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Medical Coding Services

Coding decides what a claim says happened, and payers pay, deny or audit based on it. We assign CPT, HCPCS Level II and ICD-10-CM codes from the provider's documentation, check modifiers and edits, and query providers when the note does not support a code.

  • Experienced coders who work from current code sets and payer rules
  • Office E/M leveled by medical decision making or total time
  • Modifier, NCCI and MUE review before every claim is released
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Coding work we take on

  • Evaluation and management (E/M)

    Office and outpatient visits (99202 to 99215) leveled by medical decision making or by total time on the date of the encounter.

  • Procedure coding

    CPT codes for office and surgical procedures, with attention to global periods and what each code already includes.

  • ICD-10-CM diagnosis coding

    Diagnoses coded to the specificity the documentation supports, including laterality and sequencing, because unspecified codes often fail payer medical necessity rules.

  • HCPCS Level II

    Drugs, supplies and services that CPT does not describe, with drug units calculated from the dose given and the amount in the code descriptor.

  • Modifier review

    Modifiers such as 25, 59, XE, XS, XP, XU, LT, RT, 50 and 76 checked against the documentation and each payer's rules.

  • NCCI and MUE checks

    Procedure-to-procedure edits and medically unlikely edits (the maximum units most providers would report per day) checked before submission.

  • Coding audits and provider feedback

    Periodic samples of coded encounters reviewed against documentation, with findings shared as education, not blame. Audits are typically run quarterly, with a sample of each provider's encounters.

Official sources: CGS: office and outpatient E/M fact sheet (external site), CMS: NCCI medically unlikely edits (external site), CMS: NCCI procedure-to-procedure edits (external site), CMS: ICD-10 codes (external site), CMS: HCPCS (external site)

From note to code

  1. Step 1: Read the documentation

    Coders work from the signed note in your EHR, not from a superbill alone, so the codes reflect what was actually documented.

  2. Step 2: Assign and sequence codes

    Procedures, diagnoses and modifiers are assigned and linked, with the diagnosis that supports each service pointed to it.

  3. Step 3: Run the edits

    Code pairs and units are checked against NCCI and MUE tables and payer-specific policies before the charge is released.

  4. Step 4: Query when unclear

    If the note is ambiguous, the provider gets a short, non-leading query asking for clarification, never a suggested code.

  5. Step 5: Close the loop

    Recurring query topics and coding-related denials feed back into provider education and documentation templates.

Practices that benefit most

  • No certified coder on staff

    Providers or billers are choosing codes themselves, without time to keep up with guideline changes.

  • Procedure-heavy specialties

    Global periods, bundling and modifiers drive most of the risk in surgical and interventional billing.

  • Practices facing payer audits

    A documented coding process and audit trail matter when a payer or contractor requests records.

  • Groups with uneven E/M patterns

    When providers in the same specialty code very differently, an outside review shows whether documentation or habit is the cause.

Office E/M levels at a glance

For office and outpatient visits, the level can be chosen by medical decision making (MDM) or by total time spent on the date of the visit.

Office and outpatient E/M codes by level of medical decision making and total time
Level of MDMNew patient codeNew patient timeEstablished patient codeEstablished patient time
Straightforward9920215 minutes9921210 minutes
Low9920330 minutes9921320 minutes
Moderate9920445 minutes9921430 minutes
High9920560 minutes9921540 minutes

Times are the minimum total time that must be met or exceeded on the date of service. 99211 is not leveled by MDM or time. Check the current CPT code set and payer policy before applying.

Frequently asked questions

Do medical coders have to be certified?

Credentials such as the AAPC's CPC or AHIMA's CCS show a coder has passed a standardized exam and keeps up with continuing education. Ask any billing company which credentials its coders hold; we share our team's background during onboarding.

When do code sets change?

ICD-10-CM updates take effect on October 1 each year, the AMA updates CPT annually, and CMS reviews HCPCS Level II code applications on a quarterly cycle for drugs and biologicals and a twice-yearly cycle for other items. Claims must use the codes valid on the date of service, so updates have to be loaded on time.

What happens when the documentation does not support the code the provider picked?

The coder sends the provider a query asking for clarification. The provider can amend the note if appropriate; otherwise the code is assigned from what is documented, which may be higher or lower than the original choice.

Can outsourced coding lead to upcoding?

It should not. Codes are assigned from the documentation only, and the same rule applies in both directions: no inflated levels, and no defensive under-coding that leaves legitimate revenue unbilled.

Do you code directly in our EHR?

Coders work inside your EHR or practice management system with role-based access. We confirm access to your system during onboarding.

Related services and specialties

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Find out what your coding is costing you

A free audit includes a look at your E/M level distribution, modifier use and the codes that are denied most often.

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