The coding worksheet

The coding worksheet is where you choose diagnosis codes for a visit and record the evidence for each one. Every code on the worksheet carries the sentence from the note that supports it.

Open the worksheet

1. Save the note. The worksheet always works from the saved record, not unsaved edits.
2. Open Visit workflow → Coding worksheet.

Confirm the date of service

The date starts as the scheduled date of the visit. Check it and change it if the visit happened on a different day. Terra looks codes up in the official ICD-10-CM release that applies to that date, so a code added or retired on October 1 is handled correctly.

Changing the date clears unsaved selections so they can be looked up again against the right release.

Add a code

1. Search by description or code. Common abbreviations work, for example HTN, T2DM, COPD, CHF, GERD, CKD, LBP or afib.
2. Select the code.
3. Copy the exact supporting excerpt from the saved note shown beside the worksheet and paste it into the code's evidence field. The excerpt must appear word for word in the record.
4. Save the draft with a short reason if you are changing an earlier draft.

A worksheet holds up to 30 codes. Category headers (codes that are not valid for submission) can sit in a draft while you work, but must be replaced with a billable code before approval.

What the excerpt check means

Terra checks that the excerpt appears in the saved record. That is a mechanical check: it does not decide whether the text clinically supports the code. You remain responsible for specificity, sequencing and the official coding guidelines, which the local code list does not include.

Let Terra suggest codes

If your practice has an AI provider connected, Suggest codes proposes candidates with their excerpts. See Code suggestions.