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CDI & E&M Companion
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CDI & E&M Companion
Rules
Admin
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HP
HPI
AP
A&P
DC
DC Builder
SU
Summary
Current service
*
Select encounter for CPT review
Subsequent hospital care
Initial hospital care
Consult / discharge / critical care / other
Initial means the first service by your same specialty and group during this stay. Other families require separate coding review.
01
Current Encounter
ER note · HPI · labs · consults · progress notes · any order
▶
Prior Records
optional · older H&Ps · prior DC summaries · old consults
Your note
optional comparison baseline
Consultant / nursing notes
Generate
HPI + Initial A&P
HPI only
Initial encounter · Draft for physician review before signing
01
Source notes
ER physician · triage / nursing · labs · imaging · consults
01
Initial H&P
paste from MT
02
Consult Note(s)
optional
03
Last Progress Note
paste from MT
Tip:
Paste in any order — ER note, HPI, labs, consult notes, A&P. Multiple pastes are fine. Choose the current service first — it sets the CPT family.
Analyze Note
Clear
E&M Level
—
Complexity
—
MCC/CC
—
DRG Opportunity
—
CDI Alerts
—
Analysis
Clinical Criteria
Optimized A&P
DC Summary
Summary
HPI
Clinical Summary
Copy Summary
Clinical Summary
Paste your note and consultant or nursing notes, then click Generate Summary.
E&M Level Analysis
Medical Decision Making (MDM)
E&M
E&M Level Analysis
Paste your note and click Analyze
CDI Alerts
Clinical Documentation Integrity
CDI
CDI Alerts
Specificity gaps and coding opportunities appear here
DRG & ICD-10 Optimization
Revenue impact + GMLOS
DRG
DRG & ICD-10 Analysis
DRG comparison, GMLOS, and ICD-10 codes appear here
Sepsis Criteria Assessment
Denial Prevention Tool
SP
Sepsis Criteria
Run analysis first — sepsis criteria will be evaluated based on your note data
Malnutrition Assessment
RD-driven · AND/ASPEN
NUT
Malnutrition
Runs when the note contains nutrition findings or a dietitian assessment
Optimized A&P
CDI-enhanced · ready to paste into MT
Copy A&P
A&P
Optimized A&P
Run analysis first — your CDI-optimized note appears here ready to paste into MT
Compare with my final A&P
Not stored — only rules you save are kept
Learn from my edits
History of Present Illness
Copy
HPI
History of Present Illness
Paste the ER and other notes on the left and click Generate HPI
Hospital Course
Copy
DC
Hospital Course
Paste source notes on the left and click Generate DC Summary
Discharge Diagnoses
Copy
DX
Discharge Diagnoses
CDI-optimized diagnosis list appears here
CDI Flags
Final documentation check
CDI
CDI Flags
Last-chance documentation opportunities appear here
Teach DocAssist
Your feedback becomes a rule you approve
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