Medical Coding Class – What You’ll Learn

The medical coding class focuses on the critical link between clinical documentation and accurate reimbursement. Coding isn’t just about numbers—it’s about translating what happens in the exam room into the language insurance companies understand, while keeping your documentation audit-proof. Students will learn:

• Documentation & Medical Necessity
  You’ll learn why the golden rule in coding is: “If it’s not documented, it didn’t happen.” Every CPT or HCPCS procedure code must be supported by a corresponding ICD-10 diagnosis. We’ll cover how to document clearly and thoroughly so your services are justified, billable, and defensible in an audit.

• ICD-10 to CPT/HCPCS Linking
  Discover how to properly connect diagnoses to procedures to show medical necessity. For example: linking an ICD-10 diagnosis of Major Depressive Disorder (F33.1) to a CPT code for a psychiatric evaluation (90791) or a medication management visit (99214). This is where revenue is either gained or lost.

• E/M Coding Under 2023 Guidelines
  Master the updated Evaluation & Management (E/M) coding system, which now relies heavily on Medical Decision Making (MDM) or total time spent. You’ll learn how to:

  • Assign codes based on complexity, not just length of the visit.

  • Correctly use time-based coding when time is the controlling factor.

  • Apply psychiatric-specific examples for clarity (e.g., documenting SI/HI risk, med changes, or therapy recommendations).

• Breaking Down the MDM Elements
  Learn how to score all three MDM elements that determine the level of service:

  1. Number & Complexity of Problems Addressed – How sick is the patient and what conditions are you managing today?

  2. Amount & Complexity of Data Reviewed – Labs, external records, imaging, or collaboration with other providers.

  3. Risk of Complications/Morbidity/Mortality – The risk tied to the patient’s condition, your treatment decisions, and any medications that require close monitoring.

• New vs. Established Patient Rules
  Understand the “3-year rule” and why it matters in determining which E/M codes to use. Learn how coding differs for brand-new patients versus those who have been seen previously, and how mistakes here often lead to costly denials.

• Psychiatry-Specific Codes & Scenarios
  The class includes an in-depth look at behavioral health coding, with practical examples and many other codes:

  • 90791 – Psychiatric diagnostic evaluation

  • 99213–99215 – Outpatient visits, with real psychiatric chart note examples

  • 96372 – Injection administration for long-acting injectables (e.g., Abilify Maintena, Invega Sustenna)

  • Prolonged service codes (99417) – When time and complexity exceed the standard visit
    You’ll learn not just the codes, but also the documentation language needed to justify them.

• Avoiding Common Coding Pitfalls
  Insurance companies love to exploit mistakes. We’ll cover how to avoid:

  • Downcoding (when insurers reduce your level of service).

  • Cloning notes (copy-paste documentation that looks fraudulent in audits).

  • Unsupported diagnoses (billing for conditions not actually addressed).

  • Vague documentation that doesn’t demonstrate medical necessity.

• Audit-Proof Documentation
  Finally, you’ll learn how to document in a way that not only supports billing but also protects you if audited. From phrasing safety risk considerations to showing why you prescribed or didn’t prescribe a medication; your documentation will become your best defense.