Overview
Heidi automatically suggests clinical codes for your patient encounters, supporting both SNOMED-CT and ICD-10-CM code sets. These suggestions are designed to help you document more efficiently, ensure proper reimbursement, and maintain accurate medical records. Always review suggested codes for accuracy in the context of each patient.
Heidi's suggested codes appear alongside your documented findings, diagnoses, and plans. You have full control over which codes are confirmed and included in your final note.
The coding feature is available exclusively to users on paid plans and represents one of the premium benefits of Heidi's tier offerings.
How codes are generated
Start by completing an encounter as you normally would.
After Heidi processes your text, it automatically generates related codes in the background. You'll see a progress indicator (e.g., "Generating codes").
Once code generation finishes, the total count of suggested codes displays. Click it to open the Review codes sidebar.
Viewing codes
In the Review codes sidebar:
Each code appears as a card, listing its description, ID, and code set type (SNOMED-CT or ICD-10-CM).
Codes are sorted by relevance (High relevance, Medium relevance, or Low relevance).
Billable codes are marked with a dollar sign ($) indicator.
Clicking the code's info icon shows more detailed information about the code.
Clicking the waveform icon reveals the exact part of your note that triggered the suggestion, showing you the supporting evidence.
Confirming codes
Confirm individual codes by checking the box on each relevant code card.
As you confirm codes, the indicator changes color from red to orange to green to reflect your progress:
Red: No codes have been confirmed
Orange: Some codes are confirmed
Green: All codes are confirmed
Use "Confirm all" if all codes in a relevance category apply.
Confirmed codes are embedded within your note with visual distinction and labeled by their code set. You can click them in your note if you need to revisit details or make changes.
Code specification & evidence
To learn more about a suggested code:
Select the info icon to see detailed information about the code, including its full definition and classification.
Select the waveform icon to see exactly where in your encounter notes Heidi identified the code's keywords or concepts. This helps you verify the evidence supporting each code suggestion.
Replacing & adding codes
If a suggested code isn't suitable, hover over it, click Replace, then use the search bar to find a better option. You can search within either SNOMED-CT or ICD-10-CM code sets, depending on your needs.
Add a new code if one you need isn't on the list. Choose Add new code, search for what you need, and apply it to your note.
You can view any code's specification before confirming it to ensure it accurately reflects the patient's condition.
Removing a code
If a suggested code isn't relevant, hover over it and select Unlink.
Removing a code only affects the coding list; your original note text remains unchanged. This gives you complete control over which codes are associated with your documentation.
Managing coding preferences
You can customize your coding experience in the Settings menu:
Enable or disable the entire coding feature
Choose which code sets you want to use (SNOMED-CT, ICD-10-CM, or both)
Set regional preferences for code generation
These settings allow you to tailor the coding experience to your specific practice needs and regional requirements.
Regional code set support
Currently, SNOMED-CT is particularly suited for UK clinicians, while ICD-10-CM is optimized for US healthcare providers. We are actively expanding to include regional variants of these code sets. Once our phased rollout is complete, all users will have the flexibility to use any code set regardless of region. If you find ICD-10-CM useful in a non-US setting or SNOMED-CT valuable outside the UK, you'll have the freedom to configure Heidi according to your specific practice requirements.
Expanding code set support
Heidi is actively expanding its code set support beyond SNOMED-CT and ICD-10-CM. We are methodically adding new code sets to support various specialties, regions, and billing requirements. This expansion will continue to enhance Heidi's coding capabilities, making it more valuable for diverse medical practices around the world. You may suggest desired code systems on the Roadmap in your sidebar.
Feedback and support
If you have questions or feedback about the coding feature, reach out to the Heidi team, we'd love to hear from you!
You can provide coding-specific feedback by clicking the "Provide feedback" link in the coding section. Your insights help us continuously improve the accuracy and relevance of code suggestions.