Month: March 2019

Learn Anatomy and Medical Terminology

cwamca logoFeatured Coffee – Hot Fudge Caramel Truffle Coffee

When studying for coding certification, you’re provided a review of anatomy and medical terminology.  It is expected that students have already completed full anatomy and medical terminology courses.

Students sometimes ask for creative strategies to aid them to memorize body parts and organ systems and medical terms.  Well, don’t try to remember them. Learn them.

According to Merriam-Webster[1], to memorize is to “commit to memory” and to learn is “to gain knowledge or understanding of or skill in by study, instruction, or experience.”

Keep in mind that as coders we’re translating words into alpha and/or numeric codes.  When we can visualize the body area or organ system, it’s much easier to correctly assign the codes.  Once anatomy and medical terminology become part of our everyday thinking, we’ll know anatomy and medical terminology without devising strategies to memorize it. 

For example, most of us will say, “My stomach hurts.”  That means nothing to our medical provider, and we’ll be asked to point to the location of the pain.  Why? Because we’re only telling the clinician that we have abdominal pain and that’s a large area that includes many organs. 

In your anatomy and physiology classes, you learned there are nine abdominopelvic regions and four quadrants, and you identified all of the organs within the regions and quadrants.

So next time your “stomach hurts,” associate the pain with the region or quadrant of the abdomen and visualize the organs in that area.

“Oh, your aching back”? Is the pain in the cervical, thoracic, lumbar, sacral, or coccygeal region?  Visualize each region and label the vertebrae at each level.

 Hopefully, you’re getting the point.  You’re not self-diagnosing, you’re visualizing your anatomy and using correct terminology.  That’s how you learn instead of just memorizing.

 

WOV, enjoy!

 

1Learn | Definition of Learn by Merriam-Webster. https://www.merriam-webster.com/dictionary/learn

All content is original and owned by coffeewithamedicalcodingauditor

Encoder Dependent

cwamca logoFeatured Coffee – Hot Buttered Toffee Coffee

Recently, a coder needed help with an ICD-10-CM® code.  She explained that she was rusty using her coding book and she wanted to brush up on her manual coding skills.

When I meet with coders, I expect them to bring their coding books because my sessions are always interactive and they have to abstract codes from the books.  I’ve noticed that it’s sometimes a challenge to manually abstract codes because they don’t use the coding books.

There are benefits of using coding software, but what happens when it’s not available? You have to manually code.  Let’s look at the benefits of using an encoder for the complexity of Icd-10-CM coding.

Simply put, coder productivity is increased because coders enter keywords and the software assists them through options to the final code(s).  The encoder automatically checks for edits such as sex or age restrictions.  It follows the same path as the index, and processes tabular instructions such as code first, use additional code, and code also.  Additionally, it scrubs for Include and Exclude notes as well as other code-level notations (all within a few seconds).

So the obvious disadvantage of manual coding is decreased productivity.  What are the disadvantages of a coder depending on the encoder?

The coder is either not gaining, or is losing coding knowledge.  The coder will not know or will forget general coding and chapter-specific guidelines.  Will the coder know a code has an age or sex restriction? Will the coder know the difference in Exclude 1 versus Exclude 2? Will the coder know the code cannot be reported as a primary diagnosis? Will the coder understand etiology/manifestation coding rules and the importance of sequencing? Will the coder be able to follow the code-level notations?

I have a lot of respect for the coder who recognized that her manual coding skills were rusty and I commend her effort to turn a weakness into a strength.

Challenge yourself.  Select one complex encounter each week and code it manually.

 

WOV, enjoy the coffee!

 

All content is original and owned by coffeewithamedicalcodingauditor

ICD-10® is copyrighted by the World Health Organization (WHO)

Cite Your Source (Your Opinion Doesn’t Matter)

cropped-cwamca-logoFeatured Coffee –Caramel Cloud Macchiato

When giving coding advice, always cite your source.  Without a reliable source, it’s just an opinion, and in this industry, opinions don’t matter.  If you are given coding advice without references to support it, take it with a grain of salt.

It’s not disrespectful to ask for a source, and it is unprofessional to give guidance without citing your source.   Citing a source provides opportunities to review the resource to ensure that there’s not a misinterpretation of the guideline and to verify that it is a credible resource.  In the event of an audit, you will need a reliable reference to defend your codes.

I had a coder who insisted that a high dollar service was non-covered by Medicare and she could not appeal the denials because of a Local Coverage Determination (LCD).  I did not find an LCD for the specific state, and I asked her to provide documentation.

She gave me a copy, but it was not applicable for the state the providers were in.  The claims were incorrectly denied.  We had to have all of the adjusted charges reversed, we filed appeals, and the claims were paid.

If you receive coding guidance, you should request the source so that you can verify the information.

I failed a pro-fee coder, who up to that time always scored high on her audits.  We discussed the results, and she said that she was instructed by her coding manager to make the changes.  Her manager was a facility coder, and facility coding guidelines differed from pro-fee.

One of my most awkward moments was when I had to disagree with another auditor in front of a group of coders.  They challenged my (based upon guidelines) recommendation because they were following the guidance given to them by a previous auditor.  According to the coders, they initially were coding the way that I recommended.  I asked if the former auditor provided a reference for the recommendation and she did not.  The coders had changed the way they coded a particular service without having a resource to use as a defense, and the advice was not correct.  So, we reviewed procedure notes and guidelines to support my recommendation, and the coding manager instructed the coders to follow the coding guidelines that I recommended.

What are reliable medical coding resources?  Here are some of my favorites:

Always cite a source, it validates your advice.

Always request a source, it validates your coding in the event of an audit.

 

 

All content is original and owned by diaryofamedicalcodingauditor

CPT® is a registered trademark of the American Medical Association

ICD-10® is copyrighted by the World Health Organization (WHO)

Coding Clinic® is a registered trademark of the American Hospital Association