Working With Your Medical Coder
Posted Mar 3, 2025
Your medical coder is a valuable ally — but should you trust them with 100% of your billing and coding decisions? Not quite. Understanding what coders know, what they don't, and what actually motivates them will change how you protect your revenue.
Your Coder Knows Coding — Not Medicine
Start with education. The person handling your billing and coding may hold a bachelor's or even a master's in coding — but not in medicine. They're pros at CPT codes, ICD-10 codes, and the coding guidelines. What they can't do is judge medical risk. Unless you spell out the risk explicitly and clearly in your note, they have no way to see it. So when you talk with your coder, understand where each of you is coming from: you're looking at different pieces of the same big picture.
What's Actually in Your Coder's Best Interest?
Here's the part most physicians miss: your coder's incentive is to avoid audits — and to survive them if they happen. They are not there to help you bill the maximum you've earned. They're there to make sure charges are defensible and to have you fix anything that could get flagged. That's a legitimate job, but it means their default posture is conservative — often more stringent than the guidelines require.
The Guidelines Are Universal — and Averages Rule
What feels like high complexity to you may not match the coding guidelines, and the guidelines are the only thing that counts. The Centers for Medicare and Medicaid Services (CMS) defines low, moderate, and high complexity, explicitly and universally, so the whole country speaks the same language — there's no negotiating around them.
And the system runs on averages. Think of the bell curve from Statistics 101: most physicians cluster in the middle, and outliers — high or low — stand out. Stay near the average and you sail smoothly. Charge high complexity frequently and you may get flagged; get flagged and you get audited; fail the audit and you pay back.
Why Audits Terrify Coders: A Worked Example
Say a major insurer mails you a letter: "Doctor, please send us 30 notes from your patients with us." They review them and reply: "70% of these were overcharged — billed high complexity when they should have been moderate."
Here's the painful part: they don't audit your whole history. They audit a tiny sample and extrapolate it back across your entire relationship with them. Suppose you've had 5,000 encounters with their patients over five years, the average overcharge was $50, and 70% of the sample was overcoded. Their math: 3,500 encounters × $50 = $175,000 you now owe to settle. No joke.
(Notice the asymmetry: if you undercharge, nobody audits you — the insurer pays less and is perfectly happy. The risk runs one direction, which is exactly why your coder leans stringent.)
Don't Let Fear Run Your Practice
But there's another way to think about this. In your specialty — medicine or surgery — do you refuse complex patients, or do you welcome them? We spent years training to help patients with what we've got. We have difficult conversations, take on high-risk procedures when the patient agrees and we have the skill, and we often get excellent outcomes. Fear isn't the problem in medicine; not knowing what you're doing is.
The same is true in billing. The question to ask yourself: are you getting all your coding knowledge from your coder — or from physicians who are genuinely experienced in billing and coding? Master your own business, and you can code accurately and confidently, without leaving earned revenue on the table out of fear.
Your Coder Is Still a Valuable Resource
None of this makes your coder an adversary. Guidelines change every year, and staying current is essential — that's where your biller and coder shine. They're on top of the updates and will tell you what's changing. Signing up for the CMS newsletter is another easy way to stay informed.
The Bottom Line
Your coder is your ally on compliance and updates — but their incentives make them conservative, and they can't see the medical risk you don't document. Learn the guidelines yourself, document risk explicitly, code to the criteria with confidence, and use your coder as the safety net they're meant to be — not the ceiling on your revenue.
Everything here comes back to one idea: the fusion of efficiency and effectiveness — finishing on time while doing the right things well for your patients, your practice, and your revenue. Explore the full MD Efficacy philosophy to see how the pieces fit together.
Want to master this yourself? Physician Revenue Mastery covers coding criteria, documentation, and audit-proof billing step by step — CME-accredited and built for practicing physicians.
The Bottom Line
Centers for Medicare & Medicaid Services — Physician Fee Schedule: https://www.cms.gov/medicare/payment/fee-schedules/physician
American Medical Association — Medical coding mistakes that could cost you: https://www.ama-assn.org/practice-management/cpt/medical-coding-mistakes-could-cost-you
MD Efficacy © 2026, All Rights Reserved.
By visiting this page, you agree to Terms of Use, Privacy Policy, & Earnings Disclaimer.