Medical coding
Medical coding translates clinical documentation into the ICD-10-CM, CPT, and HCPCS Level II codes that a claim is built from.
Follows prior authorization. Feeds into charge entry.
Where practices lose money here
Under-coding and over-coding both cost money
Under-coding leaves legitimate revenue uncollected. Over-coding creates compliance exposure and eventual clawbacks. Both come from the same root cause: coding that does not match documentation.
Modifier errors trigger denials or edits
Missing or incorrect modifiers, especially around bundled procedures, are one of the most common reasons a technically correct code set still gets denied or edited down.
How we handle it
Assign ICD-10-CM, CPT, and HCPCS Level II codes using certified coders with specialty-specific experience, not general coders working outside their depth.
Apply modifiers accurately, including the pairs that trigger the most scrutiny, and check against National Correct Coding Initiative edits before submission.
Support E/M level selection under the 2021 guidelines using time or medical decision making, whichever the documentation actually supports.
Query providers directly when documentation does not support the level or code being considered, rather than guessing or defaulting low.
Apply specialty-specific code sets correctly, since the same visit type can code differently across specialties.
Run periodic internal coding audits to catch drift before a payer audit does.
What you receive
Concrete output for this step, delivered on a set schedule rather than on request.
- Coded encounters ready for charge entry within the standard turnaround.
- A provider query log showing what was asked and how it was resolved.
- A monthly coding accuracy summary.
Where this sits in the cycle
Coding sits between charge capture and charge entry. Every downstream step, submission, payment, denial handling, inherits whatever accuracy problems exist here.
Questions about this step
Are your coders certified?
Coding is handled by coders holding current professional coding certification, assigned by specialty where volume supports it. We will confirm the specific credentials covering your account before you engage.
What happens when documentation does not support a code?
We send a query back to the provider rather than coding around the gap. This protects the practice from both under-billing and audit risk.
Do you code same-day or is there a lag?
Standard turnaround is within 24 to 48 hours of the encounter being available for coding.
Want us to review how this is handled in your practice right now?
The free billing audit looks at medical coding alongside the rest of the cycle, and comes back with specific findings.