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Clinical Coding Expert Witnesses

Clinical coding disputes in commercial litigation typically arise when a healthcare organization, payer, or government program challenges whether a provider's coding and billing practices for services rendered complied with applicable coding guidelines, payer contracts, or reimbursement regulations. These disputes surface in False Claims Act and qui tam actions alleging systematic upcoding or unbundling, in payer audits disputing reimbursement for services coded under a particular set of diagnostic or procedural codes, and in contract disputes between providers and payers over interpretation of fee schedules and coverage terms. Because coding systems such as ICD and CPT apply detailed, frequently updated rules to complex clinical documentation, reasonable coding professionals can reach different conclusions about which code a given service or diagnosis warrants. The central issue in these cases is typically whether the coding applied to a claim or set of claims was consistent with the documentation, the applicable coding guidelines, and the payer's coverage requirements at the time.

A clinical coding expert helps attorneys evaluate that question by reviewing the underlying medical records, coding assignments, and billing submissions against the coding guidelines, payer policies, and documentation standards that governed the claims at issue. In a False Claims Act matter, that analysis might involve auditing a statistically significant sample of claims to determine whether documentation supported the codes billed; in a payer-provider reimbursement dispute, it can mean interpreting how a fee schedule or coverage policy applies to a specific set of procedure codes. These findings translate directly into positions on liability, damages calculated from improperly coded claims, and compliance program adequacy, giving attorneys a defensible, methodologically grounded basis for litigation strategy.

Selecting the right clinical coding expert means matching the assignment to a background in the specific coding system, care setting, or specialty at issue, since inpatient hospital coding, outpatient evaluation and management coding, and specialty areas such as oncology infusion coding each apply distinct rules. Round Table Group's clinical coding network includes health information management professionals, certified coders, and healthcare administrators, several of whom are fellows of the American Health Information Management Association and have published on coding compliance and reimbursement systems. With more than 75,000 expert searches completed for litigators, we help attorneys match a case's specific coding and billing issue to an expert whose credentials will withstand scrutiny. Let us help you find the right clinical coding expert for your case by calling us at (202) 908-4500.

Kinds of Cases We Work On

Round Table Group helps our clients find a wide variety of Clinical Coding expert witnesses for cases like:

01

PDPM Case-Mix Dispute Over Skilled Nursing Reimbursement

A managed care payer sued a skilled nursing facility operator alleging its clinical assessments systematically assigned residents to higher-paying PDPM case-mix groups than their functional and clinical status supported. We identified experts with experience in PDPM coding methodology, MDS assessment accuracy, and skilled nursing reimbursement compliance. The expert's review of assessment documentation against assigned case-mix groups found a substantial share miscoded to higher-paying categories, supporting a significant recoupment claim.
02

Rehab Impairment Overstatement in IRF-PAI Assessments

A payer sued an inpatient rehabilitation facility operator alleging its IRF-PAI assessments overstated patients' functional impairment levels to qualify for a higher-paying case-mix group across thousands of admissions. We identified experts with experience in IRF-PAI coding standards, functional independence measure scoring, and inpatient rehabilitation reimbursement compliance. The expert's reassessment of a sampled patient cohort against the underlying clinical records found scores inflated well beyond what the documentation supported, anchoring a substantial recoupment claim.
03

The POA Indicator Fight Over Hospital-Acquired Conditions

A payer sued a hospital system alleging it had systematically marked conditions as present on admission that its own nursing and physician notes showed developed after admission, avoiding penalties tied to hospital-acquired conditions. We identified experts with experience in present-on-admission indicator assignment, hospital-acquired condition coding rules, and clinical documentation review. The expert's chart review found a consistent pattern of POA indicators inconsistent with the timing documented in the clinical notes, supporting a meaningful recoupment claim.
04

Clinical Trial Billing Crossover Into Medicare Claims

A pharmaceutical sponsor sued an academic medical center's research billing office after discovering routine care costs that should have been billed to the sponsor under the trial's coverage analysis had instead been billed to Medicare, exposing the sponsor to compliance risk. We identified experts with experience in clinical trial billing compliance, Medicare coverage analysis methodology, and research charge coding review. The expert's line-item review of the trial's billing against the approved coverage analysis found a significant share of sponsor-responsible charges misdirected to Medicare, supporting an indemnification claim of meaningful size.
05

The Coding Engine Defect in Surgical Procedure Codes

A hospital system sued the vendor of its computer-assisted coding software after a natural language processing defect caused the system to systematically suggest incorrect procedure codes across a large share of surgical cases over several months. We identified experts with experience in computer-assisted coding software validation, natural language processing accuracy testing, and coding software quality assurance. The expert's review of the defect's error pattern confirmed it had misread a specific class of operative note language, supporting a substantial breach of contract recovery.
06

Crosswalk Failure During an ICD-10 System Migration

A revenue cycle vendor's client sued the vendor after a faulty ICD-10 crosswalk mapping used during a system migration caused a significant share of claims to be submitted with mismatched diagnosis codes, triggering a wave of denials and a subsequent compliance audit. We identified experts with experience in ICD-10 code mapping methodology, coding crosswalk validation, and claims accuracy auditing. The expert's review of the mapping tables identified systemic errors in a specific diagnosis category, supporting a sizable damages claim.
07

Behavioral Health Session Coding Dispute Over Therapy Intensity

A managed care organization sued a behavioral health facility chain alleging it had billed group therapy sessions under codes reserved for more intensive individual therapy across a large share of encounters. We identified experts with experience in behavioral health coding standards, therapy session documentation review, and mental health billing compliance. The expert's review of session notes against billed codes found a substantial mismatch between the documented service intensity and the codes billed, supporting a significant recoupment claim.
08

Dialysis Case-Mix Adjustor Dispute Under ESRD Payment Rules

A payer sued a dialysis provider network alleging it had systematically coded comorbidity adjustors under the ESRD prospective payment system that patient records did not support, inflating per-treatment reimbursement across its clinics. We identified experts with experience in ESRD PPS case-mix methodology, dialysis clinical documentation review, and renal care reimbursement compliance. The expert's chart-level review found a significant share of adjustors unsupported by the underlying clinical documentation, supporting a substantial recoupment claim.
09

Long-Term Care Site-Neutral Dispute Over Payment Criteria

A payer sued a long-term care hospital operator alleging patient records had been coded to avoid the criteria that would have subjected certain stays to lower site-neutral payment rates. We identified experts with experience in LTCH coding and payment criteria, ICU utilization documentation review, and post-acute reimbursement compliance. The expert's review of qualifying stay documentation found a pattern of coding that did not reflect the actual level of care provided, supporting a meaningful recoupment claim.
10

The Missed Queries in a Documentation Improvement Program

A hospital sued the clinical documentation improvement consulting firm it had retained after an internal review found the firm's coding staff had systematically failed to query physicians on ambiguous documentation, resulting in significant under-coded and under-reimbursed claims across a multi-year engagement. We identified experts with experience in clinical documentation improvement program standards, physician query methodology, and coding revenue capture analysis. The expert's review of a sampled chart set found queries that should have been generated under the firm's own protocols were consistently skipped, supporting a substantial breach of contract claim.

Here are a few of our favorite Clinical Coding Expert Witnesses:

Louisiana Medical Billing, Coding, Charges Expert #17141

I have 29 years of experience, and specialize in the field of health information management with specific knowledge in the areas of medical coding, medical billing and reimbursement. I have published on such topics as medical billing and reimbursement systems, ICd-9-CM coding and current procedural terminology coding of diagnoses and procedures and hospital statistics. I am a fellow of the American Health Information Management Association (AHIMA).

 

Florida Coding, Regulations, Billing Expert #26103

I have 18 years of experience, and specialize in the field of medical coding and billing with specific knowledge in the areas of fee schedules, super bills and PQRI. I have published on such topics as coding for biologicals, communication and PQRI. I have been in healthcare field for over 18 years. I specialize in the creation and maintenance of superbills and fee schedules as well as coding training for providers and staff. I have often been asked to research unique coding situations or offer my opinion on how to handle the coding of a specific case. I have conducted…

 

Tennessee Chiropractic, Fraud, Coding Expert #27727

I have 20 years of experience, and specialize in the field of chiropractic with specific knowledge in the areas of coding, billing and malpractice. I have testified on malpractice, disability and impairment and fraud.

 

New Hampshire Coding, Health Care Billing Expert #30406

I have 30 years of experience, and specialize in the field of health care administration with specific knowledge in the areas of ambulatory care, leadership and board training. I have published on such topics as health care system. I have testified on administrative complexities.

 

Hawaii Compliance, Healthcare, Coding Expert #34971

I have 12 years of experience in the field of oncology health care coding and compliance, with specific knowledge of chemotherapy infusion, medical necessity, and claim reimbursement. I have published on such topics as ESA (EPO/DPA) coding, medical infusion claims service capture and correct.

 

Your Case Deserves The Best Clinical Coding Expert Witnesses

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The right expert witnesses and consulting experts can make your case. That’s why we have spent so many hours over the past quarter century making sure our clients have just the right expert team — whether one expert or many, early-stage advice or expert reports and testimony. Across over 50,000 expert search assignments, we have honed a unique, customized approach to identifying, analyzing and connecting with expert talent so you can focus on winning your case.

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Massachusetts Video, Coding Expert #37294

I have 5 years of experience and specialize in the field of signal processing, with specific knowledge of video compression, image processing and communication systems. I have published on such topics as image processing, image and video compression and efficient system design. I have testified on video coding standards and image compression.

 

California Information Theory Expert #37974

This sample expert has 40 years’ experience in electrical and computer engineering.

 

New Hampshire Coding Expert #37989

I have 15 years of experience, and specialize in the field of coding with specific knowledge in the areas of multi-specialty, teaching physician and hospital-based. I am an instructor at a college and work daily as a coding education manager.

 

Oregon Coding, Billing, Professional Expert #41202

I have 9 years of experience, and specialize in the field of professional coding and billing, with specific knowledge in the areas of surgical coding, evaluation and management coding, and documentation guidelines.

 

Massachusetts Medical Billing, Coding Expert #45333

I have 35 years of experience, and specialize in the field of medical billing with specific knowledge in the areas of reimbursement, codint and compliance. I have published on such topics as medical billing.

 

Texas Orthodontics, Billing, Coding Expert #45725

I have 21 years of experience, and specialize in the field of healthcare with specific knowledge in the areas of practice management, billing and collections. I’m well-rounded having experience on both the provider side and the insurance side of health care.

 

Put Our Clinical Coding Expert Network to Work for You

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Our huge network of experts – eminent university professors and practitioners who have achieved renown as thought leaders in their fields – combined with unparalleled research capabilities puts the experts you need at your disposal when and where you need them.

If you’re a litigator or general counsel, we want to put this network to work for you and your clients. Let us know how we can help by calling us at (202) 908-4500 or filling out the form on this page. We’re so confident you’ll love what we do that unless you retain an expert we present there’s no charge!

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Questions Attorneys Ask About Clinical Coding Expert Witnesses:

A clinical coding expert becomes important when a case turns on whether billed diagnosis or procedure codes were supported by the underlying medical documentation, such as in False Claims Act and qui tam actions, payer audits and recoupment disputes, or contract disputes between providers and payers over fee schedule interpretation.
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