Doctora generates diagnosis and procedure codes from your exam documentation, giving you a starting point for billing. This guide explains how coding works in Doctora and how to get the most accurate results.
How Doctora generates ICD-10 codes
After an encounter is recorded, Doctora's AI analyzes the transcript, exam findings, and clinical data to suggest ICD-10 diagnosis codes. The system works in two stages:
- AI analysis -- The AI reads the exam transcript and structured findings (visual acuities, refraction, slit lamp, fundus, etc.) and identifies diagnoses discussed or documented during the visit.
- Catalog resolution -- Each AI-identified diagnosis is matched against Doctora's curated optometry ICD-10 catalog. The catalog resolves the correct billable code based on axis values like laterality (OD, OS, OU), severity, stage, and other clinical specifics.
Refractive diagnoses (myopia, hyperopia, astigmatism, presbyopia) are handled separately using the refraction data, so these codes appear even if the doctor didn't explicitly discuss them during the exam.
The ICD-10 catalog
Doctora maintains a curated ICD-10 catalog built specifically for optometry. Rather than searching through the entire ICD-10 code set, the system uses diagnosis "families"--groups of related codes organized by condition. For example, the "primary open-angle glaucoma" family contains all laterality and severity variants.
Each family has defined axes (laterality, severity, stage, eyelid location, etc.) that the AI fills in based on the clinical documentation. The catalog then resolves these axis values to the precise billable code.
Reviewing suggested codes
After Doctora processes an encounter, the suggested ICD-10 codes appear in the encounter editor under the diagnosis section. Each code shows:
- The ICD-10 code and its description
- Associated care plan recommendations
- Axis details (which eye, severity, etc.) when applicable
If the AI could not determine all required axis values from the documentation--for example, laterality was not stated--the code will be flagged for your review.
CPT code modes
Doctora supports three CPT code systems for office visits. You can set your preferred mode in your practice settings:
- Eye care codes (920XX) -- The default. Uses ophthalmology-specific exam codes: 92002/92004 for new patients, 92012/92014 for established patients.
- E/M codes (99XXX) -- Evaluation and Management codes. Doctora determines the level using medical decision-making (MDM) complexity.
- S-codes (S0620/S0621) -- Used by some vision plans for routine exams.
Care plans and coding
Doctora links care plan recommendations to specific diagnosis codes. When the AI suggests an ICD-10 code, it also suggests relevant care plan items drawn from your practice's care plan library. These associations help demonstrate medical necessity.
Editing codes before sync
You always have full control over codes before they sync to your EHR:
- Add codes that the AI missed
- Remove codes that don't apply
- Change axis values (laterality, severity) if the AI got them wrong
- Reorder codes to set the primary diagnosis
Nothing syncs to your EHR until you review and approve.
Tips for billers
- Always review AI-suggested codes before syncing. The AI is accurate for common optometric diagnoses, but edge cases benefit from human review.
- Use custom instructions to improve accuracy. If your practice has specific coding patterns, add instructions in your settings.
- Check laterality carefully. If the doctor said "right eye" but the code shows OS, correct it before syncing.
- Review care plan associations. Payers increasingly look at care plans to support medical necessity.