This page lists the review alerts you meet most often on evaluation and management visits. It covers office and outpatient visits (99202-99215), hospital inpatient and observation services (99221-99239), and emergency department visits (99281-99285). Every alert carries a plain-language description, a type, a severity from 1 to 10, and a suggested reviewer role.

Two facts explain most of these alerts. First, a deterministic engine picks the visit level from evidence the autocoder quotes word for word from the note. Second, the office and the hospital evidence reviews can both run on one chart, because they share note types such as history and physical notes. A deterministic step then picks the billing lane.

## When the autocoder produces no visit code

These alerts mean the autocoder found no defensible visit to code. It records the reason instead of guessing.

- **E/M Coding Request Refused - No Qualifying Encounter Note** (`eandm_qualifying_note_refusal`). HARDSTOP, default severity 9. The chart contains no qualifying encounter note. The default qualifying list is an office visit note, a history and physical note, or a progress note. Confirm the packet really lacks a visit note. If the visit note is present but typed wrong, correct the note type and resubmit.
- **No E/M Extraction Results on Chart** (`eandm_no_coding_results`). HARDSTOP, default severity 9. A qualifying visit note was present, but the evidence review returned nothing to level. Reprocess the chart. If it fails again, code the visit manually and report the chart to support.
- **Multiple E/M Extraction Results on One Chart** (`eandm_multiple_coding_results`). HARDSTOP, default severity 7. The chart carried more than one distinct visit result, and only the first was leveled. Review the packet for more than one encounter. Split a multi-visit packet into one chart per visit.
- **No E/M Level Supportable From Documentation** (`eandm_leveling_insufficient_evidence`). HARDSTOP, default severity 8. The engine could support no level at all. The alert text lists the reasons, for example fewer than two determinable decision-making elements with no usable total time, or a new-or-established status that could not be derived. The engine never guesses a level, and it never assigns 99211 on its own. Level the visit manually, or obtain the missing documentation.

## Level evidence alerts

These alerts describe how the level was reached. The level exists, but a coder must confirm the basis.

- **E/M Evidence Excluded - Missing Verbatim Citation** (`eandm_uncited_evidence_dropped`). COMPLIANCE, default severity 6. The autocoder asserted a determination without the required quote from the note, so it excluded that determination. The level rests on the remaining cited evidence only, so it can be lower than the full documentation supports. Compare the level against the note.
- **MDM and Time Support Different Levels** (`eandm_mdm_time_disagreement`). COMPLIANCE, default severity 6. The medical decision making path and the documented total time path support different levels. The engine selected the higher supportable level. Confirm the winning basis is defensible.
- **E/M Level Sits at a Decision Boundary** (`eandm_level_boundary_sensitive`). COMPLIANCE, default severity 5. A one-step change in a single decision-making element, or one minute of documented time, would change the level. Verify the contested element or the time statement against the note.
- **E/M Level Rests Solely on Documented Time** (`eandm_time_only_level`). COMPLIANCE, default severity 6. Fewer than two decision-making elements were determinable, so only the documented total time supports the level. Confirm the time statement is credible for the visit and is not a template artifact. Confirm that no separately billed procedure time was counted.
- **MDM Element Bin Below Confidence Threshold** (`eandm_low_confidence_bin`). HARDSTOP, default severity 6. A decision-making element that contributed to the level carries a confidence score below the configured threshold. The default threshold is 80. Re-derive the element from the note, then confirm or correct the level. Your facility configuration controls this threshold through `claimValidation.codeConfidence.thresholds.surgicalCodes.primary`. Contact your Hank representative to change it.
- **No Total Time Documented (MDM-Only Level)** (`eandm_no_time_documented`). INFORMATIONAL, default severity 3. The note documents no total time, so the level rests on medical decision making alone. That is a valid basis. No action is required.
- **Prolonged-Service Time Documented But Not Billed** (`eandm_prolonged_time_unbilled`). FINANCIAL, default severity 6. Documented total time reaches prolonged-service territory, which is 75 minutes or more for a new patient and 55 minutes or more for an established patient. This version does not emit 99417 or G2212. Review the visit for a manually added prolonged-service code that suits the payer.

## Same-day procedures with the visit

- **Same-Day Procedure Alongside E/M Visit (Modifier 25 Review)** (`eandm_mod25_same_day_procedure`). COMPLIANCE, default severity 7. The note documents one or more procedures performed at the same encounter as the visit. A procedure with an explicitly documented CPT code becomes its own billable line. A procedure without a documented CPT code appears in the alert text only, and the autocoder never codes it for you. Confirm that modifier 25 applies, or remove the visit line. Then verify the procedure lines and code any documented but uncoded procedure. Your facility configuration controls this through `emPolicy.mod25Aggressiveness`. The default value `conservative` never appends modifier 25 on its own. The value `standard` appends it with evidence and still raises this alert. Contact your Hank representative to change it.

## Setting and lane alerts

These alerts tell you which family of codes the autocoder billed, and why.

- **E/M Coding Lane Selected (Office vs Hospital)** (`eandm_lane_arbitration`). INFORMATIONAL, default severity 3. Both the office and the hospital review produced results on one chart. The hospital lane wins only on a quoted, verified inpatient, observation, or emergency department setting statement. Otherwise the office lane applies. Confirm the selected lane matches the true site of service.
- **Hospital Lane Selected But No Level Supportable - Fell Back to Office** (`eandm_hospital_lane_fallback`). COMPLIANCE, default severity 6. The chart carried verified hospital setting evidence, but the hospital engine found no supportable level, so the office result was billed instead. Confirm the true site of service. Repeated fallbacks from one facility point to systematic lane misrouting.
- **ED Visit Bundled Into Hospital Admission** (`eandm_ed_bundled_into_admission`). COMPLIANCE, default severity 6. The same practitioner saw the patient in the emergency department and admitted the patient to inpatient or observation care. Per CMS IOM 100-04 chapter 12 section 30.6.9.1.A, the emergency department visit rolls into the initial hospital care service, so the claim carries the admission service only. Confirm that no separate emergency department claim goes out for the same practitioner and date.
- **Consultant on Observation Patient - Payer Rule Check** (`eandm_observation_consult_payer_rule`). COMPLIANCE, default severity 6. A physician with a verified consultant role evaluated a patient in observation status. Medicare directs observation-status consultants to the office and outpatient codes (99202-99215), while the leveled code follows the CPT hospital family. Check the payer rule before submission.
- **Initial Hospital Care Without Cited First-Encounter Evidence** (`eandm_initial_without_first_encounter_evidence`). COMPLIANCE, default severity 5. Initial hospital care (99221-99223) was leveled without an explicit quoted first-encounter statement. Initial codes apply only to the first encounter of the stay for that physician or group. Confirm this is not a subsequent visit (99231-99233). A templated "Admission" header on a daily note is not admission evidence.

## Length of stay and discharge alerts

These alerts apply the Medicare length-of-stay rules for hospital and observation stays.

- **Same-Date Admission and Discharge - Documentation Requirements** (`eandm_same_date_doc_requirements`). COMPLIANCE, default severity 6. The engine leveled a same-date admission and discharge code (99234-99236). Per CMS IOM 100-04 chapter 12 section 30.6.9.1.D, Medicare requires all three of the following: documentation that the stay involved 8 or more hours but less than 24 hours; documentation that the billing physician was present and personally performed the services; and admission and discharge notes written by the billing physician. This alert fires on every claim in this range. Verify all three requirements before submission.
- **Same-Date Admission/Discharge Downgraded to Initial Care** (`eandm_same_date_downgraded`). COMPLIANCE, default severity 6. The documentation pointed at a same-date admission and discharge, but 99234-99236 could not be supported. Common reasons are an unverified admitting or attending role, missing admission or discharge times, contradicting times, or a stay span under 8 hours. The engine leveled initial or subsequent hospital care instead. The downgraded code pays less, so correct the time documentation if the stay genuinely qualifies.
- **Discharge Day Management Not Separately Billable (Under-8-Hour Stay)** (`eandm_discharge_service_suppressed`). HARDSTOP, default severity 8. The quoted admission and discharge times prove the stay spanned less than 8 hours. Per CMS IOM 100-04 chapter 12 section 30.6.9.1, a stay under 8 hours is reported with initial hospital care only, so the discharge service is not separately billable. The autocoder built no visit line from this chart. Confirm the documented times. If they are right, bill only the initial hospital care service on the admission date.
- **Discharge Time Not Documented - Lower Code Applied** (`eandm_discharge_time_undocumented`). INFORMATIONAL, default severity 3. A discharge day management encounter carried no documented discharge-day time, so 99238 was applied. 99239 requires an explicitly documented time over 30 minutes. No action is required. If discharges at your facility routinely run longer, coach providers to document the discharge-day time.

## Claim integrity and configuration alerts

- **E/M Line Carries Wrong Type of Service** (`eandm_em_line_wrong_tos`). HARDSTOP, default severity 8. An office visit line (99202-99215) carries a type of service other than 1, Medical Care. Correct the type of service to 1 and report the chart to support.
- **Multiple Office E/M Lines on One Claim** (`eandm_multiple_em_lines`). HARDSTOP, default severity 8. More than one office visit line appears on one claim. This version levels exactly one visit per claim. Review for duplicate leveling or a multi-visit packet.
- **E/M Line Without Its Leveling Audit Trail** (`eandm_missing_leveling_artifact`). COMPLIANCE, default severity 8. The claim carries an office visit line but no leveling record. The record holds the evidence, the quotes, the paths, and the table year that justify the level. Re-level the visit, or document the manual leveling basis, before billing.
- **E/M Encounter Summary Issue Detected** (`eandm_encounter_summary_flagged`). HARDSTOP, default severity 5. The encounter summary step found an issue on this visit. Review the flagged issue against the chart.
- **E/M Diagnosis Validation Failed** (`eandm_icd_verdict_error`). COMPLIANCE, default severity 5. The claim-wide diagnosis validation step failed, so diagnosis codes ship as extracted without that extra check. Review diagnosis support in the documentation before submission.
- **Required Note Type Missing (E/M)** (`eandm_validation_required_note_missing`). COMPLIANCE, default severity 5. A note type that your facility requires is absent from the chart. Obtain the missing documentation, or correct the note classification. This list ships empty by default, so the alert fires only when a facility adds its own required types. Your facility configuration controls it through `claimValidation.requiredNoteTypes`. Contact your Hank representative to change it.
- **E/M Policy Election Configured But Not Yet Implemented** (`eandm_policy_election_not_implemented`). COMPLIANCE, default severity 7. Your facility configured a billing policy election whose behavior has not shipped yet. The autocoder did not apply the election and kept the safe default, so your billing expectation and the produced claim can differ. Bill manually where the election matters, or ask your Hank representative to remove the election until the feature ships.

## Alerts that apply to every specialty

E/M visits also receive the shared alerts. Patient and claim information alerts fire when demographics, insurance, or provider details are missing or do not match. Coding confidence alerts fire when a code or a modifier carries a low confidence score. They behave the same way on every specialty; ask your Hank representative for the full catalog of shared alerts.

## How these alerts reach you

What happens next depends on how your organization consumes HANK CODES. In HANK Claim Maker, a HARDSTOP alert places the claim in the review queue your administrators configured for it. Organizations that consume the coding API directly decide in their own workflow which alerts pause a claim, who reviews them, and when a claim is released.