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How does the coding process work?

Put simply, the software asks itself the same questions that humans ask themselves while coding a chart. We call these questions 'judgement factors'.


Here’s what a few of these judgements themselves look like in question form:

  • “How severe was the presenting problem?”

  • “What diagnostic procedures were ordered?”

  • “Were any consultations required?”

  • “Which management options were chosen?”

These, and many more, questions are asked (and subsequently answered) in order to decide the level of MDM complexity for any given patient encounter. The different models used to answer these questions are run in parallel and converge on a final set of codes after they have each carefully weighed all of the relevant factors present in a chart. Because the judgements of each model have been trained by and are based on the past coding experience of some of the world's best coders, we have been able to effectively recreate the process humans use to analyze and code an encounter.


ICD-10 codes are extracted using semantic analysis on the raw chart data and are then linked to procedure codes using advanced algorithms that understand how to best support a claim. Semantic analysis involves “reading” each sentence in the chart the same way a human would, so that all pertinent information (Patient Attributes, Medications, Diagnoses, Body Areas, Laterality, Signs and Symptoms, Negations etc.) can be extracted and analyzed for use in generating the ICD-10 codes and links to the procedure codes. 

Physician notes are inherently messy. Our system performs all required chart clean-up and normalization functions, such as medical spell checking, term normalization and checking for the use of any templates.


Feel free to browse through actual output from our software run against sample medical charts that were created from scratch by our team of in-house MD’s for demonstration purposes. As part of a trial, we can produce these results for your charts.



As you expect, there is a lot that goes into coding a medical chart. We hope this high level overview was helpful, but the best way to understand our quality is to try our solution for yourself with our risk free trial. Please contact us for a demo.

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