Welcome to Medera Medical Coding

Medera Medical Coding generates accurate, defensible codes from clinical context — every code anchored to a quoted note span and reported with calibrated confidence. The engine is behavioral-health-aware — F-code specificity, BH-relevant CPT and E&M, psychotropic RxNorm — but supports the full coding surface for primary care overlap.

Every code returned by the Medera API includes the documentation span that supports it. Suggestions never auto-post — the coder or clinician confirms.

Supported code systems

ICD-10-CM

US diagnosis

ICD-10-PCS

US inpatient procedure

ICD-10

WHO international

CPT

Outpatient procedure / E&M

HCPCS Level II

Non-physician services

SNOMED CT

Clinical terminology

LOINC

Lab + instrument observations

RxNorm

Psychotropic + general medication

Endpoints

Endpoint	Surface	Purpose
`POST /api/therapy/suggest-codes`	AI Services	Standalone suggestion from diagnosis + procedure text
`POST /api/pa/coding-suggest`	AI Services	Real-time detection during intake — flags PA-required codes
`POST /api/therapy/generate-soap-note-enhanced`	AI Services	SOAP with `include_billing_codes: true`

Use cases

Encounter coding

Assign accurate diagnosis and procedure codes to behavioral-health encounters using documentation-anchored suggestions.

Clinical Documentation Improvement

Surface missing specificity, severity qualifiers, and gaps as clinical queries before sign-off.

Revenue cycle

Sweep panels for missed codes, run retrospective audits, resubmit cleanly.

Response shape

{
  "system": "icd-10-cm",
  "code": "F32.1",
  "display": "Major depressive disorder, single episode, moderate",
  "confidence": 0.92,
  "anchor": {
    "documentId": "doc_abc",
    "span": { "start": 412, "end": 489 },
    "quote": "Patient reports persistent low mood for 6 weeks..."
  },
  "severity_qualifier_suggestions": ["severe"],
  "documentation_gap": null,
  "pa_required": false,
  "payer_policy_url": null
}

Common BH codes

ICD-10-CM (F-code subset)

Code	Description
`F32.0` – `F32.9`	Major depressive disorder, single episode (severity range)
`F33.0` – `F33.9`	Major depressive disorder, recurrent (severity range)
`F40.x`	Phobic anxiety disorders
`F41.0`	Panic disorder
`F41.1`	Generalized anxiety disorder
`F43.10`	PTSD, unspecified
`F43.11`	PTSD, acute
`F43.12`	PTSD, chronic
`F11.20`	Opioid use disorder, moderate / severe
`F10.20`	Alcohol use disorder, moderate / severe
`F90.x`	ADHD subtypes
`F84.0`	Autism spectrum disorder
`F31.x`	Bipolar disorder (specifiers)
`F20.x`	Schizophrenia spectrum
`F50.x`	Eating disorders

CPT — behavioral health subset

Code	Description
`90791`	Psychiatric diagnostic evaluation
`90792`	Psychiatric diagnostic evaluation with medical services
`90832`	Psychotherapy, 30 min
`90834`	Psychotherapy, 45 min
`90837`	Psychotherapy, 60 min
`90839`, `90840`	Crisis psychotherapy (60 min + add-on)
`90846`, `90847`	Family psychotherapy (without / with patient)
`90853`	Group psychotherapy
`96127`	Brief emotional / behavioral assessment
`96130`, `96131`	Psychological testing evaluation services
`99213` – `99215`	Established patient E/M
`99491` – `99494`	Collaborative care management (CoCM)
`G2214`	Behavioral health integration

HCPCS Level II

Code	Description
`H0001` – `H0050`	BH-specific services (assessment, IOP, PHP, peer support)
`H2011`	Crisis intervention service
`S9480`	IOP, mental health
`S0201`	Partial hospitalization, mental health

SNOMED CT (BH concepts)

Concept ID	Description
`35489007`	Depressive disorder
`48694002`	Anxiety
`47505003`	Post-traumatic stress disorder
`6471006`	Suicidal ideation
`193462001`	Insomnia
`13746004`	Bipolar disorder
`58214004`	Schizophrenia

RxNorm — psychotropics

RxCUI	Description
`36437`	Sertraline
`321988`	Escitalopram
`4493`	Fluoxetine
`32937`	Paroxetine
`39786`	Venlafaxine
`72625`	Duloxetine
`10737`	Trazodone
`39993`	Zolpidem
`1827`	Buspirone
`25480`	Gabapentin
`187832`	Pregabalin
`6850`	Lithium
`28439`	Lamotrigine
`42347`	Quetiapine

What’s next

Quickstart

Suggest codes for your first note.

Core Concepts

Understand every field in the response.

How it works

Request structure + best practices.

Coding Systems

Feature availability per system.

Overview

Code Systems

Welcome to Medera Medical Coding

Supported code systems

ICD-10-CM

ICD-10-PCS

ICD-10

CPT

HCPCS Level II

SNOMED CT

LOINC

RxNorm

Endpoints

Use cases

Encounter coding

Clinical Documentation Improvement

Revenue cycle

Response shape