Williams Academy of Medical Coding

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WAMC Coder’s Corner Tip
“Building Confident, Experienced Coders One Tip at a Time.”

“Is It Really Necessary? — Understanding Medical Necessity”

Medical necessity has been a cornerstone of accurate coding for decades. Whether coders were struggling with handwritten diagnoses on paper face sheets in the 1990s or navigating auto populated EHR templates in 2026, one truth has never changed:
If the diagnosis doesn’t support the service, the claim won’t get paid.

What Is Medical Necessity?
Medical necessity means the service, test, or procedure is reasonable, appropriate, and needed based on the patient’s condition. It answers the essential question:
“Why did the patient need this?”
If the “why” is missing or unclear, the claim is vulnerable — even when the codes are technically correct.

Why Medical Necessity Is Still a Challenge?
Even with ICD 10 CM, templates, and electronic records, medical necessity remains a top denial reason because of:
• Paste or copy forward notes
• Incorrect diagnoses selected from drop down lists
• Outdated problem lists
• Missing ICD 10 CM specificity
• Documentation that doesn’t match the service
Technology has evolved — but the responsibility to ensure medical necessity has not.

Four Tips to Ensure Medical Necessity Every Time
1. Match the Diagnosis to the Service
Always confirm the diagnosis explains the service performed. If the diagnosis doesn’t justify the test, procedure, or level of service, medical necessity is not met.
2. Look for Specificity — Not Generalities
ICD 10 CM requires detail. Check for:
• Laterality
• Severity
• Episode of care
• Etiology and manifestations
Specific documentation = strong medical necessity.
3. Verify That Documentation Supports the Story
Read the note. Does the provider clearly show:
• The patient’s condition
• The reason for the visit
• The clinical decision making
• The need for the service
If the story isn’t there, the necessity isn’t either.
4. Always Query When Documentation Is Questionable
If something is:
• Unclear
• Incomplete
• Conflicting
• Missing
• Or simply doesn’t make sense
Query- Every query protects accuracy, compliance, and integrity.

Coder’s Corner Tip
“Building confident, experienced coders one tip at a time.”

The Great Unbundler: Why Modifier 59 Matters

What Is Modifier 59?
Modifier 59 tells the payer that a procedure or service was distinct and separate from another service performed on the same day. It helps you show that the services should not be bundled under NCCI edits.
In simple terms: “These two services are different — pay them separately.”

When Should You Use Modifier 59?
Use Modifier 59 only when documentation supports a truly separate service, such as:
Different session (performed at another time)
Different procedure (not part of the main service)
Different site or organ system
Separate incision, lesion, or injury

Why Modifier 59 Matters
Prevents Denials
Without Modifier 59, NCCI edits will automatically deny the second code in a bundled pair.
Protects Reimbursement
It ensures the provider is paid for all distinct work performed.
Supports Clean Claims
Correct use reduces rework, appeals, and delays.
Help Compliance

Modifier 59 is one of the most audited modifiers. Using it correctly keeps your coding accurate and compliant.

What Happens If Modifier 59 Is Missed?
Lost Money
The second procedure is denied — meaning no payment for a service that was actually performed.
Incorrect Coding Record
The claim may not reflect the true clinical picture.
More Work
Appeals, resubmissions, and provider queries slow down the revenue cycle.

Memory Trick
“Modifier 59 says: This service stands alone — pay it on its own.”

Coder’s Corner Tip
“Building confident, experienced coders one tip at a time.”

“Don’t Get It Twisted: Exclude the Confusion”

Excludes1 = “NOT CODED HERE!”
An Excludes1 note means the two conditions are mutually exclusive — they cannot logically occur together or be reported together based on how the code is defined.

⚠️ Important Exception
If the two conditions listed under an Excludes1 note are unrelated, then both codes may be assigned.
When it’s not clear whether the conditions are related or unrelated, it’s best to query the provider so the documentation accurately reflects the patient’s situation.

Memory Trick:
“Excludes1 means one — never both… unless they’re unrelated, then it’s fair!”

Excludes2 = “Not Included Here — But Can Coexist!”

A Type 2 Excludes note means “Not included here.”
It indicates that the excluded condition is not part of the condition represented by the code — but the patient may have both conditions at the same time.

When an Excludes2 note appears under a code, it is acceptable to assign both the code and the excluded code together, as long as both conditions are documented and clinically appropriate.

Memory Trick:
“Excludes2 means you can use two!”

Happy Medical Coder Day!

Behind every accurate code assignment, proper reimbursement, validated clinical documentation, appeal preparation, and compliance with federal and payer regulations — behind every application of official coding guidelines — stands the unsung hero: the Medical Coder!

Today, we celebrate and honor you for the dedication, precision, and integrity you bring to healthcare. Your work transforms patient care into standardized codes that drive reimbursement and quality improvement — all while supporting documentation excellence and compliance.

Your commitment makes a difference every single day.
Job well done, Medical Coders!

Thank you for all you do behind the scenes to keep healthcare running smoothly.

Coder’s Corner Tip: “Building confident, experienced coders one tip at a time.”
“Pro FREE Your Coding Power!” — Understanding Pro-Fee Coding

Every coder runs into it sooner or later — Pro-Fee Coding and MDM. And while it might look a little intimidating at first glance, trust me, it doesn’t have to be.
Pro-Fee (Professional Fee) Coding is simply the process of assigning CPT and E/M codes for the professional services a provider performs — the work they personally do, document, and bill for.
Here’s the first truth to keep in your coder toolkit: providers document the care… YOU determine the code. That means you’re not just entering numbers — you’re interpreting the medical story, connecting the dots, and bringing clarity to the documentation to support accurate reimbursement and reduce denials.

The Pro-Fee MDM Formula

Think of Medical Decision Making like a super‑simple recipe:
MDM = Problems + Data + Risk
Three ingredients. One powerful outcome.

What You’re Really Looking For:

1. Problems
What is the provider treating?
Is it mild, moderate, or high severity?
2. Data
What did they review, order, or analyze?
Labs, imaging, records, consults — it all counts.
3. Risk
How risky is the condition or the plan?
OTC meds? Prescription meds? IV therapy? Hospitalization?

Quick Reality Check
Providers will not write:
❌ “This is a moderate MDM case.”
Instead, you’ll see clues like:
“Worsening condition”
“Ordered CT scan”
“Started IV antibiotics”
“High risk of deterioration”
You are the decoder of the story.

⚠️ Common Misunderstanding
Just because a note says:
“Level 3 care”
❌ That does NOT automatically mean 99283. ✔ You MUST confirm the MDM supports the level.

Pro-Fee Coding in One Sentence
It’s not about what is said — it’s about what is documented and supported.

Pro Tip for Coders
When you read a note, ask yourself:
What is the provider worried about?
(sepsis, pneumonia, sore throat, fracture)
How much information did they review?
(lab, x-ray, CT scan)
How risky is the plan?
(IV medications, application of cast, hospitalization)
If you can answer those three questions, you can determine the MDM.

Bottom Line
Pro-Fee Coding isn’t memorization — it’s interpretation. Once you master MDM, you unlock the confidence and clarity of becoming an experienced coder.

This Coder’s Corner Tip is for educational purposes only and is not intended to replace official coding guidelines or policies.

Coder’s Corner: Confidence Starts Here

Today’s Tip: Don’t Let “See” and “See Also” Trick You!

If you’ve ever been happily scrolling through the Alphabetic Index and suddenly hit a “See” or “See Also” note… you’re not alone. These two tiny phrases confuse every new coder — because they look similar but behave totally differently.

Here’s the fun way to remember them:

🔵 “See” = Stop, Turn Around, and Go There NOW
Think of “See” as a strict teacher pointing you to the right page.

👉 Mandatory. Required. No skipping.
If the Index says “See: X”, you must go to that new main term to find the correct code.
No exceptions. No shortcuts.

It’s basically saying:
“You’re in the wrong spot — go look over there instead.”

🟡 “See Also” = Optional Bonus Clue
Now imagine “See Also” as a friendly tutor whispering:
“Hey, you might find even more helpful info over here too.”

👉 Optional. Helpful, but not required.
You only follow it if you want more options or if the first term didn’t give you what you needed.

If your original main term already leads you to the right code, you’re good.
No need to chase the extra clue.

WAMC’s Virtual 90 Day Transition Bootcamp

Being a new coder without prior experience can feel overwhelming — I understand that deeply. That’s why, inside the Williams Academy of Medical Coding, I created a course that simulates the first 90‑day probationary period you experience when you’re hired as a medical coder.

Over time, I realized this training was helping students build real confidence, real accuracy, and real readiness… so I decided to offer it as a stand‑alone bootcamp for new coders who want to strengthen their skills and build a solid coding portfolio.
You don’t lack potential. You just need a safe place to practice, make mistakes, and grow.

This 90‑Day Transition Bootcamp is not about rushing you through content or selling you another program.
This 90‑Day Transition Bootcamp gives you:
• Real‑world medical coding cases, graded for accuracy for your coding portfolio
• One weekly 1:1 mentoring session where we walk through your growth together
• A supportive environment that feels like your first coding job — without the pressure

My goal is simple: to help you grow your confidence, sharpen your accuracy, and strengthen your coding foundation.
I believe in quality over quantity, so seats are limited. This allows me to give each student the personal interaction and feedback they deserve.

If you’re ready to enhance your skills and gain true hands‑on experience, you’re welcome to join us.
Click the link below to visit our website and go to the Bootcamp tab.

https://wamcodings.com/
Or
Call 757-230-5048