I Code It One Way. My Peer Codes It Another. Now What?
Article Reference Code: NAMAS.04.24.2026
Written by: Cristin Robinson CPC, CPMA, CCC, CRC, CEMC
In today’s healthcare environment, coding is no longer a one‑size‑fits‑all process. Two experienced professionals can review the same medical record and arrive at different coding conclusions—both believing they are correct. With the increasing reliance on encoders, AI‑supported tools, and remote workflows, these differences have become more visible and, at times, more challenging to resolve. Encoders and technology have undeniably transformed the coding profession. They allow coders, auditors, and educators to work more efficiently, process records faster, and navigate increasingly complex code sets. However, efficiency should never come at the expense of accuracy. Technology is a tool, not a replacement for a solid understanding of official coding guidelines, documentation requirements, and clinical context. I am one of those people who love to use an encoder for ease of finding the answer quickly but I also like to go to the books to verify that I am not missing anything.
A common example involves diabetes coding. An encoder may suggest reporting Type 2 diabetes with complications based on provider documentation, but a closer review of the tabular list may reveal an Excludes1 note indicating that Type 1 diabetes cannot be reported concurrently. If the provider has documented both types without clear clarification, assigning both codes would be incorrect. This is an error that can easily be missed if the coder does not take the time to review the guideline in full. Another frequent issue involves code first instructions. Encoders may point directly to symptom codes—such as abdominal pain, shortness of breath, or dizziness—when those symptoms are documented. However, official guidelines may require the underlying condition to be coded first when it is known and documented. Missing this sequencing instruction can lead to inaccurate reporting and potential compliance concerns. These scenarios highlight why foundational coding knowledge remains essential, even in a technology‑driven environment.
Since transitioning to remote work in 2018, I have adapted my workflow to rely heavily on digital tools such as Adobe and Word to review and annotate records. During record review, I may highlight documentation that supports medical necessity, flag areas where laterality or severity is unclear, or add comments questioning whether a condition is acute, chronic, or historical. These digital annotations allow me to clearly document my thought process and provide a reference if the record needs to be revisited or discussed with leadership or a provider. Regardless of the setting—onsite or remote—the responsibility remains the same: ensure that documentation supports the codes reported and that all guidelines are followed. I like to stay organized with file folders and specific sections on my computer, so if I need to go back to it or need to discuss something with a manager or provider, I have already marked up that record with my thought process at that time. Another thing that looks different when you are a work from home professional, is that review and one on one feedback or mutual conversation on a record being reviewed. In coding, auditing, and education, we need to be able to work together. We need to make sure it is documented at the highest specificity, and that everything documented is captured when additional information is needed. We also need to know how to communicate with our providers to ensure proper addendums are performed when necessary.
Differences in coding interpretation often surface during peer review or audits. For example, two coders may select different evaluation and management levels based on how they interpret medical decision‑making, risk, or time documentation. One coder may feel the documentation supports a higher level due to complexity, while another may find that key elements are missing. In these situations, collaboration is critical. Reviewing the official guidelines together, discussing documentation requirements, and explaining each coder’s rationale not only resolves the immediate discrepancy but also promotes learning and consistency moving forward. These conversations are an important part of professional growth and quality improvement.
Provider documentation plays a vital role in accurate coding, and sometimes clarification is necessary. Documentation may reference a condition such as “history of congestive heart failure” without indicating whether it is active, monitored, or treated during the encounter. Without clarification, assigning a code may be inappropriate. A compliant, well‑written provider query can resolve this uncertainty. When providers respond with clarification or addendums, the medical record becomes more accurate and defensible. Effective communication between coding professionals and providers protects both reimbursement integrity and compliance.
My role as an educator is to help coders and providers understand why these details matter. This includes reviewing missed Excludes1 notes, reinforcing sequencing rules, and explaining how documentation supports code selection. Education is not just about teaching codes—it is about fostering critical thinking, consistency, and confidence. We are all part of a larger healthcare system that includes providers, coders, auditors, educators, and administrative staff. Each role contributes to the accuracy and integrity of the medical record. When one piece is weak, the entire system is affected.
Healthcare coding is constantly evolving. Annual coding updates, new LCDs and NCDs, local Medicare contractor policies, and specialty‑specific changes all directly impact daily coding decisions. Staying current is not optional—it is essential. Ongoing education through webinars, seminars, and professional resources allows coding professionals to remain informed and confident. The more we learn, the better equipped we are to navigate complex cases, resolve discrepancies, and support providers effectively.
Coding approaches may differ from one professional to another, but the foundation of quality work remains the same. Accuracy, collaboration, continued education, and adherence to official guidelines are essential in every setting. When coding professionals understand both the tools they use and the guidelines behind them, they are better prepared to address differences, support their peers, and protect the integrity of healthcare data.
In a field where details matter, taking the time to slow down, review guidelines, and communicate effectively can make all the difference.
Contact Cristin on LinkedIn by Clicking her Name Below:
Cristin Robinson CPC, CPMA, CCC, CRC, CEMC
Cristin Robinson is a nationally recognized coding and auditing professional, holding multiple certifications including CPC, CPMA, CCC, CRC, and CEMC, and serving as an AAPC Approved Instructor. With extensive experience across coding, compliance, and education, she specializes in breaking down complex documentation and regulatory concepts into practical, real-world application. Cristin is passionate about empowering healthcare professionals to strengthen accuracy, reduce risk, and build confidence in today’s ever-evolving audit environment.
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