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.
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]"
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).
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.
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.
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
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 ✓
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 |
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 |
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. |
