After medical services are provided, what is the next step?

• A. Schedule follow-up appointment.
• B. Code the diagnosis and procedures.
• C. Verify payer identity.
• D. Submit release of information form.

Answer: (B)

The step after providing services is coding the encounter. Coders review the clinician’s documentation and translate it into standardized codes: ICD-10-CM for diagnoses and CPT/HCPCS for the procedures performed. These codes communicate to the payer exactly what was diagnosed and what was done, and they establish medical necessity for payment. Accurate coding is the foundation of the claim because it drives reimbursement, helps prevent denials, and supports compliance with coding rules. While scheduling a follow-up, verifying payer eligibility, or handling a release of information may occur in the broader workflow, they are not the action that directly enables billing. Coding the diagnosis and procedures is the essential next step to generate a bill.