6 Key Steps in the Medical Coding Process

Published December 4, 2019

Shelley Safian

When teaching new medical coders, the most important time is the beginning… doing everything to help them build good, effective habits from day one. Start your students off with a framework upon which they can succeed in your classroom, in your program, as well as on the job after graduation.

These 6 Action Steps provide students with a checklist to follow, to support them as they develop their medical coding process and build good coding habits, starting now!

Action 1. Abstract the documentation

Remind them this is why they had to take anatomy, physiology (A&P), and medical terminology before coming into coding class. Suggest that they pull out their A&P textbook and their medical dictionary to keep close at hand so they can look up any word or term that they don’t understand while reading the physician’s notes. It is important to emphasize that they, as up-and-coming professional coders, need to use their resources because accuracy is the most important thing.


They must read the entire documentation – procedure notes, operative report, or history & physical -- so they can uncover the ENTIRE STORY: Who, Where, Why, What, and How!

Action 2. Query, if necessary

In the classroom, and on the job, asking for clarification or additional information is critical to accuracy. Questions, and their answers, smooth the path to learning when in school, and to reimbursement when on the job. Physicians are notorious for incomplete documentation because they do not know what coders need to know. And we must never forget: “If it’s not documented, it didn’t happen. If it didn’t happen, you can’t code it!” Reinforce to students that just because there are unspecified codes does not mean they should be reported. A query will result in all the required details being added to the documentation and then, coding specificity can be achieved.


Review with your students that a legal query must ask open-ended questions or provide multiple choice options to ensure the question does not appear to influence the answer.

Action 3. Code the diagnosis or diagnoses

Action 4. Code the procedure or procedures

Typically, your class will focus on diagnosis or procedure coding, and the basics remain the same: determination of the most accurate, most specific code to reflect what was documented. Prompt your students to use their resources to ensure their interpretation of the documentation is accurate.


This is a great time to revisit the requirements for specificity as well as reviewing inclusive signs and symptoms, along with inclusive procedural components. For example, when a 3rd degree burn and a 2nd degree burn both affect the same anatomical site as categorized by the codes, only the 3rd degree burn is reported; and a simple repair performed after the excision of a lesion is already included in the Excision code and not reported separately.

Action 5. Confirm medical necessity

Aligning the diagnosis codes with the procedure codes to ensure medical necessity is being evidenced is the next action that must be performed by professional medical coders. They may need their A&P textbooks to reference, but often logical, critical thinking can support success. In addition, point your students toward websites such as MedlinePlus [medlineplus.gov], an online medical encyclopedia and dictionary from the National Library of Medicine and the National Institutes of Health.


Explain that medical necessity justifies the provision of the procedure, service, or treatment in accordance with the standards of care. This is a key factor for reimbursement, as well as legal and ethical reviews.

Action 6. Double-check your codes

Teach your students to take a few minutes to code backwards [look up the code, re-read the description, and compare this to what the documentation states]. Remind them that it is always better to correct their own mistakes… especially before anyone knows they made them.


To err is human, and therefore, building the habit of double-checking our own work is key, especially in a field where accuracy is the most important work product.

Encouraging your students to use this checklist can help reduce students’ frustrations as they learn how to interpret documentation and translate those medical terms into accurate codes. Those of us who know coding understand how challenging it can be for a beginner venturing into this unknown territory.

Starting your students’ coding education off with a fixed structure, such as this checklist, can really support their building of a strong, accurate coding process that will not only help them succeed in your class, it will give them a solid foundation upon which to build a successful career.

For more information about Let’s Code It! 2e by Shelley C. Safian and Mary A. Johnson, go to https://www.mheducation.com/highered/product/let-s-code-2019-2020-code-edition-safian-johnson/M9781260366570.html