Documentation Review checks the current note against a primary Current Procedural Terminology (CPT) code. You can also choose an optional add-on code. It shows supported items, details that need attention, and details to confirm.
In this guide, we'll cover:
Checking availability
Running a review
Understanding the results
Reviewing again after editing
Understanding the coding limitation
Checking availability
Documentation Review appears only when it is enabled for your practice. You must also be able to edit the note.
Running a review
Important: The note must contain text before you can run a review.
To run a review:
Open the patient's Notes.
Open an editable note.
Select the checklist icon labeled Review documentation.
Select a Primary CPT code.
Select an Add-on CPT code if needed.
Select Review documentation.
Understanding the results
The results group the checks into Clinical documentation and Code-specific requirements. Each check has one of these labels:
Supported: The note supports the item being checked.
Needs attention: The item may need more information or review.
Confirm detail: A detail needs your confirmation.
Not applicable: The item does not apply.
Open a check to view its explanation, a note excerpt, and a suggested next step.
Important: Nothing from the review is added to the note automatically. Use your clinical judgment to decide whether to update the note and how.
Reviewing again after editing
If you edit the note or change a selected CPT code, Allia marks the previous results as out of date. Select Review again to update them.
Understanding the coding limitation
Important: The selected codes are used only for the review. They are not billing recommendations. Documentation Review does not choose the correct code, replace coding guidance, or guarantee reimbursement. You are responsible for confirming that the documentation and selected code match the service provided.