Code from the note, not from the superbill

A superbill circled at the door is a useful hint. It is a poor legal record. If the circle says a level-four visit and the note documents a stable blood pressure and a refill, the claim is ahead of the record. If the payer asks for the note, you will be glad the coder read it first.

MedFlow’s coding screen starts from the note. It suggests ICD-10-CM and CPT codes and shows the sentence each one came from. The code list is the CMS ICD-10-CM file, and procedure pairs are checked against NCCI edits. A coder still has to agree. The suggestion is not the claim.

The failures we send back are boring and important. No side on a joint injection. No time on a psychotherapy visit. “Rule out pneumonia” coded as pneumonia. A problem listed in the history that was not addressed. Each of those is a question to the provider, not a creative code.

Primary care, urgent care and behavioral health notes are short enough to read. That is why this service stays inside those specialties. We are not offering surgical coding from an operative report we have not agreed to handle.

If you want the rules of thumb in one place, the glossary defines clean claim, NCCI, and the difference between a rejection and a denial.