medical-billing-coder

# Medical Billing Code Suggester ## Overview This skill analyzes clinical documentation and suggests accurate ICD-10, CPT, and E&M codes — reducing coding errors, claim denials, and revenue leakage for medical practices. **What it can do:** - Suggest ICD-10-CM diagnosis codes from clinical notes or descriptions - Suggest CPT procedure codes for documented services - Determine correct E&M visit level (99202-99215) - Validate code combinations for payer compliance - Flag common denial triggers before submission - Identify undercoding opportunities (lost revenue) - Generate a coded superbill ready for billing **Data sources:** - **CMS ICD-10-CM** — official diagnosis code database (free, public domain) - **CPT codes** — common procedure codes are referenced by number only; CPT is a proprietary code set owned by the AMA and requires a license for production use in claim submission. This skill does not include or distribute CPT code descriptions — it references codes by number and widely-known descriptions for educational/advisory purposes only. - **CMS Fee Schedule** — RVU and reimbursement data (free, public domain) - **CMS NCCI Edits** — National Correct Coding Initiative (free, public domain) > ⚠️ **Disclaimer:** Code suggestions are AI-assisted and must be reviewed by a qualified medical coder or clinician before claim submission. Incorrect coding may constitute fraud. > 🔒 **Privacy / PHI Warning:** Do not include patient-identifiable information (names, MRNs, DOBs, addresses) in any query. Submit de-identified clinical descriptions only (e.g. "58F with T2DM and HTN, diabetes follow-up"). If `CMS_API_KEY` is set, only billing code pairs are transmitted to the CMS API — no clinical text leaves your environment. --- ## Trigger Phrases - "What ICD-10 code is this?" + description - "Code this visit note" - "What CPT code for [procedure]?" - "Check my codes for this claim" - "What E&M level is this visit?" - "Generate a superbill for this visit" - "Are these codes compatible?" - "What's the reimbursement for CPT [code]?" - "Find the ICD-10 for [diagnosis]" --- ## ICD-10 Code Lookup ### From plain language ``` "What's the ICD-10 for Type 2 diabetes with diabetic neuropathy?" "ICD-10 code for hypertensive heart disease with heart failure" "Code for acute appendicitis without peritonitis" ``` **Example output:** ``` ICD-10 CODE SUGGESTIONS Query: "Type 2 diabetes with diabetic neuropathy" Primary Code: • E11.40 — Type 2 diabetes mellitus with diabetic neuropathy, unspecified Confidence: 95% More Specific Alternatives: • E11.41 — T2DM with diabetic mononeuropathy • E11.42 — T2DM with diabetic polyneuropathy ✓ (most common for peripheral neuropathy) • E11.43 — T2DM with diabetic autonomic neuropathy Coding Tip: If polyneuropathy is documented, use E11.42 for higher specificity and fewer audit flags. Additional codes to consider: • Z79.4 — Long-term insulin use (if applicable) ``` ### From a clinical note ``` "Code this note: Patient is a 58F with HTN, T2DM, and CKD stage 3. Here for diabetes follow-up. HbA1c improved. Refilling Metformin and Lisinopril." ``` **Example output:** ``` ICD-10 CODES — From Clinical Note Primary Diagnosis: • E11.65 — T2DM with hyperglycemia (if HbA1c still elevated) OR • E11.9 — T2DM without complications (if at goal) Secondary Diagnoses: • I10 — Essential hypertension • N18.3 — Chronic kidney disease, stage 3 • Z79.4 — Long-term use of oral hypoglycemic drugs Sequencing Note: List the condition chiefly responsible for the visit first (T2DM for a diabetes follow-up). ``` --- ## CPT Code Lookup ### Procedure coding ``` "What CPT code for an EKG with interpretation?" "CPT for a 30-minute telehealth visit, established patient" "Code for excision of a 1.5cm benign skin lesion on the back" "What's the CPT for HbA1c lab test?" ``` **Example output:** ``` CPT CODE SUGGESTIONS Query: "EKG with interpretation" • 93000 — Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 2026 Medicare Rate: $20.18 (facility) $26.45 (non-facility) Bundling Note: Do not bill 93000 separately if it's already included in a global surgical package or critical care code. ``` --- ## E&M Visit Level Coding This is where most practices lose money — undercoding out of caution or overcoding by mistake. ``` "What E&M level is this visit? New patient, 35 min face-to-face, reviewed 3 chronic conditions, ordered labs, updated medication list" "Code this established patient visit: Follow-up HTN, reviewed BP logs, adjusted Amlodipine dose, 5 minutes MDM" ``` **2021 E&M Guidelines (current standard):** | Level | New Pt | Est. Pt | MDM | Time | |-------|--------|---------|-----|------| | 1 | 99202 | 99212 | Straightforward | 15-29 min | | 2 | 99203 | 99213 | Low | 30-44 min | | 3 | 99204 | 99214 | Moderate | 45-59 min | | 4 | 99205 | 99215 | High | 60-74 min | **Example output:** ``` E&M LEVEL ANALYSIS Visit Type: Established Patient Documentation reviewed: ✓ 3 chronic conditions addressed ✓ Prescription drug management ✓ Lab results reviewed ✓ Independent interpretation of tests Medical Decision Making: MODERATE → Recommended Code: 99214 2026 Medicare Rate: $148.26 vs. 99213 (if undercoded): $93.12 Revenue difference: +$55.14 per visit ⚠️ Undercoding Risk: This visit qualifies for 99214 but is commonly billed as 99213. Ensure MDM is documented to support the higher level. ``` --- ## Code Validation & Denial Prevention ``` "Check these codes before I submit: 99214, E11.9, I10, Z79.4" "Will these codes get denied?" ``` **What the agent checks:** - NCCI bundling edits (procedures that can't be billed together) - Diagnosis-procedure compatibility (does the dx support the CPT?) - Modifier requirements (is a modifier needed?) - Common payer-specific denial patterns **Example output:** ``` CODE VALIDATION REPORT Codes submitted: 99214, E11.9, I10, Z79.4 ✅ NCCI Bundling: No conflicts detected ✅ Dx-Procedure Match: E11.9 supports 99214 ✅ Modifier Check: None required ⚠️ WARNING: • Z79.4 (long-term oral hypoglycemics) with E11.9 — payers may query if patient is actually on insulin vs oral meds. Verify correct code (Z79.4 = oral, Z79.4 ≠ insulin). If on insulin, use Z79.4 AND note insulin use. Denial Risk: LOW Audit Risk: LOW Estimated Reimbursement (Medicare): $148.26 ``` --- ## Superbill Generation ``` "Generate a superbill for today's visit: Established patient, T2DM and HTN follow-up, reviewed labs, adjusted medications, moderate MDM, 35 minutes" ``` **Example output:** ``` SUPERBILL — [Date] Provider: [Provider Name] Patient: [Patient Name] DOB: [DOB] Insurance: [Payer] VISIT CODE: 99214 — Office Visit, Established, Moderate MDM DIAGNOSIS CODES: 1. E11.65 — T2DM with hyperglycemia (Primary) 2. I10 — Essential hypertension 3. Z79.4 — Long-term oral hypoglycemic use PROCEDURE CODES: 93000 — EKG with interpretation (if performed) 83036 — HbA1c (if ordered today) MODIFIERS: None required TOTAL ESTIMATED REIMBURSEMENT (Medicare): 99214: $148.26 93000: $26.45 83036: $14.82 ───────────────── Total: $189.53 Ready for billing review ✓ ``` --- ## Common ICD-10 Quick Reference | Condition | ICD-10 Code | |-----------|-------------| | Type 2 Diabetes, uncomplicated | E11.9 | | Type 2 Diabetes, with polyneuropathy | E11.42 | | Essential Hypertension | I10 | | Hyperlipidemia, unspecified | E78.5 | | CKD Stage 3 | N18.3 | | Obesity, BMI 30-34.9 | E66.09 | | Major Depression, moderate | F32.1 | | Low back pain | M54.50 | | GERD | K21.0 | | Hypothyroidism | E03.9 | | Atrial fibrillation | I48.91 | | CAD, native vessel | I25.10 | | COPD, unspecified | J44.1 | | Asthma, mild persistent | J45.30 | | Anxiety disorder | F41.9 | --- ## Common CPT Quick Reference | Service | CPT | 2026 Medicare Rate | |---------|-----|--------------------| | New patient, moderate | 99204 | $191.12 | | Est. patient, moderate | 99214 | $148.26 | | Telehealth, est. moderate | 99214-95 | $148.26 | | Annual wellness visit | G0439 | $173.00 | | EKG with interpretation | 93000 | $26.45 | | HbA1c | 83036 | $14.82 | | Lipid panel | 80061 | $21.97 | | Urinalysis | 81003 | $4.62 | | Pneumococcal vaccine | 90732 | $112.00 | | Influenza vaccine | 90686 | $28.48 | --- ## Version History | Version | Date | Changes | |---------|------|---------| | 1.0.3 | 2026-03-29 | Corrected CPT licensing statement; added PHI warning; clarified CMS_API_KEY endpoint and data transmission scope. | | 1.0.0 | 2026-03-29 | Initial release. ICD-10 lookup, CPT coding, E&M level determination, code validation, superbill generation. |