234567890 | ✓ credentialed |
| CPT codes | 99214, 93000 | ✓ validated |
| Diagnosis codes | I10, I95.1, R06.09 | ✓ linked |
| Place of service | 11 — Office | ✓ confirmed |
| Modifier | 25 — significant, separate E/M | ✓ required · added |
| Est. reimbursement | $218.40 | ⚡ Aetna fee schedule |
Scrub passed — no denial risk factors
detected
Modifier 25 auto-attached ·
documentation complete for I95.1 · ready
to submit
MT
Maria Torres
Submitted 0:03 ago
4.2s
Total documentation time
↓ 14 min saved vs manual
$218
Claim submitted
↑ Modifier 25 captured
0
Denial risk factors
↓ vs 2.4 avg per claim
EHR Sync Log
Epic — SOAP note written to
chart
Encounter ID: EPC-2024-084721 ·
signed by Dr. Chen pending ·
FHIR R4
eClinicalWorks — medication list
+ vitals updated
eCW API v2 · lisinopril 10mg
confirmed active · BP entered to
flow sheet
Claim submitted — Aetna
clearinghouse (Change
Healthcare)
Claim ID: ATN-20241105-84721 ·
ERA expected in 14–21 days
Follow-up task created —
orthostatic BP recheck in 6
weeks
Auto-scheduled in Epic · patient
SMS reminder queued for 6 weeks
out
Intake — completed by patient
(pre-visit)
Auto-synced to Epic
Chief Complaint
Blood pressure follow-up /
medication side effects
Reported Symptoms
Lightheadedness on standing,
ankle swelling improved
Medications (self-reported)
Lisinopril 10mg daily,
Atorvastatin 20mg nightly
Insurance Verified
✓ Aetna PPO · active · copay $30
· deductible met