Coded from the documentation, not from habit
Coding decides what a claim is worth and whether it survives scrutiny. Under-coding gives away revenue quietly; over-coding creates exposure that surfaces years later. Both usually come from coding by pattern rather than from the record in front of you.
Who this is for
Is this you?
- Practices where providers assign their own codes and nobody reviews them against the documentation
- Emergency and urgent care groups where E/M levels and critical care time drive a large share of revenue
- Groups that have received payer scrutiny on coding patterns and want a defensible process
- Practices adding a service line or specialty their current coding process does not cover well
The problem
What this is actually solving
Under-coding is invisible
A claim coded a level below what the documentation supports pays, posts and closes. Nothing flags it, nobody appeals it, and it recurs on every similar encounter. It is the most common coding loss precisely because it produces no symptom anyone notices.
Over-coding surfaces late and expensively
Coding above what the record supports also pays, until a payer reviews a pattern and requests records. The exposure is retrospective and covers a period, not a claim, which is why coding needs to be defensible at the time rather than merely accepted.
Documentation and code drift apart
Codes assigned from a superbill habit or a favourite template stop tracking what is actually being documented. Nobody notices until either revenue drops or a payer asks, because the feedback loop between record and code has been broken for a long time.
Scope
What's included
- CPT procedure coding from clinical documentation
- ICD-10-CM diagnosis coding to the level of specificity the record supports
- HCPCS Level II coding where applicable
- Evaluation and management level review against documentation
- Modifier assignment appropriate to the setting and payer
- Critical care time and procedure coding for emergency encounters
- Documentation queries back to providers where the record will not support a code
- Coding pattern reporting so drift becomes visible before it becomes a problem
Scope & engagement model
Where this service ends and another begins. Stating it plainly keeps engagements clean and means every positive claim on this page is one you can hold us to.
- Clinical documentation improvement programmes, which require clinician-side training we do not deliver
- Formal coding audit defence or representation in a payer review
How we do it
The process
Specific to this service, not a generic four-step onboarding diagram reused across every page.
- Step 01
Baseline the current pattern
We review a sample of recent coded encounters against their documentation to establish where the current pattern sits, both under-coding and over-coding, before we change anything.
- Step 02
Code from the record
Encounters are coded from the clinical documentation rather than from a superbill or prior-encounter pattern, at the specificity the record supports and no further.
- Step 03
Query rather than assume
Where documentation will not support a code, the question goes back to the provider instead of being resolved by inference in either direction. This is slower and it is what makes the result defensible.
- Step 04
Report the pattern
Coding distribution is reported so shifts are visible early. Both a drift downward that costs revenue and a drift upward that creates exposure, rather than discovered when a payer raises it.
Outcomes
What changes for your practice
- Codes reflect what the documentation supports, in both directions
- E/M levels are reviewed rather than assumed, which matters most in high-acuity settings
- Documentation gaps are surfaced as queries instead of being resolved by guesswork
- Coding patterns are visible over time, so drift is caught before a payer catches it
FAQ
Questions we get asked
Who does the coding?
CPC-certified coding is part of what HMT provides. Certified Professional Coder is the AAPC credential, and AAPC maintains a public verification directory if you would like to check it. Which coder is assigned to your account is confirmed at onboarding.
Can you review our existing coding rather than replacing it?
Yes, and it is a sensible first step. A review of recent encounters against documentation establishes where your current pattern sits and whether the problem is under-coding, over-coding, or neither. That answer determines whether full coding is worth engaging at all.
What if the documentation does not support the code?
We query the provider. We do not code above the record because it pays better, and we do not silently code below it because that is safer. Both are failures, and the query is the only route that produces a defensible claim. It costs time and it is worth it.
Compliance
- HIPAA-compliant processes across every engagement
- Our team has completed HIPAA training
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Start with a free billing audit
We review a sample of your recent claims and your current A/R aging, and report where revenue is being lost. The report is yours whether or not you engage us.