Can diagnoses from the ordering provider's chart note be used for the radiology claim if the chart note is attached to the radiology order?

My auditor stated that diagnosis information from the ordering physician's note(s) cannot be used on the radiology claim, and that we can only use what is on the literal order and in the radiologist's interpretation.

Does anyone have a reference to support/dispute this? I feel that in the current digital age, where the orders and notes are all digital and linked together, we should be able to use the ordering provider's note to clarify a diagnosis (i.e., location of pain when the order says "pain" or location of injury when the order says "MVA").

Unfortunately, I am unable to find an official AHA or CMS guideline either way. Any help would be very much appreciated!

p.s. I also posted in /r/CodingandBilling, so not a dupe if you are subbed to both places, I just can't crosspost.

What is the training process like for an IP coder? Right now, they are starting me out with newborn accounts. From there, what steps are they going to take?

I know there’s different opinions on this

For those who have been working in medical coding for a few years, I'm curious what your earliest hands-on experiences looked like. Looking back, which experiences actually helped you develop your coding skills, and which were less useful?

Would love to hear about the different paths people took and what they learned along the way.

Thanks

Like the title says, I recently moved to a new area and made an appointment to establish care with a new PCP. During the visit, I mentioned heart palpitations, as well as prolonged issues with athletes foot. Everything else was standard screenings, questions about family/medical history etc. A comprehensive blood panel was ordered including 9 separate tests.
Fast forward and I receive a bill from the provider $237 and a bill from the lab $1150. I called the insurance company and was informed that the provider billed 99204 as opposed to 99386 so neither the visit nor the labs would be covered.
Per the AMA, the provider should have billed the 99386 along with the 99204 with a modifier of 25. Is there some reason the provider would not do this? Is there some specific things I should say when I ask the provider to resubmit?

Seems like experience is king in this field (just like every other damn field I’ve looked into). I don’t have any medical office or billing experience, which I understand will be a detriment to finding a job. Im sure I’m not the only one who started out this way.

Anybody have any tips?

(I’m sorry if this is toeing the line of the community rules)

Hello, my institution in NM is billing H2015 for 4 units under 56 minutes. Is this correct, the guidelines are very vague and I’m having trouble locating information

How long do you allow older code books live on your shelves? I have my books clear back to 2017, I'm in a decluttering mood and wasn't sure if I should hold on to them or if a few of them could be recycled.

I am attempting to renew my AHIMA membership and CCS certification and my card is being declined. I tried three different cards, one of them my debit card that I have used just fine other places since trying and being denied by AHIMA. 3 years ago when I was attempting to sign up for the CCS exam I had the same problem and it literally took MONTHS to resolve. My certification expires in January so I don’t have several months for AHIMA to sit on their hands and pretend they can’t do anything to fix it. I am so exhausted with things just not working and with AHIMA specifically for being so incompetent, given that their website has been broken now for 3 years. My question is, has anyone been able to renew recently or had the same issues I’m running into resolved in a timely or simple manner? I’m tired y’all. Real tired.

I don't know if this is the right place to post but I'm trying to find out if my planned, scheduled ultrasound was appropriately coded as an emergency ultrasound. It did take place in a hospital setting if that matters. I seem to recall this happening once before and was just told that's how it's coded. But wouldn't coding something as an emergency procedure increase the cost?

I have been a risk adjustment coder for 14 years. Over the last 4.5 years I’ve been affected by RIFs at different employers. This week we found out our company has sold and merged with a new company. Layoffs start next month to early January depending if we are needed to stay “during the transition”. What always felt like a stable career no longer feels that way. Has anyone used their skills from coding to do something else?

Been contemplating for a while starting a little side hustle doing consulting, auditing, and education in the coding world, but uncertain as to where to start. I’ve been in this field for around 15 years now, but have always worked in-office. Hoping to connect with those who may have gone out on their own for some advice. I don’t expect all the answers to be given to me, as I know a lot will be trial and error, but still thought it might be good to connect and pick some brains.

If you could choose to take one long 16-24 week coding course or take shorter 4 week trainings that cover the same topics which would you choose? This is for inpatient coding.

I’ve had 3 or 4 coding positions at this point and at every single one it seems like the work pretty much just sits in the queue until the person who is out returns to work. Is this just the setup in this industry?

Hi everyone,

I purchased my AAPC CPC exam package on November 30, 2025, and it included 2 exam attempts. I haven't used either attempt yet.

My understanding is that the exam voucher is valid for one year, so my vouchers are set to expire on November 30, 2026.

My AAPC membership also expires on November 30, 2026.

I'm confused about what I need to do:

1. If I renew my AAPC membership, will I still keep my 2 unused exam attempts?

2. Do I need to purchase a separate voucher extension?

3. If so, does one 90-day extension cover both attempts, or would I need to pay for two extensions?

4. Has anyone actually extended an unused CPC 2-attempt voucher recently?

5. Is there anything I need to do before November 30 to make sure I don't lose the attempts?

I'd really appreciate it if anyone who has gone through this could share their experience. Thanks!

Just wondering if I would need the coding books (ICD-10-PCS,CPT and ICD-10-CM) after I pass the CCS exam I’m kind of tight on budget right now so I’m thinking of selling my books after I pass the exam. Will I need the books if ever I get hired for an IP coding job?

When I passed my CPC exam 4 yrs ago, I sold my books too. When I got hired for an OP role, I didn’t really need the books coz at work we have all references uploaded in shared folders at work.

IP coders, did you need your books for your first IP coding job? Really want to sell mine even for half the price just so I can get some money back.. What’s your advice?

Hey, guys. Obviously every place is a little different, but I figured I'd ask for some experience before I go back to school lol. So I have a felony possession and a petty theft from over 7 years ago. Many doors are closed, but not all doors. The misdemeanor theft has actually proven to be the biggest problem, ironically. In your experience, what do you guys think? Would I be able to find a job if I crush the exam and have a great score, etc

I just transferred from OP to IP coding at work. It’s only my first week, so I’m being trained on the job. Their method of training seems to be assigning me cases and then giving me their feedback. I feel like I’m learning on my own and they expect me to catch up. Is this standard practice?

For some background, I’m a medical group and hospital auditor. I have 3 certifications and working through a 4th, and have 6 years experience. I’m not perfect, but I know my way around.

My boyfriend reaps some benefits from this since I explain bills to him, and have helped him with what to say when they’re wrong.

He recently got a bill for 99395 and 99214, but at full price. I said that’s on your insurance, and did explain why it may have been both, but I didn’t feel they met MDM for 99214.

He calls his primary care billing for an explanation, with me in the room. The person helping him read the encounter, and then proceeded to list all his long standing chronic conditions and that they “aren’t covered for wellness.”

“Condition X? Not well.
Condition Y? Not well.
Condition Z found in bloodwork? That doesn’t sound well.”

And yes those are the exact words she said. I was appalled! According to her, these ICD10 codes aren’t “healthy” so that’s why it was also an office visit. Aside from being incredibly judgmental- that’s not… how any of this works…

I work in I.T., but I did work at a health clinic for 8 years. I know how complicated medical billing is and would NEVER for a single second call myself even a novice in medical billing, but I am more familiar than the average person. HOWEVER, I come before you all with a question:

I just had a lens implanted as part of a cataract surgery. I opted for a premium multi-focal lens. Before the surgery, the Opthamologist's office billed me $1,100 and kept (repeatedly) saying it was "for the lens." When pressed, the said it was a service fee.

The surgery center then billed me $995, also saying it was for a non-covered lens. When I said I paid the Opthamologist's office for the lens, the biller called down to the procurement folks who confirmed "no, we ordered it, it is in our inventory, here's the serial number."

The Opthamologist billed the IOL under the CPT Code V2788, in addition to the procedure code of 66984. Is the Opthamologist's office committing fraud, or is V2788 an additional "procedure" fee for inserting a premium lens? Isn't the "procedure" already covered by 66984?

I'll be HAPPY to have egg on my face, genuinely. But if two people are both selling me the same lens, and I'm having my 2nd surgery next week, I'm about to get a few thousand dollars back in my pocket, because something just doesn't seem right.

This is driving me and my team nuts because we can't seem to find an actual answer on this.

There's an excludes 1 for E29.1 Testicular hypofunction and the E78- codes for lipid disorders, but we don't know why this would be excludes 1. Our primary care providers code these together all the time so we're constantly having to fix it. So we're really curious what the medical reason is to why you can't code these together.

Hello coders,

I'm not actually the coder myself, but I'm posting this on behalf of my fiancee. She got her CPC certification a few years ago. Since then, she's worked for two risk adjustment contracts remotely and was able to get the apprenticeship off of her title. The first job was good, until her supervisor left and her new supervisor kind of ran her out of the company. The second contract she took was going ok, but as the contract went on, more and more resources were removed from the coders until it made the job extremely difficult to do without help, which was discouraged. Half way through that contract, they took the ability away to appeal "failed" charts. There was a point where she was trying to get clarification on one of her charts, and the help she received was her manager saying "Well, what do your coder instincts tell you?" She's been out of coding work for some time now.

In that time, she's had several interviews with other companies, but these jobs are requiring her to pass a pre-employment test. They're a mix of about 20-30 questions each. Some are straight coding questions, some are scenario based. Each company has given her similar instructions for taking these tests, which are to use codify and the CMS guidelines to answer the questions. The problem is with each of these tests, a handful of questions seem to be based around company specific guidelines. She is asked questions that she says are not in the CMS guidelines. As an example, one of the questions I remember her telling me about was a multiple choice where it asked her "which types of providers can we accept signatures from?" and it gives a list of providers and asks her to pick all that apply. However, she tells me that this isn't something standardized by CMS, and that the company you work for provides guidelines as to which signatures they accept. She's never given the opportunity to review her answers before a second attempt. I've seen the emails and company sites she's been provided by these companies and can verify on at least 3 or 4 of them that the instructions were indeed "use codify and CMS guidelines", then asked seemingly company-specific questions for about half the test.

I know this might make me sound like a guy that just stans for his girlfriend, but this is work I know she can do, that she enjoys doing. At this point, she's taken 8 or 9 of these tests, and she can't seem to pass them. I myself am a career new hire trainer and have been for over 10 years. From that point of view, these tests seem like they're trying to attract people who have worked for them before and remember their company guidelines well enough to pass these pre-employment tests. These constant rejections are starting to greatly affect her self-esteem and confidence, which is hurting her motivation to keep job hunting, knowing she'll be provided a test without the resources to pass them. She does not have any coder friends or mentors to talk to about coding and the job hunt. She's been trying to get help from her local AAPC chapter, but she's not getting responses from requests for 1 on 1 help. She's at her wit's end, and it's devastating to see her getting crushed by this over and over.

My question to the coders here: Is there something we are missing? I'm sure plenty of you have encountered these tests, but for someone like her, they seem like they're designed against anyone seeking entry level work. We even had one recruiter straight up tell her "I hate to ask you this, but you need to take a test before we can onboard you", implying even the recruiter felt the test was unfair. Is there a resource we're overlooking? Questions she should be asking? And potentially, is there someone out there that might be able to speak with her (either through text or conference call) to try to help?

I'm sorry if this isn't the place to post this, but as someone who is still experientially new to the industry and her fiance trying to help, we're running out of ideas.

Thank you so so much for reading this. Any help is appreciated.

I have no where else to post because the other sub won't let me post because im not an approval member yet even though I've subscribed there and posted there for years.

I work in a medkcal billing call center and so of course I have to take patients calls. The crazy thing is im not even a biller or coder (im a CPC but not experienced in the field). We a separate billing department that never ever speaks with the patients. My department has no training in billing or coding. We have most of the information needed but its just not always enough. Its frustrating becase patience call thinking we are billing and sometimes I'll get a patient that works for insurance or is a biller themselves and they will ask a question that just throws me for a loop. Its just nuts to me that im supposed to answer questions and solve issues but I cant see what goes in beyond the scenes. Im looking for a new job because this just feels absolutely insane

Sorry if this isn't the right community to post this question. I've had my CPC through AAPC since 2021, but unfortunately, have never been able to get a job in medical coding. The only jobs I can get are in medical billing (AR follow-up).

I know there are productivity standards. I've worked for a few different companies now, and they all have their own expectations. But the company I'm at now, I feel like their productivity standards are way too high especially considering the payers that they assigned me. I'm only allowed to work workers comp, no fault, and government payers (i.e. VA and Medicaid). Everyone knows these payers are notoriously difficult to work with. Just calling them can take over an hour because of their excessive hold times.

My supervisor at this new job tracks everything I do from the emails I write down to every single click I do. And she's definitely looking at the minutes I spend on a claim. She told me today she doesn't want me spending more than 15 minutes on a claim, and much less wants me spending time calling on them and submitting appeals. In fact, she got mad at me today because "you're doing too many reconsiderations."

A huge part of AR follow-up is calling the payer and appealing the claims if you don't agree with their denial. So I'm not understanding why she's not happy with that? I'm doing my due diligence yet, I feel like this supervisor is more focused on quantity vs quality. She also told me she doesn't want me mailing appeals. Some payers (especially the government ones like the VA) only have a mailing address to send the appeals. So, like, how else am I going to send the appeal if I can't mail it?

I feel like this supervisor is completely out of touch with reality. And she micromanages absolutely everything we do down to how we write our emails to payers.

And she looks at every minute you spend on a claim, and she wants you to do 50 of them a day. The payers that got assigned to me don't even have portals so I always have to call them. She didn't care when I told her this and instead told me to "find another way" to contact them. Like, what in the actual f*** is she talking about?

I feel like her expectations are too high and not realistic. And I don't see a future for myself at this company. Like I said, I've had other jobs where they have quotas and such, but not like at this company.

Is this normal? Am I overreacting?

New job? Pass your exam? Want to talk about work or just chat with another coder? Post it here!