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.

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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]"

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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).

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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.

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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.

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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

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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 ✓

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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 |

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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 |

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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. |