Ten Useful Tips For Efficient Coding Chart Abstraction

Medical coding is more than just choosing numbers and letters for procedures. Coders need serious skills to get information from patient records. They use this information, along with their knowledge of reimbursement and coding rules, to help doctors get paid properly.

No two medical notes are the same. This can be intimidating for new coders. Understanding medical records is crucial.

Here are some useful tips for new coders to improve their skills:

1. Ensure Proper Documentation

Make sure all important details are in the medical records. This includes the patient's name, gender, age, address, facility and provider information, insurance details, and signed clinical data like SOAP notes and diagnosis.

2. Review Code Sets

Before coding a procedure or diagnosis, make sure you have all the necessary materials. Code sets identify specific diagnoses and procedures. These include:

  • HCPCS and CPT codes for physician services
  • Coding manuals
  • Updated coding guidelines
  • NCD or LCD documents from CMS
  • NCCI coding protocols
  • ICD-10 materials and conversion tools
  • A medical dictionary
  • CPCS codes for supplies and drugs
  • National Drug Classifications (NDC)

3. Perform Proactive Face-sheet/Superbill Analysis

Start by reviewing the provided data. Look at the size and complexity of the medical notes. Keep the Payer Policy document handy for any reimbursement and compliance issues, especially for Medicare patients.

4. Focus on key elements in the SOAP note

SOAP notes are based on Subjective, Objective, Assessment, and Plan. They include essential information for coding Evaluation and Management (E/M) codes. Look for:

  • History and Physical Report (H&P)
  • Chief Complaint (CC)
  • History of the Present Illness (HPI)
  • Review of Systems (ROS)
  • Personal, Family, and Social History (PFSH)

You can now choose the E/M code level by Medical Decision Making (MDM) complexity or total time spent with the patient. Be careful with up-coding or down-coding and look for any coding patterns.

5. Analyze Diagnosis Code

Identify the primary and secondary diagnoses. Do not code diagnoses labeled as "probable," "suspected," "questionable," or similar terms. Code the conditions to the highest degree of certainty. You need a basic understanding of anatomy, physiology, and pharmacology to ensure accurate documentation.

6. Analyze Procedure note

Different specialties use different codes. Coders should learn about the specialties they work with. Know the sections, appendices, and symbols in the CPT manual. Pay attention to Add-on codes. Have sessions with providers and managers to improve coding strategies.

7. Make a query when not sure

If you're unsure, ask the physician. Remember, "if it's not documented, it's not done." Good communication helps both coders and practitioners understand the coding process better.

8. Perform Audits

Regular audits improve billing practices. Do a quarterly or annual audit to catch coding mistakes and understand coding patterns. Internal audits protect against external audits and track the quality of your coding.

9. Review the Explanation of Benefits

Reviewing EOBs of unpaid and denied claims helps identify recurring errors. Work as a team to resolve issues and refile claims.

10. Make Specialty Coding Profiles and Protocols

For single-specialty practices, create specific coding protocols. Include instructions from providers and information on necessary codes and modifiers. Update these protocols regularly.


With constant changes in medical coding, coders must stay updated. A good coder should:

  • Keep learning about specialties
  • Track performance
  • Learn from mistakes
  • Attend training sessions
  • Understand their EMR or EHR
  • Perform regular coding audits
  • Ask questions when needed

AltuMED PracticeFit enables Medical Billers with an inbuilt scrubber feature, reducing the chances of coding errors to 92%. Schedule a PracticeFit demo to know more:

Subscribe to Our Newsletter!


Subscribe to Our Newsletter!

Enter Your Email Address. We Promise We Won't Spam You

Relevant Articles


Follow Us

Subscribe to newsletter

Enter your email to receive our newsletter, so you can stay in the loop with our latest promos.

Subscribe to Our Newsletter!

Enter your email address to

receive "Go Practice" as an email newsletter.