Under-Coding vs Over-Coding: How to Avoid Lost Revenue and CMS Audits

Under-Coding vs Over-Coding is the single biggest coding decision that determines whether your facility keeps its revenue or hands it to CMS on a silver platter. Under-coding happens when a coder assigns a lower-level code than the documentation supports, which quietly erases revenue every single day. Over-coding happens when a coder bills a higher-level code than the […]

Top 10 ICD-10-CM Coding Errors and How to Prevent Them

The Top 10 ICD-10-CM Coding Errors costing healthcare organizations the most revenue in 2026 are unspecified code overuse, missing 7th-character extensions, upcoding/undercoding, sequencing mistakes, mismatched laterality, outdated code use after annual updates, missing Excludes1/Excludes2 checks, incomplete documentation-to-code linkage, modifier-coding conflicts, and failure to apply new payer-specific edits. Each one triggers denials, audit exposure, or silent underpayment, […]

What Are the Correct Abdominal Pain ICD 10 Codes for Claims?

The correct Abdominal Pain ICD 10 Codes fall under category R10 (Abdominal and pelvic pain), and as of October 1, 2025, that category looks nothing like it did a year ago. CMS added 16 new R-codes just for abdominal, pelvic, perineal, and flank pain specificity, deleted the old catch-all R10.2, and gave payers new grounds […]

How to Use CPT Code 99213: Complete Guide for Established Patient Office Visits

CPT code 99213 is used for established patient office or outpatient visits that meet the applicable low-complexity medical decision-making requirements or 20–29 minutes of total time on the date of the encounter. Accurate documentation of the patient’s condition, medical decision-making, and time when applicable is essential for correct billing, proper reimbursement, and avoiding coding errors. […]

General Coding Guidelines for ICD-10-CM

The general coding guidelines for ICD-10-CM come down to two rules: locate the diagnosis in the Alphabetic Index and verify it in the Tabular List, then report the code at the highest number of characters and level of specificity the record supports. The remaining guidelines cover combination codes, sequela, laterality, and when sign, symptom, or […]

Diagnosis Coding Guidelines for Aftercare

Diagnosis coding guidelines for aftercare say to use an aftercare Z code when the initial treatment is complete and the patient needs continued care during healing or recovery. The Z code is not used when treatment targets a current acute disease, or for injuries, which keep the injury code with the 7th character for a […]

Coding Guidelines for Interprofessional Internet Consultations

Coding guidelines for interprofessional internet consultations assign CPT 99446–99449 and 99451 to the consulting specialist and 99452 to the treating physician who requests the opinion. The consultant must not have seen the patient face to face in the previous 14 days, and consultations under five minutes are not reported. Interprofessional Internet/Telephone/EHR Consultations Interprofessional Telephone/Internet/EHR Consultations […]

E/M Time-Based Coding

E/M time-based coding selects the visit level from the total time the physician or other qualified professional personally spends on the patient on the date of the encounter, with face-to-face and non-face-to-face time combined. Time spent on tasks normally done by clinical staff does not count. The physician or other qualified healthcare professional are using […]

Outpatient Coding and Inpatient Coding

Outpatient coding and inpatient coding differ in the patient’s admission status and in the procedure code set. Outpatient coding reports procedures with CPT or HCPCS codes, inpatient coding reports them with ICD-10-PCS, and both use ICD-10-CM for diagnoses. The hospital coding and billing is truly a complex system, considering the complexity of the hospital environment. […]

Medical Coding for Group Visits

Medical coding for group visits works on one simple rule: you bill for the individual care each patient gets, not for the group session itself. If a physician gives a patient a medically necessary, face-to-face E/M service during a shared medical appointment, it can be billed with a regular office visit code like 99213 or […]

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