Services
Physician Coding, Auditing, and Compliance Services
E/M coding and documentation review, billing compliance, and hands-on provider education that protect physician revenue and reduce risk.
Overview
Confident, Compliant Physician Coding & Documentation
HMI helps physician practices and hospital-employed providers code, document, and bill evaluation and management (E/M) services accurately and in line with current CMS guidelines. Our specialists review physician and mid-level (NP, PA) documentation against the services billed, confirm the required elements are supported, and pinpoint where documentation or coding can improve.
Just as important, we close the loop with education. Providers and office staff receive one-on-one guidance on documentation requirements, coding, and billing — so improvements stick and the next encounter is cleaner than the last. Where teaching settings apply, CMS Teaching Physician documentation guidelines are built into the review.
What’s Included
Physician-Focused Consulting Services
Physician / Provider Claims Review
Validation of the billed E/M visit code against the documented encounter note under current CMS E/M Documentation Guidelines, confirming MD, NP, and PA documentation supports the level reported.
Physician Office Services
Review of office and inpatient E/M visits, the office superbill, and staff policies and procedures — confirming coding and billing compliance and that current ICD-10-CM and CPT® codes are in use.
Charge Capture – Physician Services
Medical-record review for appropriate diagnosis assignment and accurate capture of E/M levels and procedures for billing.
Provider Documentation Review
Assessment of whether documentation supports the key components of each E/M visit, with clear, specific guidance on closing any gaps.
Teaching Physician Guidelines
Where applicable, CMS Teaching Physician documentation requirements are applied to the review — important for academic and provider-based settings.
One-on-One Provider Education
Individualized education for physicians, providers, and designated office staff on documentation, coding, and billing — the part that makes improvement last.
Why It Matters
Why Physician Groups Partner with HMI
We recently transitioned to HMI from another physician documentation and coding compliance vendor, and the entire experience has been positive. HMI adapted to our workflows for a seamless transition, our providers have shared positive feedback, and the Coding Hotline has been an invaluable resource. I would highly recommend HMI.
How We Work
How We Support Your Providers
Frequently Asked Questions
Physician Services, Answered
What does a physician E/M review cover?
Do you review NP and PA documentation too?
Do you provide provider education?
Can you review our office superbill and processes?
Will this help us prepare for audits?
Related Services
Explore More of What We Do
Strengthen Provider Documentation & Coding
Help Your Providers
Code with Confidence
Talk with HMI about an E/M and documentation review — and the provider education that makes it stick.