Medical Coding & CDI
The problem
Coding is where revenue is most quietly lost. Under-coding leaves earned dollars on the table; over-coding invites audits and takebacks. And when documentation doesn't support the code, denials and downgrades follow. Many practices never see this happening — the downgrades are silent, the missed specificity invisible, and the only symptom is a collection rate that's lower than it should be.
How NuGenera Health does it
Our certified coders assign CPT, ICD-10-CM, HCPCS, and modifier detail based on the clinical documentation, capturing the correct level of specificity — no reflexive downgrades to avoid scrutiny, and no upcoding to inflate revenue. The goal is accuracy, because accuracy is what survives an audit and what protects the relationship between your practice and its payers.
Our clinical documentation improvement (CDI) work closes the gap between what happened in the encounter and what the documentation supports. When documentation is thin, we query in a compliant, non-leading way so the record reflects the true complexity of care — which is what makes accurate coding possible in the first place.
Coding quality is measured, not assumed. We track coding-related denials, downgrade rates, and query response rates, and we report them so you can see whether documentation and coding are actually improving over time.
Key capabilities
- CPT, ICD-10-CM, HCPCS, and modifier assignment by certified coders
- Specialty-specific coding across multiple provider types
- Compliant, non-leading documentation queries (CDI)
- Coding audits and error-pattern feedback to providers
- E/M level review aligned to current guidelines
- Downgrade and coding-denial tracking
Technology that supports it
Coders work inside your EHR with computer-assisted coding support where available, but every code that goes out is reviewed by a human. Automated scrubbing catches obvious mismatches before submission; denial-pattern detection tells us which codes and payers generate the most rework so we can fix the root cause upstream in documentation.
Frequently asked questions
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