Is Your Coding Strategy Falling Behind? 5 Signs HIM Leaders Shouldn’t Ignore

How to identify hidden gaps in your coding operations—and where to focus next

As an HIM leader, you’re responsible for more than just code accuracy—you’re managing risk, supporting your team, and keeping up with constant change. But even strong coding operations can quietly slip off course when documentation, education, and feedback loops aren’t aligned.

Here are five indicators that your coding strategy might need a closer look—and what to do about it.

1. Audit findings are repeating—but not improving

If your audit reports feel familiar month after month, your team may be stuck in a cycle of review without resolution. Without structured follow-up, even the most accurate audit findings lose their value.

Leadership move: Don’t just share audit reports—translate them into targeted actions. Identify trends, assign follow-up education, and close the loop with coders and CDI staff.

2. Query volume is too low for case complexity

Low query rates can look like strong documentation—but they can also signal missed clarification opportunities. When productivity pressures rise, coders may avoid queries to save time.

Leadership move: Evaluate query rates by service line and compare them to documentation risk. Encourage coders to use queries as part of their workflow—not a last resort.

3. Coders are accurate—but overwhelmed

Accuracy metrics may look good, but staff are burned out, struggling to keep up with changes, or unsure about new coding guidance. That’s a culture problem, not a coder problem.

Leadership move: Balance expectations with support. Reassess productivity targets based on case complexity, and check in regularly to identify gaps in resources or confidence.

4. Education is delayed or disconnected

Annual updates arrive, but education often comes after the fact. Or it’s one-size-fits-all, regardless of team needs.

Leadership move: Shift to a continuous education model. Tie learning directly to audit trends, and provide options for coders at different experience levels or specialties.

5. There’s no clear roadmap for quality

You know where you want to go—better accuracy, fewer denials, stronger documentation—but you’re not sure where to start or how to scale improvements.

Leadership move: Use a strategic framework. Focus on where breakdowns happen most often and build from there. Coders don’t need perfection—they need clarity, consistency, and leadership.

Ready to refocus?

We’ve created a practical resource designed specifically for HIM leaders.

What's included:

• Common breakdown points HIM leaders should monitor
• How to translate audit findings into measurable improvements
• Guidance for balancing productivity, quality, and coder education
• Next steps you can take now—without overhauling everything at once

Whether you're refining your internal processes or evaluating external support, this toolkit can help you take the next step toward sustainable accuracy.

For more than 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice 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.