An Institute of Medical Coding guide to understanding how accurate documentation supports sound coding decisions.
Choose suitable cases
Begin with short, de-identified encounters that have clear documentation and a defined care setting. Add complexity gradually, such as multiple diagnoses or conflicting notes. Never use identifiable patient records outside authorized training.
Read before looking up codes
Summarize the reason for the encounter and underline the provider’s documented diagnoses. Separate confirmed information from assumptions and note any unanswered question.
Verify the code pathway
Use the current code set and official instructions applicable to the case. Start at the documented term, verify the candidate in the tabular listing and check required details and sequencing. Write down the evidence for your selection.
Review mistakes constructively
Compare your work with an answer key or instructor explanation, not just the final code. Classify errors: missed documentation, incorrect lookup, unsupported inference or sequencing. Revisit the error category with a new case.
