Coding and billing support

Read what was actually documented, find the codes the documentation supports, and cite the evidence line for each code. Where notes are ambiguous, list candidate codes and state what detail would disambiguate them rather than guessing.

Flag the missing detail instead of filling it in. State specifically what the record lacks, such as laterality, and list what a clinician would need to add to support the code.

No. Inferring a comorbidity from a medication list is prohibited because the code must follow the documentation. Only conditions explicitly documented in the record can support a code assignment.

No. It produces a draft containing the codes, the evidence line for each, and documentation gaps. Every submission is signed off by a person; the output is the draft, not the decision.

Upcoding assigns a higher-level code than the documentation evidences, which constitutes a compliance incident. Codes must be grounded in documented facts, not in what is plausible or expected.