CPT, ICD-10-CM and HCPCS codes that match your documentation, so claims get paid and hold up to review.
Codes matched to documentation
Our medical coding services turn provider documentation into the codes payers need: CPT for procedures, ICD-10-CM for diagnoses and HCPCS for supplies, drugs and some services. Accurate codes are the base of every clean claim.
Coding errors cut both ways. Codes that are too low leave money behind. Codes that are too high, or not supported by the note, create denials and compliance risk. We aim for codes that are complete and fully supported.
Coding works best as part of the full billing cycle, where coding feedback reaches providers and the front desk. It is also available as a service on its own.
Every claim uses more than one code set. Each one has its own owner and its own update schedule, so coding has to keep up all year.
When a new code set takes effect, we review your most-used codes first. That way claims filed after the change still match what payers expect.
Our healthcare coding services cover the coding tasks most practices need every day.
Office visits, procedures and services billed by physicians and other providers.
Visit levels chosen from documented medical decision making or total time.
Surgical, diagnostic and therapeutic procedures coded with the right modifiers.
ICD-10-CM codes coded to the specificity the documentation supports.
Charges reviewed before billing so nothing is missed or duplicated.
Patterns shared with providers as short, practical documentation tips.
A simple workflow inside your systems.
Documentation and charges are pulled from your EMR each day.
Codes and modifiers are assigned or checked against the note and payer rules.
Unclear documentation goes back to the provider with a specific question.
Clean, coded charges move straight into claim submission.
These errors cause many coding-related denials. Each one is checked before a claim goes out.
Unspecified diagnosis codes
Payers question medical necessity
Code to the specificity the note supports, or query the provider
Diagnosis does not support the procedure
Denied as not medically necessary
Check diagnosis and procedure pairing before billing
Missing or wrong modifier
Services bundled or denied
Apply modifiers such as 25, 59 and XS only when documentation supports them
E/M level too high or too low
Audit risk or lost revenue
Match the level to documented decision making or time
Unbundling
Denied or flagged for review
Apply National Correct Coding Initiative edits
Wrong units
Underpaid or denied drug and therapy claims
Check units against time, dosage and payer limits
Outsourced medical coding services give you coding coverage without hiring. They also keep work moving when an in-house coder is out, and they bring a second set of eyes to documentation.
One person, one schedule
A team keeps charges moving
Limited to the coder’s experience
Billers across 49+ specialties
Informal
Patterns shared as documentation tips
Separate handoff
Coded charges flow straight into claims
Coding pairs naturally with our medical billing audit, which checks coding accuracy across a sample of claims.
Clear notes mean faster, more accurate codes and fewer queries. A few habits make the biggest difference:
We turn the patterns we see into short, specific feedback for each provider, not generic training.
Many denials start with a coding problem: a diagnosis that does not support the procedure, a missing modifier or a code that does not match the note. In a Premier Inc. survey, nearly 15% of claims to private payers were denied at first, and contesting each denial cost an average of $43.84.
Accurate coding also protects you. Medicare and Medicaid overpayments must be reported and returned within 60 days after they are identified, so coding problems are best caught early.
Source: Premier Inc.. This page is general information, not legal advice.
Evaluation and management visits are the most common codes for many practices, and the rules changed in recent years.
Since 2021, office and outpatient visit levels are chosen by medical decision making or by total provider time on the date of the visit. History and exam no longer set the level. In 2023, the same approach was extended to other settings, such as hospital, nursing facility and home visits.
We check that each note supports the level billed, either through decision making or through documented time. When a note supports a higher or lower level, we tell the provider so future notes improve.
Source: American Medical Association, CPT Evaluation and Management.
Getting started
Five simple steps from the first call to clean monthly reports.
1
Tell us about your practice, payers and how coding review runs today. We reply within one business day.
2
We look at your open A/R, denial patterns and payer mix, and show where revenue is slipping.
3
We work inside your EMR, practice management software and clearinghouse. No software switch.
4
Our team takes over coding review on an agreed start date, with one point of contact for your staff.
5
Weekly or monthly reports show what was filed, paid and still open, and what we fixed.
Yes. We select E/M levels based on documented medical decision making or total time, following current guidelines.
Yes. Coding is available on its own, or as part of full revenue cycle management.
Our billers work across 49+ specialties, from primary care to surgery.
Yes. We work in multiple billing software and with any clearinghouse.
Our Austin team supports practices across Texas and in all 50 states.
Yes. When a note is unclear or missing a detail the code depends on, we send the provider a short query. We never guess or code beyond the documentation. Queries are written so the answer is quick, and repeated questions become feedback that helps future notes.
We track the yearly CPT and ICD-10-CM updates and the HCPCS changes CMS releases during the year. Before each change takes effect, we review the codes your practice uses most and update your charge setup, so new claims match the current code sets.
Yes. We code for 49+ specialties and match each provider with coders who know that specialty’s codes and payer rules. Multi-specialty groups get one team, one process and one report, with results shown by provider and by specialty.
Tell us about your practice. A billing specialist will get back to you within one business day.
5900 Balcones Drive STE 100, Austin, TX 78731
Open 24 hours, 7 days a week
Tell us about your specialty and volume. The consultation is free, and we reply within one business day.
