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The Services section of a visit note captures the billable work you performed. It is built around the four things a payer actually requires — so there are fewer fields to fill in and fewer ways for a claim to come back.
  • CPT / HCPCS code — the specific service you performed.
  • ICD-10 diagnosis — the medical necessity behind it.
  • Units — how much of the service was delivered.
  • Modifiers — optional context for special billing circumstances, like laterality.
Services also works with the Air Scribe, which can populate the section straight from your visit conversation instead of you typing it in. Services section with services grouped under Evaluation & Management and Radiology
Services replaces the older Treatments section of the visit note at enabled sites.

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What counts as a service

Think of a service as a single billing line item. Every service you add is the same simple building block: A service = CPT code + modifiers + ICD-10 code(s) + units Everything else is optional context.

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Adding a service

Open a visit note and scroll to the Services section. Before you add anything, the section reads No Services. Three controls sit in the section header: Clear All, Apply All ICD To All Services, and + Add Services. Empty Services section showing No Services with the Clear All, Apply All ICD To All Services, and Add Services controls To add a service:
  1. Click + Add Services to open the service picker. Service picker open with a search field and a checkbox list of services
  2. Search for what you did. Type the CPT code directly (e.g., 73560), or free-text the name from your site’s list (e.g., “X-ray exam of knee”) — the name resolves to the right CPT code for you.
  3. Check every service you want to add. The picker is multi-select, and the confirm button counts your selection — Add 2 Services, for example. Click it to add them all at once. Two services checked in the picker with the Add 2 Services button active
  4. Review the details. Diagnosis codes are auto-applied from the Diagnosis Codes section above, and units default to 1. Adjust the Mod, ICD-10, and Units fields on any row as needed. Services rows auto-populated with the diagnosis code from the Diagnosis Codes section above
✨Smart Tip: Enter your diagnosis codes in the Diagnosis Codes section before you add services. Every service you add then arrives with the right ICD-10 codes already attached, and you rarely have to touch the ICD-10 column at all.
Services auto-saves. Refresh the page or come back later and your services, units, modifiers, ICD-10 links, and category grouping all reload exactly as you left them.

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Editing and removing services

  • Edit any service inline — change the units, swap the CPT code, or adjust the linked diagnoses directly on the row.
  • Add a comment with the comment icon at the end of a row to open the optional Comments flyout.
  • Delete a single service with the trash icon at the end of its row.
  • Clear All removes every service at once when you want to start fresh.
You cannot add the same CPT code twice unless the second instance carries a different modifier. This is deliberate — it prevents accidental double-billing.

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Automatic categories

You never have to categorize a service manually. Services reads the CPT code and files it under the right billing section for you, so your entries organize themselves into labeled groups as you add them. Because codes are mapped by range, new CPT codes released each year automatically slot into the correct group.

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Linking diagnoses (ICD-10)

Every service needs at least one diagnosis to justify it. Services pulls from the diagnoses already on your chart note, so you can attach them quickly.

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Apply All ICD To All Services

This is the headline shortcut. One click links every diagnosis on the note to every service, in chart-note order — instead of linking the same codes over and over, line by line.

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Per-service control

  • Fine-tune diagnoses on any individual service using the ICD-10 dropdowns on its row. Use the – control to remove a diagnosis from that service.
  • You can only attach ICD-10 codes that are already on the chart note. Codes that aren’t on the note are rejected, which keeps claims clean.
  • Most specialties link two to three diagnoses per service. The system supports more when you need them.
The CMS claim form allows up to 12 diagnoses per appointment and 4 diagnosis pointers per service line. Staying inside those limits ensures nothing gets dropped downstream.

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Modifiers

Modifiers tell the payer about special circumstances — which side of the body, whether a service was distinct, whether an E&M was separately identifiable. They are optional, and the Mod dropdown on each service row is where you set them. Note: A CPT code can appear more than once on the same note as long as each instance carries a different modifier.

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Air Scribe auto-fill

Services was built to work hand-in-hand with the Air Scribe. Instead of typing services in yourself, the scribe can populate them from your visit conversation. How it works:
  • The scribe listens to the encounter and infers the likely CPT code, ICD-10 code(s), units, and modifiers.
  • Open the Scribe panel and choose Apply to accept everything, or apply individual services and ICD-10 codes one at a time.
  • Already-added services are de-duplicated automatically — matched on CPT plus modifier — so applying the scribe won’t create doubles.
  • The scribe shows a short justification for why a code was or wasn’t suggested, which makes for a quick sanity check.
✨Smart Tip: Say the service or CPT code out loud during the visit. Spoken services are captured far more accurately, and modifiers in particular perform best when you state them explicitly.
You are always the final reviewer. Scribe-suggested services are a starting point, not the last word. Review them, tweak diagnoses, adjust units, and confirm what belongs on the claim — the provider remains responsible for the signed note.

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FAQ

No. The billing pipeline downstream is unchanged — Services feeds it through the same path. You are simply entering the data through a cleaner front door.
They were removed, because none of them are required for billing.
  • Medical necessity is established by the visit note itself and the ICD-10 link.
  • The rendering provider comes from the encounter.
If you need to add context to a specific service, use the optional Comments flyout on that row.
Yes. A Comments flyout is available on every service row. It’s optional and tucked away so it doesn’t clutter the section.
It lands under Other. Genuine billing codes are mapped by code range, so anything outside the standard ranges — including HCPCS Level II codes — is grouped there rather than being left uncategorized.
Yes. Orders configured with a CPT code, and orders configured in Smart Charge Capture, flow into the Services section automatically — so there’s no duplicate entry.