Medical coding services for professional fee claims
Fastora's medical coding services turn each visit note into the CPT, ICD-10-CM and HCPCS codes and modifiers a payer needs. We provide professional medical coding for physicians and outpatient providers, delivered as outsourced medical coding for practices, and every claim is handled by certified coders.
Professional fee coding covers the services a provider personally performs and bills on the CMS-1500 or 837P claim. It is not facility coding. That focus is deliberate: the rules for office visits, procedures, therapy and diagnostic interpretation are where practices lose the most to coding errors.
Coding happens inside your existing EHR/PM system, with no software to install. Because coding sits right before claim submission, our medical coding and billing teams work from the same claim, which shortens the loop when a question comes up. Coding is one part of our wider medical billing services.
E/M coding services: MDM and time
Since 2021, office and outpatient E/M visits have been leveled on either medical decision making (MDM) or the provider's total time on the date of the encounter. History and exam are still documented as medically appropriate, but they no longer determine the level.
- Medical decision making weighs the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications from patient management.
- Total time counts the provider's face-to-face and non-face-to-face time on that date, such as reviewing records, ordering tests and documenting.
| MDM element | What the coder looks for in the note |
|---|---|
| Problems addressed | How many problems were addressed at the visit and how complex they were, such as a stable chronic illness versus one with an exacerbation. |
| Data reviewed and analyzed | Tests ordered or reviewed, external records reviewed, an independent historian, or discussion with another clinician. |
| Risk of patient management | The risk from the management options chosen, such as prescription drug management or a decision about surgery. |
In MDM coding, the level is set by two of the three elements. When time is used instead, the note needs the total time and what it was spent on. A note that supports neither clearly is a common reason a visit level is changed on audit.
Our E/M coding services check that the level billed is supported by the MDM or time in the note, and that the choice between the two is clear. Where the note supports a different level, higher or lower, we flag it for the provider rather than change it silently.
Specialty coding for behavioral health, therapy and procedures
Specialty coding is where general coding knowledge runs out. Our specialty medical coding services apply each specialty's rules, not one generic checklist. A few examples of what our specialty coding services check:
Behavioral health
Psychotherapy time codes are chosen by the time spent in psychotherapy: 90832 (30 minutes), 90834 (45 minutes) and 90837 (60 minutes). When a provider who bills E/M services provides an E/M visit and psychotherapy on the same day, the psychotherapy is reported with add-on codes 90833, 90836 or 90838 alongside the E/M code. The two services must be separately identifiable, and time spent on the E/M does not count toward psychotherapy time. See our behavioral health billing page for more.
Therapy and rehab
For Medicare, therapy timed units follow the 8-minute rule: total timed treatment minutes are added up, and a single unit requires at least eight minutes. Units are then assigned across codes based on the total time. Many commercial payers use their own counting methods, so we follow each payer's policy. Our physical therapy billing team applies these rules daily.
Pain management and radiology
Pain management procedures need attention to spinal levels, laterality and the fact that several injection codes already include imaging guidance. In radiology, a study can be split into a professional component for the interpretation (modifier 26) and a technical component for the equipment and staff (modifier TC).
The code sets we work with
| Code set | What it describes | Example use |
|---|---|---|
| CPT coding (Level I HCPCS) | Procedures and services performed by providers, maintained by the AMA | Office visits, psychotherapy, injections, imaging interpretation |
| ICD coding (ICD-10-CM) | Diagnoses, symptoms and reasons for the encounter | Establishing medical necessity for each service line |
| HCPCS coding (Level II) | Supplies, equipment, drugs and some services not in CPT | Braces, injectable drugs, certain Medicare-specific services |
ICD-10 coding for billing
ICD-10 coding for billing is about more than finding a code that matches the condition. The diagnosis must be coded to the highest specificity the documentation supports, including laterality, episode of care or severity where the code set asks for them. The ICD-10-CM code set and its official guidelines are updated each fiscal year, with changes taking effect October 1, so code lists in templates and superbills need a yearly check.
Each procedure line must point to a diagnosis that supports it. That linkage is one of the checks in Fastora's Advanced Pre-Submission Claim Review, before the claim moves to claims management. CPT codes are maintained by the AMA and are also updated annually, so retired or revised codes are reviewed at each update.
Modifiers and what they mean
- 25: a significant, separately identifiable E/M service by the same provider on the same day as a procedure or other service.
- 59: a distinct procedural service, used to show that two services normally bundled were separate. Medicare also recognizes the more specific XE (separate encounter), XS (separate structure or organ), XP (separate practitioner) and XU (unusual non-overlapping service).
- 26 and TC: the professional and technical components of a service that has both.
- GP, GO and GN: services delivered under a physical therapy, occupational therapy or speech-language pathology plan of care.
Modifiers change how a payer processes a line, so each one has to be supported by the documentation. The National Correct Coding Initiative (NCCI) publishes procedure-to-procedure edits that identify code pairs which normally should not be billed together. CMS guidance is clear that modifier 59 or an X modifier should not be used just to bypass an NCCI edit; it belongs only where the services were truly distinct.
Coding audits and coding compliance
A medical coding audit compares a sample of claims with the documentation behind them. Our medical coding audit services look at:
- Whether E/M levels match MDM or time.
- Modifier use, especially 25 and 59.
- Diagnosis specificity and code-to-diagnosis linkage.
- Units and time documentation for timed services.
Coding compliance is not only about catching overcoding. Undercoding leaves earned revenue unbilled. Findings come with education for providers and staff, and ongoing coder education keeps our team current with payer rule changes.
How our coding audit services run
- Scope. Agree on providers, date ranges, visit types and payers to sample, often weighted toward high-volume codes and recent denials.
- Review. Certified coders compare each sampled claim with the note and record agreement, a different code, a modifier issue or a documentation gap.
- Report. Findings are summarized by provider and error type, with the documentation guidance behind each one.
- Educate and follow up. Providers get specific, note-level feedback, and a later sample checks whether the change held.
A coding audit is separate from the free billing assessment, which looks at the whole revenue cycle before you commit. Many practices start with the assessment and add a focused coding audit if coding issues show up.
How medical coding services connect to denials
Many denials trace back to coding: a missing modifier, a diagnosis that does not support the service, or units that exceed a payer limit. When our denial management team sees a coding-related denial, the reason code goes back to the coders.
That feedback loop matters more than any single correction. If a payer keeps denying the same code pair, the fix belongs in how the claim is coded, not in appeal after appeal.
Coder credentials and how we work remotely
Every claim is handled by certified medical billing and coding professionals. When you compare medical coding companies, ask which credentials the coders on your account hold and how they keep them current. Common credentials include the CPC (Certified Professional Coder) from AAPC and the CCS (Certified Coding Specialist) from AHIMA.
Our remote medical coding services work under the user access your practice grants in your EHR/PM system. We sign a Business Associate Agreement before accessing PHI, and our workflows are aligned with HIPAA and HITECH, with encryption, secure server environments, strict access controls and regular internal audits.
Coders who code for a practice also need the provider setup to be right. A claim coded correctly can still be denied if the rendering provider is not enrolled with the payer, which is why coding and provider credentialing are tracked together.
Choosing a medical coding company
Medical coding outsourcing works best when the arrangement is clear from the start. Before you sign with any medical coding company, ask:
- Which specialties the coders handle every week, not just occasionally.
- How E/M levels are chosen and how disagreements with a provider are handled.
- Whether coding questions go back to the provider before the claim is sent.
- How coding denials are tracked and fed back into coding rules.
- What audit sampling and reporting are included, and how often.
Outsourced medical coding services should leave you with more visibility, not less. Fastora provides transparent dashboards, monthly performance reporting and a monthly review call, with a dedicated account contact for coding questions. Pricing for certified medical coding services depends on scope and volume; see how we approach pricing for billing and coding.
If your team is deciding where coding ends and billing begins, medical billing vs medical coding explains the handoff.
Outsourcing medical coding: when it makes sense. Practices usually decide to outsource medical coding when claim volume outruns their coder, when specialty rules get complex, or when coding lag holds up submissions. It works best with a clear handoff: documentation standards agreed up front, a defined turnaround, and audit feedback that goes back to providers. If your coders keep up and denials are steady, you may not need it.
Certified medical coders on your account
Every account is staffed with certified medical coders — credentialed professionals who code to the documentation, not to the payment. As a medical coding company, we keep coding separate from billing so each gets its own review: the coder reads the note, the billing team checks the claim, and audit feedback goes back to the provider when documentation needs to support a higher level of service. Background: medical billing vs medical coding.
What medical coding services cost
Medical coding services cost is usually quoted per chart or folded into the billing percentage — the right structure depends on whether coding is the whole engagement or one piece of it. Practices that choose a medical coding outsourcing company for coding alone typically pair it with in-house billing, and the handoff is what decides whether that works: documentation standards agreed up front, a defined turnaround per batch, and a feedback loop when the same documentation gap keeps appearing. Example of the judgment involved: modifier 59 vs X modifiers.