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. 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.
