Specialty coding
Family and internal medicine, cardiology, orthopaedics, OB/GYN, dermatology, behavioural health, oncology, urology, ophthalmology, GI and more.
02 · Medical Coding
Medical Coding & Documentation Integrity
Accurate codes, defensible documentation, and coders who know your specialty — not a generalist queue working from a cheat sheet.
Engagement at a glance
- Engagement modelPer-chart, per-provider monthly, or project-based clean-up
- Ramp-up5–10 business days, including specialty calibration
- CredentialsCPC, CCS, CRC and specialty-specific certifications
- QA10% monthly internal audit with written coder feedback
- ToolingEncoder and code-checker access included, no per-seat cost to you
- ComplianceCoding decisions documented and defensible on review
95%+
Coding accuracy target
Measured against internal QA on a 10% sample each month.
< 24 hrs
Coding turnaround
Charts coded and released so billing never waits on us.
10%
Monthly QA sample
Every coder audited every month, with feedback in writing.
The problem
Code what the note supports — and fix the note where it falls short.
Under-coding leaves money on the table. Over-coding invites take-backs, audits and repayment demands. Both usually come from the same place: documentation that does not clearly support the level of service the visit actually was.
Our certified coders work your specialty, review the encounter against payer and CPT guidance, apply modifiers correctly, and raise a documentation query where the note is ambiguous — so the provider clarifies once and the record stands up years later.
We code for professional and facility claims, E/M and procedures, surgical packages, injections and infusions, behavioural health, and risk-adjusting environments where HCC capture matters.
What's included
Everything in this service, in writing.
E/M level review
Level distribution analysed by provider against peer and specialty norms, with a bell-curve review that flags both under- and over-coding.
Surgical & procedural coding
Global periods, surgical packages, assistant surgeon and multiple-procedure modifiers, injections, infusions and supplies.
Risk adjustment & HCC
Chronic condition capture, MEAT documentation review, and hierarchy management for value-based and Medicare Advantage populations.
Documentation queries (CDI)
Structured queries routed to the right provider with the specific clarification needed — not a generic 'please document more'.
Coding education
Monthly one-page specialty alerts, quarterly provider education sessions, and onboarding for new clinicians and residents.
How it runs
The engagement, step by step.
01
Specialty calibration
We code a sample of your last 100 encounters blind, compare to what was billed, and report the variance by category and provider.
02
Guideline alignment
We write your specialty coding policy: E/M methodology, modifier rules, query process, and what 'supported' means in your practice.
03
Production coding
Daily coding with a 24-hour turnaround, documentation queries raised same day, and a coding que that never becomes a backlog.
04
Audit & educate
Monthly accuracy reporting by coder and by provider, plus targeted education where the same issue keeps appearing.
What we hold ourselves to
These are the operational targets we report against for this service. They are industry benchmarks and internal commitments — your results depend on your volume, payer mix and specialty, and we will tell you honestly where you should expect to land.
95%+
Coding accuracy
< 24 hrs
Chart turnaround
< 2%
Modifier-related denials
100%
Coders specialty-certified
FAQ
Common questions.
Can you code for our specialty?
We staff 22 specialties and match coders to your case mix. If we do not have depth in a niche service line — some surgical subspecialties, for example — we will tell you before you sign rather than learn on your charts.
Do you use AI to code?
We use code-assist tooling to speed up review, and every code is reviewed and released by a certified human coder. The coder owns the decision and the audit trail.
What is a documentation query and will it annoy our providers?
A query is a specific, answerable question — 'was the laceration 2.5 cm or 3.5 cm?' — not a demand for a rewrite. We batch them, keep them short, and route them to the right person so they get answered in a minute, not a week.
Will your coding increase our audit risk?
The opposite is the goal. We code to the documentation and tell you when the documentation needs work. If a provider's level distribution is an outlier we address it with education rather than letting it drift until a payer notices.
Can you take over mid-year from another vendor?
Yes. We will request the prior vendor's coding policies and QA reports, run our own blind sample, and reconcile the differences in writing so you know what changed and why.
Related services
Often bought together.
Credentialing & Payer Enrollment
Payer enrollment, CAQH maintenance, Medicare and Medicaid, hospital privileging, revalidations and expirables — tracked to the day.
- New-provider enrollment in 60–90 days, tracked daily
- CAQH, PECOS, NPPES and roster maintenance
- Expirables calendar so nothing lapses unannounced
Practice Auditing & Compliance
Pre- and post-payment chart audits, coding and billing reviews, HIPAA and OSHA assessments, and corrective action plans that hold up.
- Independent audit of coding, billing and documentation
- HIPAA, OSHA and program-integrity risk assessments
- Corrective action plans with measurable follow-up
Employee Management & Practice Staffing
Recruiting, onboarding, HR files, payroll and benefits administration, scheduling, policy handbooks and performance management for practice teams.
- Front desk, MA, billing and management recruiting
- Onboarding, HR compliance and payroll administration
- Handbooks, job descriptions and review cycles that hold up
Talk to someone who has run this before.
Thirty minutes with an operations lead who works this service every day. Bring your numbers if you have them; we will tell you what we see either way.
A 30-minute call with an operations lead. No obligation, no sales sequence, and we will say so if you do not need us.