An Institute of Medical Coding guide to understanding how accurate documentation supports sound coding decisions.
Before the claim leaves
A coder translates supported diagnoses and services into codes. Billing staff or software may combine those codes with patient, provider, service and payer information. Internal edits can flag missing or inconsistent fields.
Submission and initial checks
The claim may pass through a clearinghouse before it reaches a payer. Format or data problems can cause a rejection that needs correction and resubmission. A rejection at this stage differs from a payer denial after adjudication.
Payer review
The payer evaluates the claim against eligibility, benefits, coverage, coding and payment rules. The result may be payment, partial payment, denial or a request for more information. The specific steps depend on the payer and claim type.
Follow-up and learning
Billing and coding teams examine remittance details, investigate denials and correct supported errors. Recurring issues can reveal documentation gaps or workflow problems. Accurate coding is one part of a longer revenue cycle.
