Read a result
A result is the report for one note. It leads with the code the documentation supports, then shows the reasoning behind it, with each finding tied to the exact words in the note.
To open a result, click its code on the Results page or on Home, or click Open in the message that says the note is ready. To open a result by its request ID, paste the ID in Find by request ID on the Results page. A result has the following parts, from top to bottom.
A result that is still running
A note runs in the background for about a minute. If you open it before it finishes, the page says Analyzing the note (or Waiting to start, for a note still in line) and shows a timer and the stages of the analysis. You can leave the page. If you stay, the page switches to the report by itself when the analysis finishes.
A result that didn't finish
If the analysis failed, the page says Analysis not completed, and no credit was charged. The note is kept for 7 days, so you can run it again:
- Click Retry (1 credit).
- The page moves to the new analysis while it runs.
The retry has its own request ID. The credit is charged only if the retry succeeds. For a note from a batch, the retry runs in the same batch. Because a retry replaces the failed note, the same people who can delete it can retry it: owners and admins any note, members only the notes they ran. After 7 days the note is deleted, and the page says it can't be retried.
The code and its basis
The top card starts with The documentation supports, followed by the code in large type, such as 99214. If the
note doesn't support one code, the card says No single code.
If you submitted codes, the card compares the first one with the supported code and says whether the documentation
supports the submitted code, a higher level, a lower level, or a different code family. When the two codes are
different levels of the same office-visit family, such as 99213 and 99214, the submitted code appears struck
through next to the supported one. Any other codes you submitted are listed under Also submitted.
The card also lists the following:
- Basis: whether the code rests on medical decision making (MDM) or on total time, and the MDM level when MDM decides the code.
- Guideline: the E/M guideline the code follows.
- Time: the clinician minutes documented in the note, when the note records time.
Under these facts, chips summarize the rest of the report: the number of missed revenue opportunities, denial risks, and flagged Medicare edits. Click the missed revenue or denial risk chip to jump to that section.
The card's title bar shows the date and time the note was analyzed, how it was run, and the request ID: the first 8 characters of the result's ID. To copy the whole ID, for example to send it to support, click Copy request ID. The source reads, for example, Web · run by sam@clinic.org, Batch upload · Clinic day · run by sam@clinic.org, or API · key “Nightly export”. For a batch, click its name to open the batch. A test result also shows a Test label and the date it's deleted. For more information, see Test mode and the BAA.
Review first
Directly under the code card, Review first shows what can change payment, so you can act on it before anything else:
- Missed revenue opportunities, in a blue card. The heading gives the count, and each opportunity is its own row, such as an add-on code or a service the note supports that you might not be billing.
- Denial risks, in an amber card. Each risk is a documentation gap that could lead to a denial, followed by its Mitigation: how to fix the note or the claim.
When the report finds neither, the section is one line: No missed revenue or denial risks found. When it finds only one kind, the other kind shows one line, such as No denial risks found.
The printed report and the PDF keep the same order.
Medical decision making
This section shows the three MDM elements, each in its own card:
- Problems addressed
- Data reviewed
- Risk of management
Each card shows the level the note reaches for that element, on a four-step scale: Straightforward, Low, Moderate, or High. Under the level is the reason, and at the foot of the card is the quote from the note that supports it.
The section heading states the final MDM level and how many elements meet it, for example Moderate, 2 of 3 elements meet it. The cards of the elements that meet the final level are outlined. Under the E/M guidelines, two of the three elements decide the MDM level.
Evidence quotes
Each quote is copied word for word from the note and highlighted. To see a quote in context, click it, or click Show in note under it. The note opens in a panel with every quote highlighted, scrolled to the one you clicked.
To read the whole note, click View note above the report. On wide screens, the note opens in a panel beside the report; on phones, it opens as a sheet over the report. To close it, press Escape.
Add-on codes and modifiers
This card lists the add-on codes and modifiers the note supports, such as G2211 or modifier 25. When there are none,
it says None suggested.
Medicare checks
When you submit codes and a state, the report checks them against Medicare rules for that state. The card starts with an overall message and lists each check with its outcome:
| Check | What it looks at |
|---|---|
| NCCI procedure pairs | Pairs of codes that NCCI edits don't allow together on the same day, or allow only with a modifier. |
| Medically unlikely edits | Units over the limit Medicare allows for one code on one day. |
| Add-on code pairing | Add-on codes billed without a primary code they require. |
| Coverage articles (LCD) | Whether the diagnoses match a local coverage determination that applies to the code. |
| Code status and modifiers | Findings about the submitted codes themselves and their modifiers. |
Each flagged edit is listed under the checks, with the codes involved and the reason. If a check couldn't run, it shows Not checked.
If you didn't submit codes and a state, the card says that no Medicare rule checks ran. To include them, analyze the note again with the codes and a state, which uses another credit.
Export a result
The buttons above the report export it:
- Export PDF opens your browser's print dialog with a print layout of the report. To save a PDF, choose Save as PDF as the printer.
- Copy JSON copies the full report as JSON, in the same format as the API. For the fields, see The report.
Each export is recorded in your organization's audit log. An exported file is outside MedChartScan, so store and share it the way your organization handles patient records.