Medical coding services
Medical coding is turning what a provider documented about a visit into the standard codes payers read: CPT and HCPCS codes for what was done, and ICD-10 codes for why.
One claim line, taken apart
ExampleEvery line pairs what was done with why. Tap a part.
The payer checks that the diagnosis supports the procedure.
CPT 99214: an established patient’s office visit
What the provider did. CPT codes are published by the AMA, and a visit level higher or lower than the documentation shows can be denied, or taken back after an audit.
Procedure codes or diagnosis codes? A claim needs both to agree.
Every line on a claim pairs what was done with why it was done, and the payer checks that the two support each other.
CPT and HCPCS
What the provider did: the visit, procedure, test or supply. CPT codes are published by the AMA; HCPCS Level II codes cover supplies, equipment and services CPT doesn’t.
ICD-10-CM
Why it was done: the patient’s diagnoses and symptoms, coded to the detail the documentation supports. If the diagnosis doesn’t justify the procedure, the payer can deny the line.
Where does coding go wrong?
Codes the notes don’t support
A visit level or procedure code higher or lower than the documentation shows, which a payer can deny or an audit can take back.
Missing or wrong modifiers
A modifier left off, or used where the payer doesn’t accept it, so a correct service is denied or paid wrongly.
Diagnoses that don’t justify the service
ICD-10 codes too vague for the payer, or that don’t show the medical necessity of the procedure billed.
Code sets that change every year
CPT changes each January and ICD-10-CM each October, and a code that was right last year can be deleted or replaced.
Bundling edits
Two services billed together that the payer’s edits treat as one, so one of them is denied.
How the medical coding process works
Read the documentation
We code from the provider’s note for the visit: what was done, why, and what the record supports.
Assign the codes
CPT or HCPCS codes for each service, ICD-10-CM codes for each diagnosis, and the modifiers the services need.
Check them against payer rules
Each claim is checked for bundling edits, modifier rules and medical necessity before it is submitted.
Ask when the notes are unclear
Where the documentation doesn’t support a code, we ask the provider rather than guess.
Feed back what we see
Patterns, such as a note that keeps missing something a code needs, go back to your providers, so later visits are documented to support their codes.
Related billing services
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Medical coding questions
What does a medical coder do?
What is the difference between medical coding and medical billing?
How do you keep up with code changes?
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