Coding & Clinical Quality Assurance (QA) Review

Accurate Coding is the Foundation of Compliant Reimbursement.

Our CPT and ICD-10 coding services ensure diagnoses and procedures are coded correctly, supported by documentation, and aligned with CMS, PDGM, and payer requirements—before claims ever go out the door.

What is CPT & ICD-10 Coding?

CPT and ICD-10 coding translate clinical documentation into standardized codes used for billing, reimbursement, and regulatory reporting. Errors or unsupported codes can lead to denials, audits, delayed payments, or compliance risk.

Our team applies nationally recognized coding conventions and CMS guidelines to ensure every code is accurate, defensible, and fully supported by the medical record.

How Our Coding Process Works

We review provider documentation and assessments to assign compliant diagnosis and procedure codes that reflect the patient’s condition and services provided.

Our process includes:

Reviewing H&P, physician orders, and visit documentation
Assigning ICD-10 diagnosis codes per CMS and ICD-10 guidelines
Ensuring the primary diagnosis aligns with PDGM requirements
Coding active comorbidities that impact care
Avoiding unsupported diagnosis lists or non-compliant sources
We code only what is documented. Nothing more, nothing less.

Our Coding Service Levels

Level 1: Coding

Our foundational coding service focused on accuracy and compliance.

Includes:

ICD-10 diagnosis coding per CMS conventions
PDGM-aligned primary diagnosis selection
Review of clinical documentation to support coding
Coding of active or care-influencing comorbidities

Key Standards:

No coding from diagnosis lists alone
CMS-1823 not used for coding support
Exacerbation or onset dates assigned only when requested or required by EMR

Level 2: Coding + Assessment Review

Adds clinical and documentation validation to support assigned codes.

Includes everything in Level 1, plus:

Review of assessments for accuracy and consistency
Justification for any coding-related assessment changes
Validation of supporting documentation
Communication with clinicians for clarification or acceptance
Placement of assessments on hold for invalid or missing
Face-to-Face documentation

Level 3: Coding + Assessment + Plan of Care Review

Our most comprehensive level of review for full compliance support.

Includes everything in Levels 1 and 2 plus:

Review of the Plan of Care for alignment with diagnoses
Identification of documentation gaps or inconsistencies
Recommendations to support compliant coding and reimbursement
Validation of homebound status and focus of care

NOTE: Agencies remain responsible for final Plan of Care updates. We provide expert recommendations.

Level 4: Coding + Assessment + Plan of Care

Our most comprehensive level of review and support.

Includes everything in Levels 1, 2 and 3 plus:

Fully build Plan of Care

Discharge Coding & OASIS Review

We review discharge assessments to confirm:

Alignment with clinician documentation
Functional changes compared to SOC or ROC
Accurate medication reconciliation and patient education
Correct assessment reason, dates, and completion

If improvement is not documented, we notify the agency.

What We Review to Support Accurate Coding

Referral & Face-to-Face

Timely and compliant
Face-to-Face documentation
Correct provider signatures and dates
Alignment between referral reason and coded diagnoses

OASIS & Assessments

Correct OASIS form and completion timelines
Consistency between diagnoses, focus of care, and functional scores
Accurate wound, pain, and hospitalization risk documentation
Verification of ADLs, goals, and interventions

Plan of Care

Functional limitations and safety measures
Mental, neurological, and nutritional considerations
DME, supplies, medications, and allergies
Visit frequencies and diagnosis-driven goals

Transparency & Communication

Assessment Holds: Used when additional information is required
Resolution Workflow: Agencies update and resolve items directly
Tracker Access: View assessments in progress, completed, or on hold

This ensures clarity, accountability, and timely turnaround.

Why Outsource CPT & ICD-10 Coding?

Reduce denials and audit risk
Ensure PDGM and CMS compliance
Improve documentation defensibility
Free clinicians and staff from administrative burden
Support accurate, timely reimbursement

Accurate, Timely and Compliant Coding Starts Here

Our CPT and ICD-10 coding services provide the structure, oversight, and expertise agencies need to code with confidence.

Contact us today to learn which service level fits your agency’s needs.