Think Like a QA Reviewer (Before They Do)

Great coders do more than assign correct codes—they help build a claim that stands up to scrutiny. A simple mindset shift helps: move beyond just: “How do I code this?” to include “Could I defend this?” Below is a practical guide to apply a reviewer’s lens before the claim ever leaves your queue.

What reviewers actually look for

• Clinical coherence: Does the story of the encounter support the principal diagnosis and the procedures performed, end to end?
• Support for CC and MCC capture: Are complications and comorbidities clearly and comprehensively documented?
• Clear linkage language: Words like “due to,” “with,” and “secondary to” are used to support causal relationships when linkage is not presumed.
• Present on admission clarity: POA indicators match the documentation and the clinical timeline.
• Procedure specifics: Approach, body part, device, laterality, and procedural objective are clearly documented for precise ICD-10-PCS assignment.
• Clinical validation risk: Diagnoses with borderline criteria are identified and necessary queries posed to the appropriate provider(s).
• Sign and symptom pitfalls: Definitive diagnoses are not double reported with codes for routine signs and symptoms.
• Consistency across sections: Provider documentation (e.g., histories, progress notes, orders, and discharge summaries) is not contradictory.

A fast pre-bill review checklist

Use this quick pass on every record. It takes minutes and prevents denials and rework.

• Confirm the principal diagnosis reflects the reason for the admission or encounter and drives the clinical course.
• Verify secondary diagnoses meet coding and reporting requirements, including clinical validity.
• Check all procedures for complete character specificity and correct root operations.
• Trace documentation for any CC or MCC to ensure clear, explicit support.
• Ensure linkage terms are present where needed (for example, “anemia due to chronic kidney disease”).
• Validate POA indicators against the history and physical, emergency notes, and early progress notes.
• Scan for contradictory statements and resolve them before finalizing.
• Review device, graft, and drug names, plus lot or brand details when they affect code choice or NTAP status.
• Confirm all queries are non-leading, finalized, and reflected in the final documentation.
• Add brief, defensible abstraction notes that show your reasoning and sources.

Write defensible abstraction notes

Think of abstraction notes as a short, professional trail of how you arrived at your choices.

Keep notes:

• Concise: capture only what supports the code choice.
• Source-based: cite guideline sections, Coding Clinic references, or facility policy by title and date.
• Neutral: avoid interpretations that the documentation does not support.
• Traceable: reference exact phrases or locations in the record. 

Simple template you can copy:

Coding rationale:

• Principal diagnosis supported by [source note, date/time] describing [key clinical facts].
• Secondary diagnoses meet reporting criteria and are clinically validated by [labs/imaging/findings].
• Procedures coded per operative note [date/time], confirming approach, device, and intent.
• References: ICD-10-CM/PCS Guidelines [section], Coding Clinic [year, issue], facility policy [title].
• Queries: [none or closed on date/time].

When to pause and query

Send a query when clarification changes code assignment or supports clinical validation—not to fish for a better DRG.

Common query triggers:

• Diagnoses are suggested by clinical indicators but not specifically documented.
• Diagnoses are documented but not clearly supported by clinical indicators.
• Unclear etiology or uncertain cause-and-effect relationships.
• Ambiguous terms that could be interpreted multiple ways.
• Conflicts between documentation in the record.
• Missing procedural specifics that affect character values.

Keep the tone of a query non-leading, present clinical indicators, and give clinically reasonable options including “unable to determine.”

Close the loop with self-reviews

Quality improves fastest when you audit yourself in small, frequent doses.

• Pick a small number of recently coded cases each week and review them the next day with fresh eyes.
• Track personal trends: top edits and any recurring denial categories.
• Share quick wins with your team so everyone benefits from lessons learned.
• When you find a pattern, propose a small standard—such as a one-line note template or a clarified facility rule—and socialize it.

Metrics that matter

You do not need a dashboard full of data. A few simple measures tell a clear story.

• Rebill and denial rates related to coding or clinical validation trending down over time.
• Query volume and turnaround time staying appropriate to case mix and complexity.
• Top edit occurrences shrinking as you address the root causes.
• Peer or reviewer variance narrowing as shared standards take hold.

Bottom line: Thinking like a reviewer is not about catching mistakes after the fact. It is a calm, structured way to identify them during the coding process—so your codes are accurate and defensible, and your days run smoother.

Frequently Asked Questions

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a flexible, online education platform designed for today’s coders. With a growing catalog of AHIMA and AAPC-approved coding courses, HIAlearn supports both beginners and experienced coders looking to build confidence, accuracy, and CEU credits.

Courses are available across various coding types including CPT, E/M, ICD-10-CM, and ICD-10-PCS, and are designed for multiple specialties including inpatient, outpatient, profee, and CDI.

To stay up to date, coders can explore our Coding Updates hub for the latest ICD-10-CM, ICD-10-PCS, CPT, and IPPS changes. HIAlearn also supports organizations with group discounts and scalable team access, promoting accuracy, compliance, and continuous professional development across departments.

The information contained in this blog post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.