Patient & Encounter Verification
- Correct patient selected
- Correct date of service
- Correct rendering provider
- Correct place of service
- Correct encounter type
Medical Coding Resource
Coding Accuracy Checklist
Ensure Every Code Is Accurate, Supported, and Defensible
A practical pre-submission quality review tool for medical coders focused on documentation support, code selection, sequencing, modifiers, and medical necessity.
Use this checklist before finalizing code assignment to help ensure coding accuracy, complete documentation support, and compliance with official coding guidelines. Each item is intended to support a consistent, defensible coding review before claim submission.
Documentation Review
- Provider documentation is complete and authenticated
- Chief complaint or reason for the encounter is documented
- Assessment and plan support reported diagnoses
- Procedures and services performed are clearly documented
- Documentation is clear, complete, and internally consistent
- No conflicting or contradictory documentation exists
ICD-10-CM Coding
- Every diagnosis code is supported by provider documentation
- Highest level of specificity is assigned
- Laterality is reported correctly
- Combination codes are used when applicable
- Symptoms are not coded separately when integral to a confirmed diagnosis
- History, status, follow-up, and screening codes are assigned appropriately
- Official ICD-10-CM Coding Guidelines have been followed
CPT® & HCPCS Level II Coding
- Reported procedures accurately reflect documented services
- Documentation supports every CPT® and HCPCS Level II code assigned
- Units of service are accurate
- Supplies, medications, and devices are appropriately documented
- Add-on codes are paired with the appropriate primary procedure
- Bundled services are not reported separately
- Current CPT® and HCPCS Level II code sets are used
Evaluation & Management (E/M)
- Correct E/M category is selected
- Medical decision-making supports the reported level
- Time-based coding requirements are met, when applicable
- A separately identifiable E/M service supports Modifier 25 when reported
Modifier Validation
- Every modifier is supported by documentation
- Modifier 25 is used appropriately
- Modifier 59 or X{EPSU} modifier is supported
- Bilateral and anatomical modifiers are accurate
- Assistant surgeon modifiers are appropriate
- No modifier is used solely to bypass an edit
Sequencing Review
- Principal or first-listed diagnosis is correct
- Secondary diagnoses are appropriately sequenced
- Procedure sequencing follows official coding guidelines
Medical Necessity
- Diagnoses support the medical necessity of reported services
- Documentation supports the level of service billed
- Services provided are reasonable and medically necessary
Final Quality Check
- Diagnosis and procedure codes match the provider documentation
- Code descriptions have been verified
- Applicable payer or organizational coding policies have been reviewed
- No unsupported diagnoses or procedures have been reported
- Claim is ready for submission
Final Self-Assessment
- Does the documentation support every reported code?
- Have I followed the official coding guidelines?
- Are all diagnoses and procedures coded to the highest appropriate specificity?
- Are modifiers accurate and fully supported?
- Is the sequencing correct?
- Does the documentation support medical necessity?
- Would I be able to confidently defend these code assignments during an audit?
Best Practice Reminder
Code what is documented—not what is assumed.
If it's not documented, it's not supported.