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Reading a coding finding

Chart citations and a specific coding rule behind every recommendation, so you can defend the change with confidence.

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Written by Sergey Yudovskiy

Coding findings follow the same evidence-first approach as compliance. Nothing is recommended without showing you the proof, which means a coder can trust it and an auditor can follow it.


A coding finding with chart citations and a rule reference

A coding finding. The recommendation is backed by chart citations and a specific coding rule.


What a finding shows you

  • What we found: the coding issue in plain language, for example that the documented work supports 99214 while 99213 was billed.

  • Chart citations: the exact lines from the note that support the change, such as the relevant HPI and plan entries.

  • Rule reference: the authority behind it, for example the AMA CPT 2023 E/M guidelines for moderate medical decision making.

  • Why this matters, and a concrete recommended action, for example re-level to 99214 and add the MDM rationale to the note.


Because the recommendation points at both the chart and the rule, a coder can confirm it quickly and document the reason for the change, which is exactly what you want on file if the claim is ever questioned.

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