Medical Coding & Billing

Select appropriate ICD-10 codes for [encounter]:

Encounter: [visit type]
Diagnoses documented: [list conditions]
Provider documentation: [key clinical details]
Chronic vs acute: [status]
Complications: [if any]
External causes: [if trauma]

ICD-10 coding:
- Primary diagnosis (reason for encounter)
- Secondary diagnoses (comorbidities addressed)
- Specificity requirements met:
  - Laterality (right, left, bilateral)
  - Episode of care (initial, subsequent, sequela)
  - Severity/stage if applicable
  - With/without complications
- Combination codes identified
- Manifestation codes paired properly
- External cause codes (if injury)
- Place of occurrence
- Activity code
- Status code (if applicable)
- Excludes notes reviewed
- Code first/use additional code rules followed
- Query opportunities identified if documentation lacks specificity
- Rationale for code selection
- Compliance with coding guidelines (ICD-10-CM official guidelines)

Assign CPT codes for [procedure/service]:

Procedure: [what was done]
Approach: [open, laparoscopic, percutaneous]
Documentation: [operative/procedure note details]
Anesthesia: [type used]
Complications: [if any]
Additional services: [anything else done]

Procedure coding:
- Primary procedure code
- Approach modifiers if applicable (-22, -51, -52, -53, -59, -76, -77, -78, -79)
- Bilateral modifier (-50) if applicable
- Multiple procedure rules
- Bundling edits (NCCI)
- Separate procedure designation
- Unlisted code if no specific code
- Anesthesia code if separately billable
- Imaging guidance codes
- Supply codes (HCPCS)
- Assistant surgeon (-80, -81, -82)
- Professional vs technical component (-26, -TC)
- Documentation supports code selected
- Medical necessity established
- Modifiers correctly applied
- Compliance with CPT guidelines

Determine E/M level for [encounter]:

Encounter type: [office visit, hospital, consultation, ED]
Patient: [new vs established]
Documentation: [key elements]
Time: [if time-based]
MDM complexity: [problem, data, risk]

E/M level determination (2021/2023 guidelines):
- Visit type code range
- New vs established patient
- Selection method:
  - Medical Decision Making (MDM) OR
  - Total time on date of encounter
- If MDM approach:
  - Number/complexity of problems addressed
    - Minimal (99202/99212)
    - Low (99203/99213)
    - Moderate (99204/99214)
    - High (99205/99215)
  - Amount/complexity of data reviewed
  - Risk of complications, morbidity, mortality
  - Two of three elements determine MDM level
- If time approach:
  - Total time documented (including non-face-to-face on date)
  - Time ranges per level
  - Prolonged service codes if applicable
- Place of service code
- Modifier needs (-25 if with procedure)
- Medical necessity documented
- Supports level selected
- Compliance with CMS guidelines

Conduct coding audit for [provider/practice]:

Audit scope: [charts to review]
Provider specialty: [specialty]
Audit focus: [E/M, procedures, specific codes]
Sample size: [number of charts]
Time period: [dates]

Coding audit:
- Sampling methodology
- Documentation review for each case:
  - Code assignment accuracy
  - Specificity of diagnosis codes
  - Procedure code appropriateness
  - Modifier usage
  - Medical necessity support
  - Compliance with guidelines
- Error identification:
  - Upcoding
  - Downcoding
  - Unbundling
  - Missing documentation
  - Incorrect modifiers
- Error rate calculation (by code type)
- Financial impact assessment
- Root cause analysis
- Provider education needs identified
- Corrective action plan
- Re-audit timeline
- Compliance risk level
- Reporting to stakeholders

Establish medical necessity for [service]:

Service: [procedure or treatment]
Diagnosis: [indication]
Payer: [insurance]
LCD/NCD: [coverage determination]
Alternatives: [less invasive tried]

Medical necessity documentation:
- Diagnosis linking to service (ICD-10 codes)
- Signs and symptoms documented
- Clinical findings supporting need
- Conservative treatment failed (if required)
- Frequency and duration justified
- Alternative treatments considered/tried
- Payer-specific requirements:
  - LCD (Local Coverage Determination)
  - NCD (National Coverage Determination)
  - Prior authorization obtained
- Evidence-based guidelines support
- Anticipated outcome
- Risk vs benefit discussion
- Patient-specific factors
- Query provider if documentation insufficient
- ABN (Advance Beneficiary Notice) if may not be covered
- Appeal documentation if denial anticipated

Determine appropriate modifiers for [scenario]:

Service: [procedure/visit]
Circumstances: [what makes this different]
Payer: [insurance type]
Bundling issues: [NCCI edits]
Provider: [performing physician]

Modifier selection:
- Modifier purpose identified
- Common modifiers by category:
  - Anatomic (-LT, -RT, -E1-E4, -FA-F9, -TA-T9)
  - Procedural (-22, -51, -52, -53, -58, -59, -76, -77, -78, -79)
  - Service (-24, -25, -26, -32, -33, -57)
  - Personnel (-80, -81, -82, -AS)
  - HCPCS level II (various)
- NCCI edit bypass (modifier -59/-X{EPSU})
- Multiple procedures (modifier -51)
- Bilateral procedures (modifier -50)
- Reduced services (modifier -52)
- Distinct procedural service (modifier -59)
- Professional component (modifier -26)
- Sequencing of modifiers (when multiple)
- Payer-specific modifier rules
- Documentation supports modifier use
- Rationale for modifier selection
- Compliance with CMS and CPT guidelines

Manage claim denial for [service]:

Denied service: [what was denied]
Denial reason: [reason code]
Payer: [insurance]
Patient responsibility: [amount]
Original claim: [date and details]
Documentation: [what was submitted]

Denial management:
- Denial reason analysis
  - Coding error
  - Medical necessity
  - Prior authorization missing
  - Timely filing
  - Eligibility issue
  - Bundling/NCCI
  - Documentation insufficient
- Corrective action:
  - Corrected claim submission
  - Appeal required
  - Additional documentation needed
  - Patient responsibility
- Appeal process:
  - Payer-specific appeal requirements
  - Timeline to appeal
  - Level of appeal (1st, 2nd, external)
  - Documentation to include
  - Letter of medical necessity
  - Clinical notes
  - Evidence-based support
  - LCD/NCD coverage
- Tracking and follow-up
- Prevent future denials (education)
- Financial counseling for patient if applicable

Optimize charge capture for [practice/department]:

Practice: [type and size]
EMR: [electronic system]
Providers: [number and specialties]
Missed charges: [known issues]
Compliance: [audit findings]

Charge capture optimization:
- Current workflow analysis
- Charge entry points identified
- Missed charge opportunities:
  - Procedures not billed
  - Supplies not captured
  - E/M levels undercoded
  - Services bundled incorrectly
- EMR optimization:
  - Order sets linked to charges
  - Templates with charge prompts
  - Charge reconciliation reports
- Provider education:
  - Documentation requirements
  - Coding basics
  - Compliance risks
- Coding staff workflow
- Charge lag reduction
- Quality checks before submission
- Denial prevention
- Compliance safeguards
- Key performance indicators
- Regular auditing
- Revenue improvement estimated

Create coding query for [documentation issue]:

Chart: [patient encounter]
Issue: [what's unclear or missing]
Impact: [why it matters]
Provider: [who to query]
Timeline: [urgency]

Coding query:
- Query initiation criteria met:
  - Clinical indicators present but not documented
  - Conflicting documentation
  - Unclear terminology
  - Specificity lacking
  - Diagnosis not linked to treatment
- Query format (AHIMA compliant):
  - Clinical indicators cited (from chart)
  - Question posed (open-ended, not leading)
  - Options provided (if multiple choice)
  - Unable to determine option included
  - Space for provider explanation
- Examples of non-compliant queries to avoid
- Documentation integrity maintained
- No assumption or inference
- Physician clarification only
- Query becomes part of medical record
- Follow-up if no response
- Education opportunity identified
- Prevent future queries on same issue