a learning system for medical coding comprising : analyzing patient history before examination ; charting the patient history on a historical component table ; providing a summary of the patient history ; determining an examination component of coding ; tabulating data reviewed ; determining risk complications and managing a course of action based on the data . the patient history includes : a chief complaint , a history of present illness , review of the patient &# 39 ; s various systems and post - family or social history . the examination component may include the organ system and body area of a patient . further , the course of action includes three elements , numbering of diagnosis and management options , amount and complexity of data reviewed , risk of complication and morbidity or mortality . any tabulated data includes pathology , radiology and complex test results .