Medical Coding
Coding from your documentation, with a query back to you whenever the note does not support the code.
What Is Included
Chart Review
Every encounter coded from the note, not from the schedule or a superbill shortcut.ICD-10 and CPT Assignment
Diagnosis and procedure codes assigned to the level the documentation supports.Provider Queries
Where the note does not support the code, the query comes back to you before the claim goes out.Modifier Accuracy
Modifiers applied where the payer requires them and left off where they invite a denial.Coding Audits
A sample of coded charts reviewed against the documentation on an agreed rhythm.CPC Oversight
Coding overseen by an AAPC Certified Professional Coder.
How It Works
1. Documentation In
We work from the notes already in your system. No separate upload and no parallel record.
2. Coding
Charts coded from the signed note.
3. Query Where Needed
Anything the note does not support comes back to you as a query rather than a guess.
4. Release to Billing
Coded charts move to charge entry with a record of who coded what.
Medical Coding in Detail
Coding turns the note into codes, and the payer decides the claim on those codes alone.
The schedule says what was booked. The superbill says what the provider checked. Neither is the record of what happened during the encounter. The signed note is, and it is the only document that will be produced if a payer or a Recovery Audit Contractor asks the practice to justify a code after payment.
Coding from the note means reading the history, the examination and the medical decision making that the provider actually recorded, and assigning the evaluation and management level, the diagnoses and any procedures to the level that text supports. A checkbox that says "level four visit" is not evidence of a level four visit. A diagnosis carried forward from the problem list without being addressed is not a diagnosis for that encounter.
Working this way also surfaces the charges a superbill misses: a procedure documented in the body of the note but never checked, a second diagnosis that changes the specificity of the primary code, a supply or injection with its own HCPCS line.
The schedule says what was booked. The superbill says what the provider checked. Neither is the record of what happened during the encounter. The signed note is, and it is the only document that will be produced if a payer or a Recovery Audit Contractor asks the practice to justify a code after payment.
Coding from the note means reading the history, the examination and the medical decision making that the provider actually recorded, and assigning the evaluation and management level, the diagnoses and any procedures to the level that text supports. A checkbox that says "level four visit" is not evidence of a level four visit. A diagnosis carried forward from the problem list without being addressed is not a diagnosis for that encounter.
Working this way also surfaces the charges a superbill misses: a procedure documented in the body of the note but never checked, a second diagnosis that changes the specificity of the primary code, a supply or injection with its own HCPCS line.
A coder is not permitted to infer a diagnosis the provider did not write, and is not permitted to choose a code because it pays better or because it is what the practice usually bills. When the documentation is ambiguous, incomplete or contradicts itself, the correct response is a query back to the provider rather than a guess in either direction.
A compliant query is neutral in its wording. It sets out what the note says, what is unclear, and asks the provider to clarify or to confirm that the record is complete as written. It does not suggest the answer. The provider's response becomes an addendum to the record, signed and dated, and the code is assigned from the amended note.
Queries have a cost in provider time, so they are sent in agreed batches and tracked by type. A query that recurs every month on the same point is a documentation template problem, and fixing the template removes the query. The recurring list goes back to the practice for that reason.
Over-coding is the risk practices hear about: billing a level the record cannot support, unbundling a procedure the payer treats as a single service, or applying modifier 25 to a visit that was not significant and separately identifiable. The consequence is a denial, a post-payment recoupment or, in a pattern, an audit.
Under-coding is quieter and just as common. A provider who habitually bills a lower level than the documentation supports, or leaves off a secondary diagnosis that affects risk adjustment, is giving revenue away on every visit and misrepresenting the complexity of the panel. Because nothing comes back denied, nobody notices.
Coding audits are how both directions are caught. A sample of coded charts is re-read against the documentation on an agreed rhythm, and the variance is reported by coder, by provider and by code. The point is not to catch anyone out. It is to show where the coding and the documentation are drifting apart so both can be corrected before a payer does it for you.
Signed notes. A note that is not signed cannot be coded, and an unsigned note that is later amended is a compliance problem in its own right. The practice agrees on a documentation cadence and we work from it.
A named person who receives queries and can either answer them or route them to the right provider. Queries that sit unanswered hold the charge, and the charge holds the claim.
Read access to the EHR, provisioned by the practice, scoped to the coders working your charts, and revocable at any time. We do not take copies of the record and we do not maintain a parallel one.
Finally, an agreed audit sample and rhythm, and a decision on who receives the audit report. That is set in the written scope before coding starts and changed only in writing.
Where This Sits in the Cycle
- Eligibility and Benefits Verification
- Prior Authorization
- Medical Coding
- Medical Billing
- Denial Management
- AR Follow-Up and Recovery
After AR Follow-Up and Recovery, the cycle returns to Eligibility and Benefits Verification.
Related Services
Medical Billing
Charge entry, scrubbing, submission, payment posting and patient statements.Learn MoreDenial Management
Denials worked by reason code, corrected, appealed and tracked.Learn MorePrior Authorization
Requests, payer follow‑up and appeals on denied auths.Learn MoreAR Follow-Up and Recovery
Aged AR worked by bucket and payer, with recovery reported back to you.Learn More
Coding From the Note
Tell us your specialty, providers and coding volume. We will come back with a written scope for coding.
- CPT
- HCPCS
- ICD-10-CM
- Modifiers
- Provider Queries