Medical coding
Medical Coding Services
Our medical coding services assign ICD-10-CM, CPT and HCPCS codes from what the provider actually documented. Paired with our billing, that gives you medical billing and coding services from one team, and claims that hold up when a payer asks questions.
Coding support
- ICD-10-CM diagnosis coding
- CPT and HCPCS Level II procedure coding
- E/M level review
- Modifier review
- NCCI edit checks
- Documentation feedback
The problem
How coding errors cost practices
Coding sits between the clinical record and the claim. Small errors here become denials, underpayments or compliance exposure.
How we handle it
How we approach coding
We code from the documentation and check the result against payer and CMS rules. When a note is unclear, we flag it for clarification instead of guessing.
- Diagnosis coding to the highest supported specificity
- Procedure coding with CPT and HCPCS Level II
- E/M leveling based on medical decision making or time
- Modifier review (for example 25, 59 and X{EPSU}, 26/TC)
- NCCI procedure-to-procedure edit checks
- Medical necessity and diagnosis linkage review
- Provider queries when documentation is unclear
- Coding feedback and trend reporting
Process
Our coding workflow
Review
We read the encounter documentation and any orders or results that support it.
Code
Diagnoses, procedures and modifiers are assigned based on what is documented.
Check
Codes are validated against NCCI edits and payer-specific rules.
Clarify
Unclear documentation goes back to the provider as a specific query.
Why it matters
Why accurate coding matters
FAQ
Medical Coding Services: common questions
Which code sets do you work with?
ICD-10-CM for diagnoses, CPT for most professional procedures and services, and HCPCS Level II for supplies, drugs and certain services. We also apply the modifiers each payer requires.
How are E/M levels determined?
For office and outpatient visits, the E/M level is selected based on either medical decision making or total time on the date of the encounter, under the AMA guidelines that took effect in 2021. Similar rules were extended to most other E/M settings in 2023.
Can you review our existing coding?
Ask us about a coding review during your revenue cycle review. A coding review typically looks at a sample of encounters, compares documentation with the codes billed, and summarizes patterns and training opportunities.
How do you keep medical billing compliant?
Mostly by coding only what the notes support. We check claims against NCCI edits and payer policies, use modifiers only when the documentation backs them up, and flag notes that need more detail instead of guessing. When a provider asks for a higher code than the record supports, we say so.
Related services
Services that work alongside medical coding
Let’s take a closer look at your revenue cycle
Tell us what’s getting stuck. Denials, old A/R, credentialing, reports nobody reads? We’ll look at how you work now and tell you straight what we’d change, and why.